related literature in health education

• Research article
• Open access
• Published: 26 April 2017

Health literacy in childhood and youth: a systematic review of definitions and models

• Janine Bröder   ORCID: orcid.org/0000-0002-0399-7649 1 ,
• Orkan Okan 1 ,
• Ullrich Bauer 1 ,
• Dirk Bruland 1 ,
• Sandra Schlupp 1 ,
• Torsten M. Bollweg 1 ,
• Luis Saboga-Nunes 2 ,
• Emma Bond 3 ,
• Kristine Sørensen 4 ,
• Eva-Maria Bitzer 5 ,
• Susanne Jordan 6 ,
• Olga Domanska 6 ,
• Christiane Firnges 6 ,
• Graça S. Carvalho 7 ,
• Uwe H. Bittlingmayer 5 ,
• Diane Levin-Zamir 8 ,
• Jürgen Pelikan 9 ,
• Diana Sahrai 10 ,
• Albert Lenz 11 ,
• Patricia Wahl 11 ,
• Malcolm Thomas 12 ,
• Fabian Kessl 13 &
• Paulo Pinheiro 1  

BMC Public Health volume  17 , Article number:  361 ( 2017 ) Cite this article

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An Erratum to this article was published on 09 May 2017

Children and young people constitute a core target group for health literacy research and practice: during childhood and youth, fundamental cognitive, physical and emotional development processes take place and health-related behaviours and skills develop. However, there is limited knowledge and academic consensus regarding the abilities and knowledge a child or young person should possess for making sound health decisions. The research presented in this review addresses this gap by providing an overview and synthesis of current understandings of health literacy in childhood and youth. Furthermore, the authors aim to understand to what extent available models capture the unique needs and characteristics of children and young people.

Six databases were systematically searched with relevant search terms in English and German. Of the n  = 1492 publications identified, N  = 1021 entered the abstract screening and N  = 340 full-texts were screened for eligibility. A total of 30 articles, which defined or conceptualized generic health literacy for a target population of 18 years or younger, were selected for a four-step inductive content analysis.

The systematic review of the literature identified 12 definitions and 21 models that have been specifically developed for children and young people. In the literature, health literacy in children and young people is described as comprising variable sets of key dimensions, each appearing as a cluster of related abilities, skills, commitments, and knowledge that enable a person to approach health information competently and effectively and to derive at health-promoting decisions and actions.

Identified definitions and models are very heterogeneous, depicting health literacy as multidimensional, complex construct. Moreover, health literacy is conceptualized as an action competence, with a strong focus on personal attributes, while also recognising its interrelatedness with social and contextual determinants. Life phase specificities are mainly considered from a cognitive and developmental perspective, leaving children’s and young people’s specific needs, vulnerabilities, and social structures poorly incorporated within most models. While a critical number of definitions and models were identified for youth or secondary school students, similar findings are lacking for children under the age of ten or within a primary school context.

Peer Review reports

From a public health perspective, children and young people constitute a core target group for health literacy research and intervention as during childhood and youth, fundamental cognitive, physical and emotional development processes take place [ 1 ] and health-related behaviours and skills develop. As a result, these stages of life are regarded as crucial for healthy development, as well as for personal health and well-being throughout adulthood [ 2 , 3 ]. Moreover, health literacy is understood as a variable construct that is acquired in a life-long learning process, starting in early childhood [ 4 ]. Hence, targeting children and young people with health literacy interventions can help promoting healthy behaviors and ameliorate future health risks.

Whilst we acknowledge the recent increase in publications which focus on children and young people, the attention contributed to children’s and young people’s health literacy is still small compared to the momentum health literacy is currently experiencing in research, practice and policy-making. Within health care settings, research has mainly focused on the impact of parental or maternal health literacy on children’s health. Accordingly, most research primarily addresses questions of how children are affected when their parents lack the knowledge and skills required for making sound health decisions concerning their children’s health [ 5 ]. Within health promotion, some attention has been drawn to addressing children’s and young people’s health literacy in school health education and health promotion [ 6 – 9 ].

Moreover, there is limited knowledge and academic consensus regarding the abilities and knowledge a child or young person should possess for making sound health decisions. For the general population, the European Health Literacy Consortium integrated both drivers and differing dimensions to suggest: health literacy is “linked to literacy and entails people’s knowledge, motivation and competences to access, understand, appraise, and apply health information in order to make judgments and take decisions in everyday life concerning healthcare, disease prevention and health promotion to maintain or improve quality of life during the life course.” [ 10 ]. Moreover, an individual’s health literacy depends upon their personal situation including their health status, risks or problems, their affiliation with social group(s) (e.g. health practitioners, patients, and different age-groups) and other socio-economic determinants [ 11 ]. A more specific overview for child and youth health literacy is lacking. Hence, it is unclear, to what extent conceptual and theoretical efforts for shaping and describing health literacy in children and young people currently do consider the unique characteristics of the target group and recognise related challenges. Rothman et al. [ 12 ] proposed four categories of unique needs and characteristics to contrast the target group from the general adult population, namely (1) developmental changes, (2) dependency on resources and skills, (3) epidemiological differences, and (4) vulnerability to social-demographic determinants of health.

To address these described research gaps, this article aims:

to scope current understandings of health literacy in childhood and youth and

to understand to what extent available models capture the unique needs and characteristics of children and young people.

For this purpose, a systematic review and inductive content analysis of health literacy definitions and models for persons aged 18 or younger was conducted in English and German academic literature. To the authors’ knowledge, this work is the first to scope the conceptual understanding of health literacy in children and young people in a systematic manner. The research is conducted in the context of the German Health Literacy in Childhood and Adolescence (HLCA) Consortium [ 13 ] and seeks to provide a first step towards future effective health literacy interventions to promote children’s and young people’s health.

A systematic review of available generic health literacy definitions and models for children and young people aged 18 or younger was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines for ensuring high quality and transparent reporting of reviews [ 14 ]. Within this research, health literacy is regarded as a multidimensional construct for which the available latest research is being synthesized and evaluated. Hence, it consists of multiple underlying dimensions that entail the generalizable characteristics of health literacy. Health literacy dimensions were extracted from available conceptual models. These were clustered according to their stated purpose as conceptualisation – the process by which imprecise constructs and their constituent dimensions are defined in concrete terms – or operationalisations, which provide the base for measuring the construct or testing it with defined variables [ 15 ].

Search strategy and screening process

Between May - Nov. 2015, six bibliographic databases were searched, including PubMed, the Educational Resources Information Centre (ERIC), the Cumulative Index to Nursing and Allied Health Literature (CINAHL), PsycINFO, Web of Science, in English and the FIS Bildung Literaturdatenbank in German. Search terms in English and German were defined for three distinctive search clusters - main topic, subtopic, and target population (see Table 1 ) - and were selected upon a narrative search. Search terms were combined through Boolean operators (AND/OR) and truncations and wildcard characters were used to increase the sensitivity of the searches. The searches were not limited to any publication time frame, research design or peer-review criteria (dissertations and essays were included). Theory-building or conceptual, explorative publication are often part of an inductive research process, providing the theoretical base for hypothesis-testing research. Therefore, not all quality standards as outlined in the PRISMA guidelines applied to our research question.

The search identified n  = 1492 publications (see PRISMA Chart in Fig. 1 ). After removing duplicates ( n  = 471), 1020 abstracts were screened by JB and OO. Database searches were complemented by hand searches, e.g. in Google Scholar, and a cross-check of the reference lists of studies included for analysis, retrieving 13 additional articles that entered the selection process.

PRISMA chart of systematic search process

Articles were eligible if they: a) were fully available in English or German; b) focused on generic health literacy – while excluding any domain or topic-specific health literacy models, to ensure a focus on the core dimensions of health literacy [ 16 ]; c) offered relevant content for defining and conceptualizing health literacy in children and young people and d) addressed a target population that were 18 years or younger. Articles incorporating a life course perspective on health literacy were included as well. The life course concept refers to the sequence of age categories that people normally pass through as they develop and progress from birth to death. Thus, even without specifically stating the target group, the life course concept specifically encompasses children and young people as well. Therefore, the articles were included as they added to the comprehensiveness and the entirety of the analysis.

Whether articles were included for full-text analysis was determined by JB and SS based on the articles’ assessed fit with the eligibility criteria. Publications, for which the researchers reached a differential decision, were discussed within the core research team and if necessary assessed again until consensus was reached.

Data extraction and analysis

The 30 articles were selected for the full-text analysis for the following reasons: four contained only a definition [ 1 , 17 – 19 ], thirteen only a model [ 5 , 20 – 31 ] and eight described a definition and a model [ 4 , 8 , 10 , 32 – 36 ]. For three models two original references [ 37 – 39 ] were included as both provided additional insights to the model. All these articles were qualitatively assessed and synthesized applying a four-step inductive content analysis. Firstly, eligible publications were scanned for definitions and conceptual models that were either developed for the target group or adapted to it, or included relevant perspectives on health literacy for children and young people. Secondly, these definitions and models were coded and extracted by the research team following an inductive approach. Overlapping definitions and models from the same research group, were only included once. For non-related publications that described the same health literacy definitions or models, only the original reference was included and marked accordingly in Table 3 . Thirdly, relevant background variables were defined and extracted into a matrix. These background variables included the age of the target group, the reasons for focussing on the target group, whether the target groups’ perspectives were considered (a) in the development of the definition or model, or (b) in the applicability and relevance of these, and the setting(s) for which they were developed. The articles’ research design and methodological quality was not assessed as many studies were theoretical explorations for which the assessment criteria of PRISMA did not apply. Finally, the definitions and identified dimensions were discussed with a whole research team in autumn 2015 and the feedback was integrated into the final analysis.

The systematic review of the literature identified 12 definitions (Table 2 ) and 21 models (Table 4 ) of health literacy for children and young people.

Definitions of health literacy in childhood and youth

Of the 12 definitions (Table 2 ), two specifically targeted children younger than 12 [ 17 , 32 ], another one included children from 3 to 18 years [ 1 ]. Four definitions focused on young people at different ages between 13 and 18 years [ 8 , 18 , 19 , 33 ], while five articles considered health literacy over the life course without specifying a target group [ 10 , 20 , 34 – 36 ]. Four definitions were developed from a school health education perspective [ 8 , 18 , 19 , 32 ]. While Massey [ 33 ] specifically targeted health literacy in the health care setting, Mancuso [ 34 ] and Sørensen et al. [ 10 ] stressed the relevance of health literacy in multiple health-related settings including health care, disease prevention, health promotion, and public health. The definitions by Fok and Wong [ 17 ] and Massey et al. [ 33 ] were the only ones where the target group participated in the development of empirical and explorative dimensions. Gordon et al. [ 19 ] developed the definition as a result of a stakeholder consultation with school health community partners and Sørensen et al. [ 10 ] evolved from the results of their systematic literature review.

The inductive narrative synthesis [ 40 ] of the definitions revealed seven content categories: (1) components, namely skills, abilities, competences, etc., (2) actions or agency, (3) subjects, (4) sources of information, (5) purpose, (6) conditions, (7) time perspective (see Table 3 ).

Although diversely defined, health literacy was commonly portrayed as an individual-based construct, with a multidimensional nature [ 20 ]. As such, it exceeds basic reading, writing or numerical abilities [ 1 ]. In addition, health literacy entails a combination of different health-related skills, competences, and knowledge, as well as a motivational component that an individual possesses [ 10 ].

All definitions share a dominant demand or action-related focus mostly directed towards the access, process and application of health information [ 10 ]. These actions entail immediate cognitive or behavioural tasks that health literate persons should be able to perform when encountering situations that demand health-related decision-making in daily life or within the health care context. As such, children and young people are viewed as actors that actively and deliberately participate in seeking, processing, and evaluating health information (as well as health services, knowledge, attitudes and practices). The acquired information can be adequately used in health-informed decision-making, which form a direct output dimension for observing or measuring children’s or young people’s health literacy [ 8 ]. Fok and Wong [ 17 ] focus not only on health information-related tasks but on actions related to physical and psycho-social activities children engage in. They point out that children are health literate once they understand how to achieve health and well-being by obtaining certain attributes as personal hygiene, emotional stability, enjoyment in school life, and the ability to cope with various circumstances [ 17 ].

All definitions state an outcome dimension of health literacy - an intermediate or distant goal or purpose of health literacy. Outcomes of health literacy include rather specific tasks linked to health-related decision-making, e.g. to manage one’s health environment [ 33 ] or to make informed or appropriate health choices [ 18 ]. The intermediate or long term outcomes of health literacy refer, rather generally, to the promotion of personal health [ 35 ] and health outcomes, e.g. the reduction of health risks and the improvement of ones quality of life [ 20 ] or living conditions [ 18 ]. Borzekowski [ 1 ] perceives children and young people as vulnerable and “marginalized” groups that can be empowered to be more engaged, more productive, and healthier. Paakkari and Paakkari [ 8 ] emphasise the societal dimension of health literacy, indicating that health literacy enables students “to work on and change the factors that constitute their own and others’ health chances”. Gordon et al. [ 19 ] take an even more general view, stating that health literacy is building individual and community capacity to understand the components of health. The categories “requirement” and “time perspective” are the ones that specifically relate to the target group of children and young people: The first includes preconditions for being (able to be) health literate, namely, a reasonable degree of autonomy [ 17 ] or supporting external conditions, as the ways health-related materials are presented in an age appropriate manner, are culturally relevant and socially supported [ 1 ]. Lastly, health literacy is viewed as being an evolving construct or ongoing process [ 19 ], which needs to be acquired and developed during the life course [ 10 , 20 , 34 ].

Models of health literacy in children and young people

A total of 21 articles included models of health literacy (Table 4 ). These 16 articles conceptualized health literacy at a theoretical/abstract level. The other five operationalized health literacy dimensions for the development of measurement tools [ 18 , 32 ] or as an effect or evaluation model for an intervention programme [ 22 , 25 , 26 , 41 ]. Three models represented a clinical-medical perspective [ 21 , 23 , 33 ], but the majority of them ( n  = 18) took on a public health perspective. These studies developed health literacy from a multi-system perspective (i.e. the health system, education system, community system), covering several health-related domains, as health care, disease prevention and health promotion. Nine models were developed from a school health education perspective [ 8 , 18 , 22 , 25 – 27 , 29 , 30 , 32 ]. Three articles [ 25 , 26 , 32 ] included children younger than 12 years, while nine addressed young people or secondary school children aged 12 years or older. One article, Sanders et al. [ 5 ] covered four distinctive developmental phases. Eight studies did not exclusively focus on children and young people but considered health literacy over the life course.

How are target group specificities considered?

Twelve of the identified articles elaborated on children and young people’s distinctiveness towards adults and how these specificities are relevant for understanding health literacy in these age groups. However, most of these considerations remained on a very broad level, strongly incorporating an “external”, adult view on the target group’s situation and the relevance of health literacy for them. In summary, children and young people:

are expected to understand increasingly complex health information [ 5 ] and large amount of educational materials distributed to them by health providers, schools and intervention programmes [ 21 ];

become increasingly responsible for their own health and for dealing with different kinds of health-related issues [ 22 ];

are increasingly engaged in their health, their health service utilization [ 23 ] and usage of insurance benefits [ 33 ];

develop skills today that influence their health (outcomes) and well-being over their life course [ 24 ] and reduce health expenditures [ 33 ];

are citizens in their own right, within their current surroundings [ 8 ];

are able to construct their own views on health matters [ 8 , 35 ];

are at a crucial stage of development characterized by many physical, emotional and cognitive changes [ 21 ].

Most prominently, articles considered children and young people’s situations and needs by exploring their social embeddedness, namely the interrelated pathways between the individual and their close and distal social contexts. Wharf Higgins et al. [ 27 ] stated that in order to be effective approaches to teaching health literacy “also need to reflect a thorough understanding of the structure of adolescents’ social worlds, and their developmental appropriateness”. While, Wharf Higgins et al. [ 27 ] reflected on health literacy from a socio-ecological understanding, Paek et al. [ 28 ] complemented the social ecological approach with health socialization perspectives, adopted from political and consumer socialization. As pathways of contextual influences are considered to be strong influencing factors of health literacy in the literature, an extensive description of the inductive content analysis is provided in the “antecedents and consequences” section. Moreover, the importance of an age- and development-specific understanding of health literacy for children and young people was especially pointed out in models that were developed within the context of school health education [ 18 , 22 , 25 – 29 , 32 ]. Paakkari and Paakkari [ 8 ] stated that while health literacy learning conditions in school may include aspects of each of their five core health literacy components, students’ age-specific needs and characteristics need to be taken into account. The identified health education models conceptualized health literacy for a small and distinctive age group or specific school grade(s). Commonly, the complexity and comprehensiveness of their health literacy components increased by school grades. From a health promotion perspective, Sanders et al. [ 5 , 31 ], similar to Borzekowsik [ 1 ], explored the development of health literacy competencies from a cognitive development perspective for different age groups. They distinguish between four successive developmental stages, providing examples of health literacy skills in four categories (prose/document and oral literacy, numeracy and system-navigation skills) that were adopted from the US National Health Education Standards (NHES) [ 37 ].

Dimensions of health literacy for children and young people in the 21 models

Health literacy in children and young people is described in the literature as comprising variable sets of key dimensions – clusters of related abilities, skills, commitments, and knowledge that enable a person to approach health information competently and effectively and to derive at health-promoting decisions and actions. This section provides an overview of the inductive content analysis which reveals the important aspects of health literacy in children and young people (Table 5 ). It also offers a meta-perspective of health literacy in children and young people that enables comparison between different aspects. As the retrieved dimensions are diverse and overlapping, classification was challenging. Due to the strong focus on individual attributes, the dimensions were selected to be clustered according to three core categories: (1) cognitive, (2) behavioural or operational and (3) affective and conative.

Cognitive attributes

The mental abilities and actions that enable a person to think, learn and process information are attributed to this category.

Knowledge is regarded as an essential component of health literacy in children and young people. Mancuso [ 34 ] states that a certain level of knowledge is required for comprehending content as well as for managing and analysing information and becoming empowered regarding one’s health and the related decisions. It is either described as (a) a separate core dimension [ 8 , 30 ], as (b) an element of several dimensions [ 4 ], or (c) a foundational or cross-sectional component [ 10 , 26 , 27 , 33 ]. Lenartz et al. [ 38 ] and Soellner et al. [ 36 ] describe health-related basic knowledge as the comprehension of basic terms describing the body or basic health-related coherences and functions. Others distinguish between (a) theoretical or conceptual knowledge (i.e. facts, terms, principles in health-related matters), (b) situation-specific knowledge (i.e. knowledge of specific health situations in health-related domains), and (c) practical or operational knowledge (e.g. the knowledge of what actions are adequate in a given situation) [ 8 , 30 ]. Paakkari and Paakkari [ 8 ] describe conceptual knowledge as procedural knowledge or the skills needed “to behave in a health-promoting way” which is often experimental, situation-specific, and linked to daily practices. Massey [ 33 ] recognises that individuals must be knowledgeable and confident health care consumers. This includes the knowledge of one’s rights regarding sensitive topics, or knowledge of one’s responsibilities related to health care, e.g. health insurance benefits, how and where to find information.

Basic or functional health-related skills

Most articles recognise that health literacy requires being able to read, write, fill out a form or comprehend a text [ 4 , 21 , 38 ]. Nutbeam [ 35 ] labels these skills as functional literacy which is needed in order to understand health-related materials (e.g. medicine labels, prescriptions, or directions for home health care) and to function effectively in everyday situations. Some authors point out the relevance of numeracy skills (e.g. the ability to understand basic mathematical symbols and terms, basic probability and numerical concepts) and active listening skills (aural language) [ 5 , 24 ]. Wolf et al. [ 23 ] take on a cognitive development perspective, defining the mentioned health literacy skills as “higher order mental tasks”. The latter are determined by one’s (a) processing speed, (b) attention, (c) working memory, (d) long-term memory, and (e) reasoning (ibid. p.4). Consensus is lacking whether the described basic skills are considered as core dimensions of health literacy, or being integral in other dimensions, or rather preconditions for health literacy.

Comprehension and understanding

The ability to comprehend, to grasps a meaning of and to understand health information or concepts related to health care, promotion and disease prevention was considered to be a core dimension of health literacy [ 10 , 18 , 28 , 32 ]. Mancuso [ 34 ] refers to it as a complex process based on effective interaction of logic, language, and experience, allowing an individual to become a critical thinker and problem-solver who can identify and creatively address health issues. Subramaniam et al. [ 26 ] identified the following elements of comprehension: (a) an ability to read, comprehend and recall situated information; (b) an ability to perform basic mathematical functions (e.g. numeracy); (c) an ability to comprehend simple charts (e.g. visual literacy), and (d) an ability to filter information found and extract only relevant information.

Appraisal and evaluation

The ability to interpret, filter, judge, and evaluate health information was another core dimension of health literacy [ 8 , 10 , 18 , 21 , 26 , 29 , 30 , 32 , 34 , 35 ]. Moreover, appraising information refers to making sense of information gathered from diverse sources by identifying misconceptions, main and supporting ideas, conflicting information, point of view, and bias [ 26 ]. In the literature several relevant criteria but, as Wu et al. [ 18 ] stated, not necessarily mutually exclusive criteria for evaluating information, were identified: (a) accuracy, validity, and appropriateness (correct information or the message’s credibility); (b) impartiality (unbiased communication); (c) relevance (applicability to the problem); (d) comprehensiveness (broad coverage of the information); and (e) internal consistency (logical relationships exist between information and/or concepts). The credibility of the sources of a message or information, as well as the medium through which it is transported is also important [ 18 , 21 , 26 ]. Manganello [ 21 ] stresses that “media have been shown to influence physical and social development of youth, have been associated with health behaviour and are often cited as a source of health information for adolescents”. Zeyer and Odermatt [ 30 ] consider the evaluation of possible alternatives for action with regards to whether an action is health promoting and feasible in daily life. Hence health literacy entails evaluating the personal consequences of acting in a certain ways and the consideration concerning whether and how an intended action is feasible.

Critical thinking

Critical literacy skills or critical thinking are argued to be core dimension of health literacy [ 8 , 29 , 35 ]. They refer to the ability to think clearly and rationally and approach knowledge from various angles, formulate arguments, and make sound decisions [ 8 ]. As children and young people receive health messages from numerous sources, “they may gain a fragmented picture of health issues unless they are able to critically create links between diverse pieces of information” [ 8 ]. As a result, “critical thinking enables students to deal with large amounts of knowledge and to have power over that knowledge” [ 8 ].

Behavioural or operational attributes

All dimensions referring to actions that take place outside of the individual’s mind were assigned to be behavioural attributes.

Seeking and accessing information

Information seeking is described as another core dimension of health literacy. Subramaniam et al. [ 26 ] view it as a fluid and iterative process, including two main elements, namely information access and search. Accessing information is the ability to seek, find and obtain health information [ 10 ]. According to Subramaniam et al. [ 26 ] it includes being able to adapt to new technologies, being aware of primary health resources to begin search, having to access valid information, products, and services, being exposed to computers in everyday life and being aware of search engines and their capabilities. Massey [ 33 ] distinguishes between materials received from health providers (“passive information”) and information accessed over the Internet or by other means outside of the clinical setting (“active information”). Searching information entails developing appropriate search strategies, using relevant and correctly spelled search terms, applying an adequate search strategy drawing on reputed credibility and an understanding of how search engines work (e.g. hits, order of search results, snippets, inclusion/placement of ads, etc.). Moreover, Subramaniam et al. [ 26 ] included other elements such as being able to limit reliance on surface characteristics, among others the design of a website, the language used, etc. (e.g. surface credibility), to reduce search result selection based solely on word familiarity and to use translation features on the search engine or Web page if needed. As such critical media literacy and critical digital literacy have become important dimensions of health literacy in the information society. Moreover, Paek et al. [ 28 ] distinguish traditional media, such as TV, radio and newspapers, from digital media, e.g. the internet.

Communication and interaction

Communication, according to Mancuso [ 34 ], refers to how thoughts, messages or information are exchanged and includes speech, signals, writing or behaviour. It further involves input, decoding, encoding, output and feedback. Being able to effectively communicate about one’s own health or health information and, if necessary, to cooperate with other people, including friends and health care providers was considered an important aspect of health literacy [ 23 , 25 , 27 , 32 , 36 , 38 ]. According to Nutbeam [ 35 ], more advanced cognitive, literacy and social skills are needed in order to “communicate in ways that invite interaction, participation and critical analysis”, to extract information and derive meaning from different forms of communication, and to apply this to changing circumstances [ 35 ]. Basic communication about health (issues) in health care settings requires providing an overview of personal medical history or participating in informed consent discussions about medical treatment options [ 33 ]. Essential communication skills involve reading with understanding, conveying ideas in writing and speaking so others can understand, listening actively, and observing critically [ 34 ]. Moreover, young people and children need listening (aural language) and oral literacy or verbal/expressive skills in order to effectively communicate [ 5 , 26 ]. While Paakkari and Paakkari [ 8 ] recognise that health literacy involves being able to “clearly communicate one’s ideas and thoughts to others”, they regard general communication and social skills as foundational for health literacy and not as a distinctive dimension of health literacy.

Application of information

This core aspect of health literacy refers to the ability to communicate and use health information for health-related decision-making with the rational that one wants to maintain and improve one’s health and that of the people in one’s surrounding. The use of health information strongly depends upon the context and the goal of the health information seeking process [ 26 ]. It entails being able to synthesize information from multiple sources, draw conclusions, answer questions originally formulated to present information need, or even sharing, collaborating, communicating, creating information and adapting them as needed for intended audience (e.g. self, peers, family). On an outcome or impact level, applying health information refers to addressing or solving health problems, and make health-related decisions. This includes using health information for practicing health-enhancing behaviours or mitigating or avoiding health risks. Massey et al. [ 33 ] focus on young people’s health prevention behaviours, such as participating in annual check-ups or screening interventions as well as their attitudes and perceptions about visiting a doctor. On a population level, applying health information entails advocating for personal, family, and/or community health [ 8 , 26 ]. From a critical scientific perspective, it includes being able to interpret data of scientific articles to articulate potential limitations of published research findings and the cumulative impact of scientific knowledge (i.e. incremental process of discovery), as well as being able to recognise inaccurate information and to practice appropriate ethical standards for information (e.g. copyright, security, privacy) [ 22 , 26 ].

Other context-specific skills for the application of information and accessing services

The ability to navigate through the health care system was defined as a core dimension of health literacy [ 36 ]. It entails knowing how to access health services and being able to make an appointment or filling out a prescription [ 33 ]. Sanders et al. [ 5 ] provide age-adjusted examples for navigation skills which range from knowing proper usage of emergency numbers (e.g. 911) for school aged children to accessing confidential health and counselling services (young people) or completing enrolment processes for a health insurance and obtaining appropriate health services (young adults, 18-20 years).

Citizenship

Citizenship, the ability to act in an ethically-responsible way and take social responsibility, defines a core dimension of health literacy in the work of Paakkari and Paakkari [ 8 ]. It involves considering health matters beyond one’s own perspective, namely through the lens of others and of the collective, as well as moving from individual behaviour changes towards wider changes (i.e. organisational changes). Similarly, Zarcadoolas et al. [ 4 ] consider civic literacy a core dimension of health literacy. It describes the “knowledge about sources of information, and about agendas and how to interpret them, that enables citizens to engage in dialogue and decision-making”. Rask et al. [ 29 ] take on a societal perspective in their holistic health literacy dimension by identifying particular skills: People who possess holistic health literacy are (a) tolerant to various groups of people, (b) antiracist, (c) widely aware of the influence of cultural differences on health, (d) aware of the importance of art and civilization for health, (e) concerned about the environmental threat. Moreover, they (f) understand the significance of social capital for physical, mental, and social health, (g) appreciate and protect environment, (h) criticize the negative aspects of western life because they pose a threat to health, and (i) want to promote health globally.

Affective and conative attributes

This category includes dimensions of health literacy that evolve around the experience of feeling or emotions (affective attribute) or describe personality traits and mental stages that influence how individuals strive towards action and direct their efforts (conative attributes).

Self-awareness and self-reflection

Self-awareness involves the ability to reflect on oneself. It refers to being conscious about one’s thoughts, feelings, attitudes, values, motives and experiences as well as one’s health-related decisions [ 8 ]. “Self-awareness requires being able to link together and describe health topics from one’s own personal perspective, and to examine reasons for one’s ways of behaving and thinking in a particular way”. An adequate perception of one’s needs, wants and sensations is seen as key factor for regulating one’s own behaviour [ 36 , 38 ] and for breaking through daily-routines and considering and analysing a strategy for action [ 30 ]. Paakkari and Paakkari [ 8 ] also stress the ability to reflect oneself as a learner, namely the ability to evaluate their learning strategies, define learning goals, and monitor their progress.

Self-control and self-regulation

According to Lenartz et al. [ 38 ], self-regulation enables individuals to formulate health-related goals in line with as many personal needs, feelings, values, and interests as possible. Self-control refers to an inner focus to reach a certain goal, while possibly struggling with competing personal needs, feelings, wishes and interests. A certain level of self-control and self-regulation is therefore needed to resist the internal and external (social) pressure (e.g. to continue or start smoking again) and to deal with e.g. unpleasant feelings and emerging doubts [ 36 , 38 ].

Self-efficacy

Self-efficacy – a person’s own belief in their own ability to complete certain health-related tasks and reach defined goals was considered a foundational dimensions of health literacy in children and young people [ 23 , 25 , 26 , 35 ].

Interest and motivation

Young people’s interest in health topics and their motivation to act upon what they have learned in staying healthy were described by Paek et al. [ 28 ] as core dimensions of health literacy. Similarly, Sørensen et al. [ 10 ] regard motivation as an essential cross-sectional component, and Soellner et al. [ 36 ] emphasize the willingness to take responsibility for one’s own health.

Antecedents and consequences of health literacy in children and young people

Table 6 displays the factors that the literature review identified as influencing children’s or young people’s health literacy (antecedents) or as being influenced by health literacy (consequences).

Antecedents

Twelve of the identified models included antecedents and distinguished between individual characteristics, demographic, situational or contextual factors as well as broader system or social factors.

Internal characteristics refer to an individual’s beliefs, values, experiences, cognitive and physical abilities, general literacy skills or other abilities, e.g. technological abilities. Paakkari and Paakkari [ 8 ] argue, in line with Manganello [ 21 ], that general skills such as social or communication skills, as well as self-efficacy are antecedents for health literacy and not per se separate core dimension of health literacy. Rather, they are important for different core dimensions and are not attributable to one. However, other authors [ 35 ] regard these as being core dimension of health literacy (see Table 5 ).

Models that focus specifically on children and young people emphasize the family’s demographic factors and parental influences. The younger the child is the more likely he/she is to rely on their parents for economic and social support and, therefore, their own socioeconomic status (SES) or occupation are not applicable to variables [ 24 , 31 ]. Family demographic factors include parental health literacy levels, socio-economic status, as well as their own health status and health behaviour. Martin and Chen [ 24 ] argue that these family factors strongly influence children’s health literacy, health status, and other educational variables such as school readiness and a child’s academic outcomes.

Furthermore, families, peers, and schools are all regarded as major socialization agents in children’s and young people’s lives that influence the opportunities they have for being or becoming health literate. Family and peers can encourage or discourage health literacy actions as well as health promoting lifestyles through their norms, actions, and social support [ 27 ]. Parents can be role models of how to access and interpret health information and teach children to critically evaluate the credibility and validity of information sources and media channels. In this context, the quality and the type of the relationship play a major role, as children or young people are likely to consult peers and adults they trust, which is crucial as trust also plays a role in accessing media and online health resources.

The social and system levels refer to education, health, and community systems as well as political and cultural forces. These include the general learning conditions and environment, e.g. students’ safety on school grounds, teachers that are equipped with the appropriate skills and teaching practices that could promote critical thinking and reflexion through negotiation and discussion [ 8 , 27 ]. Next, the community where a child or young person lives may have an impact on his/her health literacy: Martin and Chen [ 24 ] and Wharf Higgins et al. [ 27 ] draw attention to the influence of the community- socioeconomic level on the health literacy in that community. Political and cultural factors refer to differences in cultural practices, political decision-making, e.g. governmental policies that decide whether to include health literacy in the school health curriculum. Synthesizing it, health literacy is argued to be promoted through health promotion actions in the general population which include an education for health, efforts to mobilize people’s collective energy, resources, skills, towards the improvement of health and advocacy for health, e.g. in form of lobbying activities and political activism [ 35 ].

Consequences

Fifteen articles mention that health literacy in children and young people leads to benefits on the individual, community or societal-level (applied from Nutbeam [ 35 ]). On individual level, health literacy enables young people to be skilled health care consumers and to overcome environmental and interpersonal barriers when interacting with the health care system [ 21 , 33 , 35 ]. Moreover, it is argued that health literacy can empower young people to understand themselves, others and the world, to make sound health decisions, and to discuss health-related social issues [ 8 , 29 ]. Health literate young people are also believed to possess an enhanced ability to establish and maintain their self-defined health-related goals such as to engage in physical activities or not to drive after drinking [ 27 ]. In addition, the benefits of health literacy are argued to extend to the full range of life’s activities – at home, at work, in society and culture and at wider health economic levels [ 4 , 10 ]. Martin and Chen [ 24 ] and Sanders et al. [ 31 ] take on a life course perspective, viewing health literacy as set of competencies that are passed from a parent to the child and do not only affect the child’s health behaviour and outcomes but also the ones of the family.

In terms of societal and communicational benefits, health literacy is argued to increase the participation in population health programmes, to improve community empowerment and the general capacity to influence one’s own health and the health of others, as well as broader social norms [ 8 , 35 ].

The objectives of this study was (a) to scope current understandings of health literacy in childhood and youth and (b) to understand to what extent available models capture the unique needs and characteristics of children and young people. The 12 definitions and 21 models identified enabled a sound depiction of health literacy for children and young people. As a strong commonality of the complex and heterogeneous definitions and models, health literacy is depicted as a multidimensional, complex construct. Moreover, by describing the construct along multiple integrated categories, a synthesis of the health literacy dimensions retrieved from the literature was possible. However, it may be the case that these categories overlap as the same phenomena can be described in various ways and many models regarded health literacy through different lenses, resulting in differential focuses. These observations are in line with Paakkari and Paakkari [ 8 ] who pointed out that “there are differences regarding what is regarded as a component of health literacy and what may follow on from or be associated with health literacy”.

Regarding the first part of the research question, the focus of health literacy exceeds the health care setting in most definitions and models. It was recognised that health literacy in children and young people is relevant in many occasions and contexts of daily life that have a potential impact on the well-being and the promotion of one’s health. Similar to health literacy in adults [ 10 ], health literacy involves actions or agency which vary according to the health literacy perspective that is applied – e.g. from a clinical or health care setting paradigm, to a more comprehensive health system or public health or health promotion paradigm [ 42 , 43 ]. While the first perspective aims to impact on the health outcomes of the individual through healthier decision-making, the latter includes actions for advocating for one’s own health and that of society through citizenship [ 8 ] and addressing broader social determinants of health [ 29 ]. These definitions and models are referred by De Leeuw [ 42 ] as “third generation” health literacy research which recognise that health literacy enables personal empowerment and is interrelated with broader determinants of health. As a result, health literacy is context and content-specific and as such varies according to the complexity of the task at hand and the contextual factors present [ 35 , 43 ]. Hence, an individual is always interwoven with and subjected to the social and cultural context it is embedded. While these “two sides of a coin” – the individual’s attributes and the many contextual factors – were considered in most definitions and models identified, the review revealed a strong emphasis on the individual attributes which were elaborated in detail. The contextual factors were acknowledged but often remained underscored in the literature. In the following paragraphs, we offer our reflection and perspective on the observed discrepancy.

The individual attributes include the knowledge and skills that a person should have in order to meet certain situation-demands, e.g. in the health (care) system, or general health-related demands that society poses upon the individual. These demands mostly are diverse and overlapping within the definitions and models. Mostly, they refer to performing actions related to the gathering, understanding, appraisal and use of health information or services, or as Fok and Wong [ 17 ] point out, general physical and psycho-social activities. However, this individual-based, action-focused perspective “appears to limit the problem of health literacy to the capacity and competence of the individual” [ 44 ]. Moreover, the behavioural components of health literacy (e.g. to apply health information) are often not distinguishable from the outcome categories of health literacy, namely the health choices and behaviours that are health literacy is expected to influence (listed in Table 6 ). Given the strong individual and skill-based focus of health literacy definitions and models that require individuals to take charge of and become actively involved in seeking, understanding, accessing information and make health-related decisions, really reflects children’s and young people’s everyday realities. In other words, do they overestimate the opportunities (Möglichkeitsraum) and scope for action (Handlungsspielraum) of children and young people within health literacy and decision-making processes? According to Schulz and Nakamoto [ 45 ], health literacy and personal empowerment do not automatically derive from one another, as one can have the capacities and skills necessary to promote one’s health but may lack the empowerment to do so. Moreover, the preferred “societal” outcome of most models is “healthier behaviour” – namely such behaviour that is considered “healthy” by health professionals, experts or society. Especially models targeting the health care system still appear to strongly favour an adherence perspective, viewing individuals primarily as receiving health information and complying with the professional (health or care) instructions provided. Such strongly “subject-focused” health literacy perspectives entail – as known from health promotion discussions – the risk of primarily holding the individual responsible and accountable for their own health. This reflects a culture of individualisation in late modernity and “the risk society” [ 46 , 47 ]. This victim blaming approach [ 48 ] ignores the universal recognition that social determinants of health – the economic and social conditions that affect individuals and communities –strongly influence a person’s individual ability to be health literate [ 11 ]. By ignoring the multifaceted and complex nature of human decision-making and behavioural change [ 49 , 50 ] and by clashing with health promotion goals and practice, individual-level health literacy perspectives “may do little to achieve the ultimate goal of promoting equitable health status” [ 51 ]. As a result, exercising health literacy is only possible if opportunities for engaging in health literacy actions as well as for participating in everyday decision-making are present. Hence, the extent to which families, communities and societies allow children and young people to take an active role and participate in health literacy practices remains a question for future research. A possibility for exploring this could be by drawing upon a resource-focused health perspective, for instance the salutogenic paradigm by Antonovsky [ 52 ]. Saboga-Nunes [ 53 ] stressed the connectedness between health literacy and salutogenesis by arguing that childhood and youth could be considered most permeable life stages where salutogenic resources are built up by transforming health information into action and the other way around. In line with Antonovsky [ 52 ], health information could be understood as stimuli from one’s internal and external environment that are met with a dynamic feeling of confidence. This feeling would be retrieved from the ability to comprehend such stimuli, to consider them to be relevant for one’s health, and to access the resources needed for successfully addressing the stimuli and the demands posed by it.

In terms of the interrelatedness of social, cultural, and environmental contextual factors, especially the role of the intermediate environment of children and young people is emphasized: The target group is especially dependent upon their parents or caregivers for the access to material, financial, and social resources (e.g. health care). However, this dependence decreases as they develop and become more mature. While most articles also identify a strong impact of adults’ health literacy on their children, little is known about the nature of this influence and the impact of social agents in the target group’s environment. Sanders et al. [ 31 ] refer to it as “collective health literacy”, which can be regarded as a form of social and cultural capital according to Bourdieu [ 54 ]. Moreover, several articles highlight the role of available and accessible social support structures and peer assistance for the health literacy of children and young people: they benefit from the health literacy related knowledge and skills which they can access through their social informal or formal support structures. This kind of assistance can help children to accomplish health-literate-related tasks or actions that they otherwise would not be able to succeed in on their own [ 1 , 55 ]. Vygotsky [ 56 ] termed this external assistance “scaffolding”. Overall, these social-cultural and economic contextual factors are primarily argued to act as antecedents or mediators for health literacy and tend to be neglected at the core of health literacy itself. We argue that the strong emphasis on health literacy as a set of skills tends to neglect and disregard the situation in which health literacy takes place, as well as the social practices relating to health literacy. In conclusion, there is a gap between the recognition of the role of contextual and cultural factors for health literacy and their implementation within strongly individualistic, skill-based conceptualisations, as well as operationalisations that focus on few distinctive health literacy dimensions [ 25 ]. Therefore, further research is needed that shifts from a functional, skill-based health literacy perspective to alternative approaches of understanding health literacy, e.g. by observing health literacy within the context that it takes place in and through the social practices in which it is performed. Such a comprehensive health literacy construct will be challenging to implement and operationalize. One option for addressing this challenge could be a modular design, which is then adjusted as necessary to specific target groups, contents and contexts.

The second part of the research question was to clarify to what extent available models capture the unique needs and characteristics of children and young people. Here, special attention was contributed to the target groups' recognition and characteristics in the analysis, which revealed the following discussion points:

While many definitions and models were identified for young people, including secondary school students, similar findings are lacking for children under the age of ten or within a primary school context. In addition, the same is true for transitional stages, e.g. from primary to secondary school level or from youth to adulthood. These findings are in line with conclusions drawn by Hagell, Rigby and Perrow [ 57 ]. Especially with regards to young children, the focus is strongly on maternal or caregivers’ health literacy competencies, enabling them to secure the child’s care needs. Children, including primary school level or younger have not yet been at the focus of health literacy conceptual and intervention research efforts. Given that research has linked health literacy to health outcomes, and to health (care) costs for the adult population, research should follow up on past efforts [ 58 ] in order to explore the relevance for young people as well as children.

Life phase specificities are only considered in 12 models, which incorporate a strong focus on children’s age-specific cognitive development. These dominantly consider health literacy to take place in several consecutive age or developmental stages, as Piaget suggested in his theory of cognitive development [ 59 ]. Although life phase specificities are argued to manifest in the target group’s social embeddedness, the articles attribute little attention to sociological approaches to childhood [ 54 , 60 ] as well as to children and young people’s social role and position, as argued by the New Sociology of Childhood [ 61 ]. The latter perspective of childhood stresses that children should not be regarded as ‘becomings’ (incomplete) but as individual “beings” and members of their own social groups. This draws attention to the social role that is contributed to children and young people by their caregivers, communities and society. Generally, the younger children are the more dependent they are on their parents in respect to economic resources and social support as well as their parents’ health literacy. However, little is known about how parental and child health literacy are interwoven and interact in the child’s developmental processes. Brady, Lowe, and Lauritzen [ 62 ] for instance argue that even from a very young age onward, children are already active agents of their own social worlds that take on an active role in their health. Viewing children and young people as active social agents draws attention to considering children’s perspective of health and how they deal with it while being subjected to different social contexts and cultures. Children continuously develop and change through socialization processes and interaction with their environment, including their parents, other adults or their peers [ 61 ]. How we view children and young people, therefore, largely depends on our – adult – perception of childhood and youth and the social role we attribute to children and young people in everyday interactions, e.g. between teachers and students or between doctors and child patients.

The essential role of media and digital communication channels for the target group [ 63 ] was a theme that was found to remain underscored in available health literacy dimensions for children and young people, apart from few exceptions [ 21 , 27 , 28 ]. Media plays an increasing role in children’s personality, cognitive and emotional development. It transports moral and cultural values and facilitates their social and political socialization processes [ 64 ]. In an attempt to bridge the conceptual gap between approaches to health and media literacy, a media health literacy model for adolescents was developed and successfully tested for the target group by Levin-Zamir et al. [ 65 ]. Moreover, critical media health literacy for young people was defined by Wharf Higgins and Begoray [ 66 ] as consisting of a skill set of reflection, discrimination and interpretation abilities, as well as empowerment and engaged citizenship. Given the important role of media in the target group, we propose to recognise the interrelatedness of (critical) media, digital and health literacies more profoundly in future models, interventions, and educational curricula.

Most of the identified dimensions of health literacy in childhood and youth were fairly similar to the ones identified for adults (cf. the review results by Sørensen, et al. [ 10 ]). This poor incorporation of life phase specificities might result from the fact that their voices and perspectives largely remain unheard: Their active participation in the conceptual development process was only realized in three articles. Overlaps to adult health literacy dimensions were observed most strongly in models that focused on a life course perspective of health literacy (and hence implicitly target children and young people as well). Those six models were analysed to be adult-focused as they incorporate neither target group specifics nor age- or development-flexible components. Therefore, their applicability and validity for the target group was found to be questionable. This is especially problematic as they have served [ 67 , 68 ] or may in the future serve as conceptual foundations for health literacy programs or interventions for children and young people. Applying general health literacy models to the target group that were not especially developed to meet the needs and demands of children and young people may actually hinder effective health literacy promotion and development in that target group. Such practices have been observed in some summarizing articles on children’s and young people’s health literacy as well [ 39 , 57 ]. The described scarcity of health literacy understandings that incorporate specific target group characteristics and perspectives reveals a current research gap.

Therefore, it is argued in line with Rubene et al. [ 55 ] that children’s and young people’s health literacy, due to their distinctive needs and life situations, should be “conceptualized as an issue in its own right and not as a derivation of adult health literacy”. Hence, future conceptual and empirical research efforts need to recognise children’s and young people’s special character and encourage the target group to actively participate, providing them with the opportunity to contribute with their own understandings and perspectives of health literacy and to the promotion of healthy behaviour.

Limitations

For pragmatic reasons, this review focused on exploring definitions and models of general health literacy of young people, excluding domain- (e.g. media ), target-group or disease-specific health literacies (e.g. mental or diabetes health literacy). However, concentrating on generic health literacy enables a broader recognition of the overall field of health literacy, hopefully preventing us from ‘not seeing the wood for the trees’ due to specific interest areas [ 16 ]. Macket et al. [ 16 ] point out that a model valid for one context is less helpful for enabling knowledge construction and learning in other contexts through cross-contextual comparison and transfer. While this is an acknowledged problematic, we strongly stress the need to view health literacy as being socially constructed, varying according to the context one is in and the tasks at hand and hence recognising the unique characteristics of the target group.

Extending the review to articles that incorporate a life course perspective on health literacy may have let to bias the analysis towards non-target group-specific definitions and models. However, these were included based on the argumentation that if they claim to provide a life course perspectives on health literacy, they implicitly includes children and young people as well. Therefore, they are of relevance for the comprehensive scoping of current health literacy understandings for the target group. While the review was conducted using sound and systematic methods, following the PRISMA guidelines to the extent possible for qualitative reviews [ 14 ], in order to ensure its validity and accurateness, several limitations certainly are present and need to be considered. Efforts were made to enhance the sensitivity of the search strategy, using a comprehensive list of search terms and applying relevant operators. The databases that were used covered multiple disciplines indexing bibliographic records of a variety of journals and publication types. Nevertheless, we might have missed relevant literature, among others, due to limitations in availability and of individual databases’ search algorithms. Focussing only on English and German language articles led to distortion in favour of native English and German speaking research contexts. To ensure that the focus remains on the key research question, the assessment and evaluation of the selected articles was performed according to a systematic data extraction method, applying a coding protocol. While the core research team was independently involved in the selection and the assessment of the articles to minimize subjectivity and interpretation, the risk of selection, coding or opinion bias still remains. Due to the differing focus of analysed definitions and models, an explicit evaluation of the content was often difficult. Hence, the final assessment depended on the researchers’ interpretation of the written content. Furthermore, no assessment of the articles’ methodological quality took place, as many were theory-building or conceptual, explorative publications that often did not follow an outlined methodological approach. Therefore, not all quality standards as outlined in the PRISMA guidelines were applicable and viable for our research design.

Addressing health literacy in children and young people should be based upon an empirical sound and measurable definitions as well as on conceptual frameworks that are valid, hands-on, and meet the specificities of the target group. This systematic review of the literature identified a broad theoretical base for health literacy in children and young people, while also pointing to conceptual shortfalls, especially related to a coinciding set of knowledge and skills adopted for the target group and how these are developed during the life course. Moreover, further operationalisation and implementation of these dimensions are necessary to test whether the described commonalities of the definitions and models are sound and measurable to describe the construct of health literacy of children and young people. Furthermore, we believe that health literacy could empower children and young people – who are especially vulnerable and to some extent marginalized social groups – to become more engaged with their health and more informed and reflective upon their future health choices. For this, it is crucial to not focus on an individualistic perspective only. Rather, it is of importance to recognize the interrelatedness and contextualisation of health literacy where people are empowered to interact with health, social and educational systems to the benefit for themselves as well as for the society as a whole. In turn organisations and systems are providing health literacy friendly services that can facilitate health for all. In such a two-sided approach, we must pursue to (i) strengthen children’s and young people’s and their care takers’ personal knowledge, motivation and competences to take well-informed health decisions; and (ii) decrease the complexity of society as a whole, and of the health care system in particular to better guide, facilitate and empower citizens, including children and young people to sustainably manage their health. Future efforts must target the redesigning of systems to be inclusive and friendly towards children and young people, the adjustment of curricula and training of health professionals, teachers and other relevant stakeholders in order to better meet the challenge of the health literacy deficit, and the recognition of children and young people as active partners in their health decision-making.

Moreover, given the relevance of social structures and support on the way health literacy skills are acquired, applied and hence practiced in very varying life situations, children’s and young people’s distinctiveness from adults, however, should become a crucial consideration when understanding health literacy. Moreover, we stress that health literacy should not become a liability for children and young people with responsibilities exceeding their influence. Hence, several critical reflections and considerations that challenge current understandings of health literacy were pointed out that could be beneficial when taken into account in future research and interventions. Therefore, future efforts should encompass these gaps and challenges identified, addressing them from a multidisciplinary perspective, viewing the target group as active social agents, who are deeply embedded in their close and distant surrounding (e.g. family, friends, and social institutions). As such, the greatest challenges for conceptualizing health literacy might ensure its generalizability and validity across context, while recognising its context- and content-dependency.

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Acknowledgements

The authors thank all partners in the HLCA consortium for contributing to the discussion of the results and the content of this article, as well as Alexandra Fretian and Sandra Kirchhoff for language editing.

HLCA Consortium members:

• Bielefeld University: Ullrich Bauer, Paulo Pinheiro, Orkan Okan, Janine Bröder, Torsten Michael Bollweg, Dirk Bruland, Michael Rehder, Sandra Schlupp.

• Robert Koch Institute, Berlin: Susanne Jordan, Olga Domanska, Christiane Firnges.

• University Duisburg-Essen: Fabian Kessl, Jürgen Wasem, Maren Jochimsen, Frank Faulbaum, Katrhin Schulze, Janine Biermann, Maike Müller.

• University of Education, Freiburg i.Br.: Eva-Maria Bitzer, Uwe Bittlingmayer, Hanna Schwendemann, Zeynep Islertas, Inga Kloß, Elias Sahrai.

• Katholische Hochschule Nordrhein-Westfalen, Paderborn: Albert Lenz, Patricia Wahl.

• Criminological Research Insititue, Niedersachen e.V.: Paula Bleckmann, Thomas Mößle.

The HLCA consortium and related research are funded by the German Ministry for Education and Research from March 2015 - February 2018, funding number: 01EL1424A.

Availability of data and materials

Tables 2 , 4 and 5 list the studies included in this review. The citavi datafile that was used for the search process and a list of excluded studies/references is available upon request.

Authors’ contributions

JB, OO, UB, and PP conceived and designed the review, developed the search strategy, lead the data analysis as well as the discussion of the results and are major contributors in writing the manuscript. JB, OO, SS, and PP carried out the systematic search and lead the data collection. DB, TMB, LSN, EB, KS, EMB, SJ, OD, CF, GSC, UHB, DLZ, JP, DS, AL, PW, MT, and FK contributed substantially to (a) the concept, the analysis and interpretation of data during the research process on a regular basis and during three intensive consultations rounds at the HLCA consortium’s meetings and (b) the manuscript drafting process by providing critically revisions for important intellectual content, ensuring that the manuscript includes the crucial result and discussion points that arose during the research process. All authors read and approved the final manuscript.

Competing interests

The authors are members and scientific advisors of the German Health Literacy in Childhood and Adolescence (HLCA) consortium and claim to have no competing interests.

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National School of Public Health, Universidade NOVA de Lisboa, Lisbon, Portugal

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Bröder, J., Okan, O., Bauer, U. et al. Health literacy in childhood and youth: a systematic review of definitions and models. BMC Public Health 17 , 361 (2017). https://doi.org/10.1186/s12889-017-4267-y

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Mini review article, the impact of health literacy on uterine fibroid awareness, diagnosis, and treatment in the united states: a mini literature review.

• Department of Health Management, Howard University, Washington, DC, United States

Limited health literacy is a social health determinant leading to poor health outcomes. General and health literacy correlate and can impact diagnosis and treatment understanding. Limited literacy can lead to women receiving more significant rates of invasive surgical treatment, including hysterectomies. This review explores the impact of health literacy levels on uterine fibroid awareness, diagnosis, and treatment. PubMed, CINAHL, and Academic Search Premier searched articles published between January 1, 2012, and December 31, 2022. The keywords uterine fibroids, fibroids, myomas, leiomyomas, and health literacy were used. A total of four articles were returned. Increased rates of hysterectomies were found among participants with low income and education, as well as those with limited health literacy. Hysterectomies are the removal of the uterus and thus removes a woman's right to have children. While increased efforts are needed to understand the impact of health literacy levels on disparities and inequities in uterine fibroid diagnosis and treatment, there is still a need for targeted patient education and community-based education that ensures patient understanding of the diagnosis and treatment options for uterine fibroids.

1 Introduction

Women's understanding of treatment options, including surgery, is critical to making an informed decision. Health literacy is defined as the possession of the knowledge and literacy skills needed to make an informed health-related decision. Health literacy is linked with reading levels and literacy levels. While there is a correlation, they are all fundamentally different. There are many definitions, but at the core of health literacy are the common elements regarding the ability to obtain, understand, and use health information to make informed decisions regarding health and treatment that will significantly impact health outcomes ( 1 ). Studies have demonstrated that people with limited health literacy struggle with medication adherence, communicating effectively with health providers, understanding diagnosis and treatment, increased emergency room visits, and an increase in mortality rates ( 2 ).

The American Psychological Association reports that numerous examinations of socioeconomic status reveal inequities concerning access to resources and care. Socioeconomic status (SES), including education and income, influences access to health care, with some treatments directly affected by insurance coverage and the cost of the procedure. While health literacy is not explicitly linked to socioeconomic status, some studies report the association between education status and health literacy levels. SES and race are known to impact access to adequate and quality health care, and access to some forms of uterine fibroid treatments is affected by insurance type and insurance status. The inequity of treatment offering and range is a concern, and more studies are needed on diagnosis and treatment access for women with low and limited health literacy levels. Determining patients' health literacy level can illuminate their understanding of their health conditions and lead to more appropriate health decisions and outcomes.

This review explicitly highlights uterine fibroid diagnosis and treatment decisions. Uterine fibroids are non-cancerous (benign) tumors of the uterus. They are also referred to as leiomyomas and myomas, and symptoms include heavy menses, pain, reproductive issues, anemia, and frequent urination ( 3 ). There are many treatment options for uterine fibroids, ranging from a “wait and see” approach to surgical treatments. Myomectomies (removal of fibroids) and hysterectomies (removal of the uterus) are more prevalent in African-American women due to more severe symptoms. African American women are two to three times more likely to undergo a hysterectomy than white women and 6.8 times as likely to receive a myomectomy ( 4 ). The rates of hysterectomies increase among women of lower socioeconomic status. Findings reveal that women in the United States with lower socioeconomic status tend not to seek care until the later stages of uterine fibroid diagnosis, sometimes resulting in larger tumors and, thus, an increased rate of hysterectomies. When income and education levels were increased, women were more likely to select less invasive treatment options such as myomectomy, uterine artery embolization, or endometrial ablation ( 3 ).

Belilovets ( 5 ) reported that over 20 million women had undergone a hysterectomy. Hysterectomy is the most performed gynecological surgery. There are alternatives to hysterectomies, such as medication, uterine artery embolization, ablation, and myomectomies. Due to the additional options, women must understand their diagnosis, the indications for treatment, treatment options, and post-surgery care.

This review article investigated the available data regarding the association between health literacy and uterine fibroids. PubMed, CINAHL, Academic Search Premier, and Cochrane Databases were used to search the literature for articles published between January 1, 2012, and December 31, 2022. The search used the following keywords: uterine fibroids, fibroids, uterine leiomyomas, myomas, and health literacy. Articles were excluded if they were conducted outside the United States and if uterine fibroids and health literacy were not the primary focus. Additionally, duplicate articles or similar articles by the same authors were excluded. Four articles were reviewed for this narrative assessment, indicating that this review may be early in a research cycle focusing explicitly on the link between health literacy and uterine fibroid awareness and treatment.

According to the results of a study conducted by Ekpo et al. ( 6 ), over 46% of the participants had incorrect knowledge of uterine fibroids and believed that a blood test could diagnose uterine fibroids. This study aimed to assess awareness and knowledge of uterine fibroid symptoms. There was a 14.1% prevalence of inadequate health literacy levels. All participants were African-American women, and approximately 34% had some form of a college education. Most women had common knowledge that uterine fibroids lead to heavy menstrual cycles and can increase the chance of a miscarriage. While this information was determined through the survey of 199 women, there was no significance between health literacy levels and overall fibroid knowledge. The study found that participants who used the internet and those with higher education were more aware of uterine fibroids.

Ghant et al. ( 7 ) conducted a research project where women with uterine fibroids were interviewed. The mean age of participants was 43 ± 6.8. Sixty women were included in the project, with approximately 62% of the participants identifying as African American and 25% as Caucasian. The researchers revealed that some women had limited knowledge of uterine fibroids and normal menstruation, which led to treatment delays and a delay in the ability to take action regarding their diagnosis. Many participants reported awareness of the issue but desired to avoid the diagnosis and symptoms.

An anonymous population-based survey was distributed to women in a study designed to assess understanding of hysterectomies and uterine fibroids and included 28 knowledge questions and ten demographic questions. The knowledge questions focused on hysterectomy indications, hysterectomy types, procedures, post-hysterectomy care, and complications ( 5 ). A total of 200 surveys were collected. Over 43% of the participants identified as Caucasian, 31% as Hispanic, 11% as Asian, and 10% as African American. Approximately 28.5% of the participants reported less than high school and high school education. The results of the study demonstrated a poor understanding of the hysterectomy procedure. Many participants did not understand uterine fibroids and did not understand different hysterectomy approaches. Eight percent of women answered the question regarding the type of hysterectomy that leads to a greater risk of bladder compromise incorrectly. It is important to note that this question was written at a lower than an eighth-grade level. In contrast, the participants demonstrated the most knowledge of the risk of hysterectomies.

Marsh et al. ( 8 ) conducted a population-based survey to determine patient awareness and treatment decisions for patients diagnosed with uterine fibroids. Women were grouped into at-risk ( n  = 300), diagnosed ( n  = 871), and uterine fibroid-related hysterectomy ( n  = 272) categories. Approximately half of the participants in the at-risk group were aware of uterine fibroids. Women with an income over $60,000 had heard of fibroids. Over 60% of women in the at-risk group tried to manage symptoms from uterine fibroids and hoped they would go away. African-American women in the at-risk group were less likely to make an appointment with a provider than White women. In the diagnosed group, 71% received some form of pharmacologic therapy. They were followed by 30% who underwent some form of a procedure. The average age of participants who underwent a hysterectomy was 41, with 11% undergoing a hysterectomy before they turned 35. Of the women who had a hysterectomy, the top reason was a recommendation from a provider (58%), followed by 55% due to pain. One-third of participants with a hysterectomy indicated an interest in a uterus-sparing option.

4 Discussion

This review demonstrates the impact of health literacy and knowledge on awareness of uterine fibroids and treatment understanding and selection. Improved health literacy can increase patient and community trust, decrease health disparities, and improve health outcomes. There are studies on health literacy and women's health; however, limited information focuses on health literacy, uterine fibroids, and treatment for uterine fibroids. Limited health literacy levels and lower education were linked to increased hysterectomy rates and lower awareness and understanding rates. While the review presents needed information on health literacy rates on uterine fibroid treatment options, it does have limitations. The main limitation is not conducting a quality assessment of the articles selected for the review. Only articles published in peer-reviewed journals were included. Only studies published in English and the United States were included.

There are many uterine fibroid articles and many articles that focus on health literacy and other health outcomes; however, articles that specifically deal with health literacy “and” uterine fibroids are limited, highlighting the need for more research. The knowledge and understanding deficiencies are tied to health literacy and other factors or determinants of health. Ensuring that providers provide all of the required information and details in an easy-to-understand manner is essential. Health literacy levels cannot be assumed and are not something that a chart review or conversation with the patient can determine. At the same time, there are limited articles that specifically discuss uterine fibroids or hysterectomies; the studies that specifically focus on health outcomes are associated with decreased use of preventive services and higher mortality rates, mainly among the elderly ( 9 ). It is essential to determine if the number of women who undergo hysterectomies is aware of all of the treatment options or if they opt for a hysterectomy due to limited knowledge.

It is important to note that mobile health, telehealth, and the increase in digital health technologies may present additional challenges to people with limited literacy. Providers can only assume that some patients have smartphones, computers, or internet capabilities. Beyond this, providers cannot assume that patients know how to work the devices or maneuver through the website or online platform. Smith and Magnani ( 10 ) studied the intersection of electronic health and digital health literacy. The study highlights that populations with a high risk of limited health literacy are likely also to have challenges with digital health literacy. For instance, people with poor digital or eHealth literacy suffer from more chronic health conditions.

The review highlights the need for additional patient education. There is a need for patient-centered education as well as community-based education. Targeted education that is culturally appropriate and at needed health literacy levels may increase the likelihood of informed decision-making. Increasing the knowledge and understanding of women diagnosed with uterine fibroids ensures that they feel empowered regarding their decisions and have limited regrets. Studies have shown that using multimedia tools and other patient education improves knowledge of uterine fibroids and anxiety levels ( 11 ). Therefore, providers should seek to use additional tools to reach patients, especially those with limited or low health literacy.

5 Conclusion

Women with limited health literacy levels and lower education have increased rates of invasive surgical procedures, such as hysterectomy, to treat uterine fibroids. This review highlighted that women in lower socioeconomic brackets tend to have poorer health outcomes and tend to not seek immediate care for uterine fibroids. Health literacy is linked to social determinants of health such as education and income. Incorporating interventions that focus on health literacy and education could drastically improve uterine fibroid treatment decisions. Community education regarding preventative care including regular pelvic exams may help ensure that all women, regardless of socioeconomic status, have early detection of uterine fibroids, thus potentially preventing the need for future hysterectomies. Providers should begin providing information on signs, symptoms, and risk factors for uterine fibroids so that women are aware of early signs. The information and education must be at an appropriate literacy level to ensure that patients understand signs and risks.

Additional research on provider-patient communication about uterine fibroid diagnosis and treatment is needed. Ensuring providers fully outline uterine fibroid diagnosis, as well as the risks and benefits of each treatment option is key to patient understanding. Providers must ensure that patients understand that treatment options vary based on each patient. These treatment options depend on a myriad of factors, including, but not limited to, severity of symptoms, number and location of fibroids, age and desire to have children. Ensuring that patients have an opportunity to ask questions and fully understand their uterine fibroid diagnosis and treatment options is vital to informed decision-making and an overall better quality of life.

While this review demonstrated that limited health literacy led to poor understanding of diagnosis and treatment, there is still a need for more research on the role of health literacy on uterine fibroid awareness and treatment options. Future research should correlate patients' health literacy levels through validated tools such as the Rapid Estimate of Adult Literacy in Medicine (REALM) or the Brief Health Literacy Screen (BHLS) and their understanding and treatment decisions.

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Keywords: health literacy, literacy, uterine fibroids, fibroids, leiomyomas

Citation: Evans J (2024) The impact of health literacy on uterine fibroid awareness, diagnosis, and treatment in the United States: a mini literature review. Front. Reprod. Health 6:1335412. doi: 10.3389/frph.2024.1335412

Received: 8 November 2023; Accepted: 27 February 2024; Published: 11 March 2024.

Reviewed by:

© 2024 Evans. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY) . The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

*Correspondence: Joyvina Evans [email protected]

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• Published: 20 March 2024

Evaluation and associated factors of public health emergency management among medical college students in a city in Southwest China: a cross-sectional study

• Xinrui Chen 1 ,
• Meng Zhang 1 ,
• Qingqing Bu 1 ,
• Bo Tan 1 &
• Dan Deng 1  

BMC Medical Education volume  24 , Article number:  314 ( 2024 ) Cite this article

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Colleges and universities face an increased risk of public health emergencies. Among them, medical colleges and universities deserve more attention as they serve as the play a fundamental role in providing public health emergency services and in cultivating medical professionals. Effectively managing infectious disease prevention and control, as well as responding to public health emergencies in medical colleges and universities, is of great importance for enhancing the capacity of social emergency governance and improving the completeness of the public health system. This study aims to understand the management of public health emergencies in medical colleges in a city in southwest China, explore the factors associated with medical college students ’ evaluations, and provide recommendations for emergency management mechanisms in colleges and universities.

In total, 781 medical college students were selected through stratified random sampling and surveyed using a questionnaire. The main factors affecting students ’ evaluation of emergency management were analyzed using multiple linear regression and structural equation modeling.

The overall emergency management situation in medical colleges was relatively complete, with satisfactory results. Medical college students ’ satisfaction with the timeliness of prevention measures was the highest, while the publicity and education were the lowest. Multiple linear regression analysis showed that grades, emergency education, -simulation training, -information reporting, and dynamic adjustment measures were associated with the evaluation of emergency management by medical students.

Conclusions

Although the evaluation of emergency management in medical colleges was generally positive, certain limitations still existed. To improve the development of the public health system, colleges and universities should constantly reform and innovate emergency management mechanisms according to the important links in the prevention and control processes.

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The construction of healthy China requires prioritizing people’s health, and effectively doing a good job in the prevention and control of infectious diseases and the response to public health emergencies [ 1 ]. A public health emergency refers to the sudden occurrence of severe infectious diseases, rapidly spreading diseases with unknown causes, widespread food and occupational poisoning, and other events or natural disasters threatening public health [ 2 , 3 ]. Public health emergencies, especially outbreaks of infectious diseases, have become increasingly frequent. Recent public health emergencies have included severe acute respiratory syndrome (SARS) in 2003, influenza A (H1N1) in 2010, avian influenza A(H7N9) in 2013, and Corona Virus Disease 2019 (COVID-19); [ 4 , 5 ] all posed a serious threat to global human health, economic development, and social stability [ 6 , 7 ]. Southwest China has a large population, abundant biodiversity, a hot and humid climate, and a complex terrain These characteristics create favorable conditions for the emergence and spread of epidemiological threats to public health. Thus, it is imperative that this region of China strengthens its prevention and control measures for managing public health emergencies [ 8 ].

Colleges and universities are characterized by a large population density, frequent personnel turnover, the presence of shared public spaces, and high social attention, thereby placing them at an increased risk for public health emergencies [ 9 ]. Previous research has found that more than 70% of public health emergencies in China have occurred in schools; more than 80% were infectious disease epidemics or food poisoning incidents [ 10 ]. These emergencies considerably disrupted the schools’ operations and adversely affected the mental health of teachers, students, and other personnel, and also posed challenges with respect to the improvement of emergency plans and management mechanisms for responding to public health emergencies [ 11 ]. Other studies show that emergency prevention and control challenges remain for some colleges and universities, such as administrators’ insufficient attention, students’ inadequate understanding, poor medical facilities, professionals’ lack of coping skills, and imperfect information reporting systems [ 12 , 13 , 14 ], which render the emergency management of public health emergencies in colleges and universities difficult. Therefore, it is particularly important to strengthen emergency service guarantees for students, standardize internal emergency prevention and control management on campuses, and develop more effective strategies for dealing with public health emergencies.

At present, research on managing public emergencies in universities in other countries is gradually developing in the direction of systematization, specialization, and qualitative analysis [ 15 ]. However, the theoretical research on emergency management in China’s colleges and universities started late; most existing research focuses on descriptive research and case studies, and they have revealed the lack of comprehensive and evidenced-based management systems. Thus, their discussions of prevention and control management show a certain one-sidedness and sundry limitations [ 16 ]. In addition, although international research on the topic is relatively mature, the different national conditions of each country mean that their findings, while insightful, are not fully generalizable to China’s colleges and universities. Therefore, it is imperative to explore management strategies applicable to China when responding to public health emergencies.

Medical colleges and universities play a fundamental role in providing public health emergency services and in cultivating medical professionals [ 17 ]. The administrators of medical colleges and universities must ensure the safety and stability of students’ education by normalizing, standardizing, and specializing the schools’ emergency management. This requires timely identification of weak links in their emergency-response implementation and recommending improvements [ 18 ]. However, few studies have offered specific suggestions for public health emergency management in medical colleges and universities in China [ 19 ]. Students are the direct beneficiaries of public health emergency management systems in colleges and universities, and medical students have relevant professional theoretical knowledge and practical skills; therefore, they have professional advantages in dealing with public health emergencies [ 20 ]. Assessing the degree of satisfaction among medical students regarding emergency management in colleges and universities can facilitate the exploration of strategies to optimize public health emergency management in educational institutes. Therefore, this study aimed to investigate medical colleges’ management of public health emergencies in a city in Southwest China, systematically summarizing their emergency prevention and control implementation and their prevention and control achievements.

The study had several goals. First, it surveyed medical students’ satisfaction levels regarding schools’ emergency management and control measures. Second, it explored factors associated with their evaluations of the schools’ early prevention management, mid-crisis interventions, and late-stage security management. Finally, it re-examined some previously identified shortcomings in medical college and university emergency prevention and control for public health emergencies. The findings of this study may help Southwest China’s medical colleges and universities develop comprehensive, effective emergency management systems.

Study design and participants

The researchers used stratified random sampling to recruit students from several medical colleges and universities in one city in Southwest China. Each school was stratified by grade, and students with different majors were randomly selected from each grade. The study commenced only after the researchers communicated and coordinated with the schools’ administrators and obtained written informed consent from the participating students. The students completed a electronic questionnaire developed in line with the study’s objectives and issued through the schools’ student affairs offices, the survey period is March to April 2022. Of the 803 questionnaires collected, 781 were deemed valid, yielding an response rate of 97.26%. This study, which involved human subjects, was reviewed and approved by the Ethics Committee of Chongqing Medical University. And all methods were performed in accordance with the relevant guidelines and regulations.

Quality control

To ensure the authenticity of the questionnaire, quality control measures were implemented. (1) Through preliminary literature research and expert consultation, based on the current situation of emergency management in colleges and universities and the policy direction of the National Health and Health Commission, the questionnaire preparation was completed and pre-investigation was conducted. Prior to the investigation, project investigators were trained. (2) The training for investigators emphasized the importance of introducing the purpose and significance of the study to participants before conducting the survey. Additionally, the training highlighted the need to clarify the requirements for filling out the questionnaire and any precautions that should be taken. And the survey should be completed anonymously to ensure the confidentiality of the participants’ responses. (3) Questionnaires requiring the same IP address could only be answered once. (4) After the questionnaire was submitted, questionnaires with any missing items and missing or unqualified basic information were deemed invalid.

Questionnaire

The questionnaire contents were designed to satisfy the principles of relevance, universality, applicability and non-inductivity [ 21 ]. The survey included basic demographic information, the current situation as implemented, and medical students’ opinions on the schools’ prevention and control measures for public health emergencies. Seven items were used to evaluate the student’s views. The items covered publicity and education; emergency measures; daily monitoring; aftercare work; timeliness of announcements; timeliness of prevention and control measures; timeliness of administrators’ responses to public opinions The participants ranked each item using a five-point Likert scale from “1 = very dissatisfied” to “5 = very satisfied” for a total score of 35. The higher the score, the more satisfied the students. When the reliability and validity of the scale were assessed, Cronbach’s α coefficient was 0.930, the KMO validity coefficient was 0.920, and Bartlett’s test of sphericity p was < 0.001. Thus, the scale was considered to have good reliability and validity.

Statistical analysis

Data were analyzed using IBM SPSS Statistics for Windows, Version 25.0, and Amos Version 24.0. The count data were described using percentages, and the satisfaction score were presented as (‾ x ± s ). Mann-Whitney U test and Kruskal-Wallis H test were used to measure differences in quantitative data with non-normal distribution. Multiple linear regression and structural equation modeling were used to analyze the factors associated with medical students’ evaluations of public health emergency management (α = 0.05).

Descriptive statistics

Among the 781 medical students, 227 (29.07%) were male, and 554 (70.93%) were female; 327 were freshmen (41.87%), 245 sophomores (31.37%), 174 juniors (22.28%), and 35 seniors or above (4.48%); 739 were undergraduate students (94.62%), and 42 were junior college students (5.38%).

Medical colleges’ emergency responses to public health emergencies

When asked about publicity and education, 60.2% of the students said their school conducted emergency-related publicity and education once every six months. On emergency drills, 46.6% said their schools conducted emergency drills for public health incidents once a year. On emergency facilities, more than half of the students stated their school had public health facilities and conspicuously posted health safety signs. On preventive measures, more than 90% of the students reported their school had taken emergency preventive measures such as screening personnel for infections; controlling personnel activities; providing epidemic prevention materials; monitoring and reporting daily health conditions; and disinfecting key areas. On the administrators’ response to public opinions, 92.7% said their school issues timely responses and reports and informed the campus about the preventive measures, and 87.8% reported their schools regularly corrected disinformation and clarified unconfirmed statements. On emergency supplies, 97.8% of students stated their school distributed masks, disinfectants, thermometers, and other supplies. On aftercare counseling, 91.2% of the students stated their school provided mental health counseling and coping strategies.

Medical colleges’ public health emergency prevention and control

The results showed that because of their school’s emergency management, the medical students reported their awareness of public health emergency prevention had improved greatly (60.1%), moderately (34.2%), or slightly (5.0%); only 0.8% thought it had not improved. Further, 58.6% thought that their school’s emergency prevention and control management ability had improved greatly compared to before the COVID-19 pandemic, 33.2% thought it had moderately improved, and 7.6% thought it had improved slightly; only 0.7% thought it had not improved.

Medical students’ satisfaction with their schools’ management of public health emergencies

The students rated their satisfaction with their schools’ publicity and education, emergency measures, daily monitoring and management, aftercare work, timeliness of announcements, prevention and control measures, and the administrators’ responses to public opinions. The mean total score of their satisfaction ± standard deviation ( SD ) was 31.38 ± 4.06. The mean satisfaction score for the timeliness of the schools’ prevention and control measures was the highest (4.60 ± 0.60); the mean satisfaction score for publicity and education on food safety, laboratory safety, or epidemic prevention and control in schools was the lowest (4.31 ± 0.76). According to the single factor difference analyses (the Mann-Whitney U test and the Kruskal-Wallis H test), there were intergroup differences in the satisfaction scores of different grades and schools regarding the need for the following: emergency education, emergency drills, information notification, dynamically adjusted prevention and control measures, public opinion responses, and psychological counseling, which were all statistically significant ( p  < 0.05). Table  1 presents these results.

Analysis of the factors influencing the medical students’ evaluations

Multiple linear regression.

The independent variables in the regression were factors with statistical significance in the univariate analysis; the dependent variable was the satisfaction score for emergency management in medical colleges. The results showed that the main influencing factors were grade; whether the school carried out emergency education, emergency drills, and information notification; and whether the school dynamically adjusted prevention and control measures ( p  < 0.05). Compared to the students in the lower grades, the students in the higher grades were less satisfied with the schools’ overall emergency management; and the higher the emergency management evaluation of the university carrying out emergency education, emergency drills, information notification, and dynamically adjusting the prevention and control measures. Furthermore, according to the standardized regression coefficient, whether the school carried out information notification had the greatest impact on the evaluations, followed by whether the school carried out emergency drills. Table  2 presents these results.

Structural equation model

The researchers used structural equation modeling (SEM) to explore the determinants of the medical students’ evaluations of their schools’ emergency management and the relationship between these factors. The SEM model included these variables: grade; whether the school carried out emergency education, emergency drills, or information notification; whether the school dynamically adjusted its prevention and control measures; whether the schools rapidly responded to public opinions; whether the school provided psychological counseling; and the students’ satisfaction scores. The SEM model used these factors to explore the influences on the students’ evaluations of the public health emergency management of their colleges and universities and the correlation among the associated factors. Figure  1 shows an SEM path analysis diagram.

Structural equation model analysis of emergency management evaluation in medical colleges

The model showed that grades and the schools’ emergency management measures directly impacted the students’ evaluations ( p  < 0.001). The standardized path coefficients were − 0.12 and 0.33, respectively. When the other variables were constant, the grades negatively influenced the evaluations, and the schools’ emergency management measures positively influenced the evaluations. These results aligned with the results of the multiple linear regression. In addition, the fitness indices met the requirements of the test statistics. Table  3 summarizes the results.

Understanding what influences medical students’ evaluations of their schools’ public health emergency management and responses could help colleges and universities in China improve their emergency management strategies [ 22 ] This study found that the satisfaction score of the timeliness of prevention and control measures taken by schools was the highest, indicating that the city’s medical colleges quickly implemented appropriate epidemic prevention policies and instituted timely and effective prevention and control measures to avoid the spread of COVID-19; thus, they would respond equally well with other epidemics and public health emergencies. Xu and Chen [ 23 ] also found that the timeliness of schools’ emergency measures effectively improved college students’ sense of security. Although more than half of the students said that their school carried out emergency education on food safety, laboratory safety, or epidemic prevention and control once every six months, the lowest satisfaction scores were for the schools’ emergency education, indicating that the medical colleges and universities lacked targeted, systematic, and universal education systems while ensuring the quantity of education, resulting in poor quality and insufficient epidemiological information. These findings align with Liu [ 24 ].

The students’ grades and the schools’ implementation of emergency management measures were the main factors associated with students’ evaluations. The students in the higher grades were less satisfied with the schools’ emergency management, and the difference was statistically significant. Zhu and Zhang [ 25 ] also confirmed this conclusion. They believe that the proportion of senior students who were confident of coping with disasters is not very high, and the proportion who believe that disaster education is beneficial to coping with disasters is also not very high. The reason might be that emergency-related education is mainly handled during freshmen enrollment, and with the deepening of professional understanding, the demand and expectation of senior students to take emergency management measures is increasing gradually. The schools had higher evaluation scores for emergency drills, epidemic prevention information, and the dynamic adjustment of prevention and control measures, consistent with Wang [ 26 ]. As emergency education can increase students’ emergency knowledge reserve, emergency drills can boost their emergency prevention and rapid response skills. Timely, comprehensive, and dynamically adjusted prevention and control measures and information can mitigate emergencies’ inconveniences and adverse effects, increasing students’ trust in the schools’ emergency management competence.

The study’s results showed that emergency prevention and intervention measures are critical in managing public health emergencies in colleges and universities, as reported by Li [ 27 ]. The administrations of medical and other colleges and universities should actively implement and improve campus emergency response systems. These systems should consider the factors influencing students’ evaluations, to ensure the continuous improvement of the schools’ prevention and control management strategies of public health emergencies, as follows.

1) Provide comprehensive education on preventing and handling public health emergencies [ 28 ]. Medical school administrations must establish a reasonable emergency education system; regularly provide high-quality, understandable, science-based information and training on epidemic prevention and control to the medical students at every level of study, especially the seniors; and ensure campus-wide compliance with posted guidelines on public health safety regulations.

2) Have professionals conduct regular, standardized public health emergency drills [ 29 ]. Colleges and universities should have professionals on-site trained in managing public health emergencies, Regularly carrying out emergency drills under the guidance of the local party committee and the government, and instructing students, teachers, and staff about emergency-response topics such as remote classes; campus closures or restrictions; health-related isolation and treatment; health data collection, sorting, and analysis; epidemic investigation and tracing; and regional detection and quarantines to expedite emergency response.

3) Dynamically respond to the needs of students, teachers, and the staff during a public health crisis. Public health emergency underscored the need for rapid, flexible, accurate communication and control strategies. Universities and colleges should provide crisis-related information; prevention, transmission, and treatment guidance; and up-to-date news and official school announcements. It is vital to keep everyone informed about everything from the nature of the emergency to teaching adjustments, such as temporarily transitioning to remote learning [ 30 ].

4) Ensure the students’ physical and mental well-being. Colleges and universities should anticipate how public health emergencies can adversely affect students’ physical and mental health [ 31 ]. They should discuss this in medical students’ classes—before, during, and after a health crisis—and provide mental health education and psychological counseling.

5) Respond honestly and swiftly to questions and concerns. Misinformation and the lack of information can exacerbate public health emergencies [ 32 ]. Medical school administrators should establish mechanisms for handling the public’s questions and concerns by building effective communication channels between colleges and students.

Limitations

The index system used in this study should be improved further, more research indicators can be included according to the specific conditions of different university types. And this study was a cross sectional design, it was aimed to explore the association between certain variables and the outcomes of interest, rather than to establish a causal relationship. In addition, the use of self-reported data may introduce some limitations to the study, as students may have answered the questions as they felt required by the university or government, rather than reflecting their true perceptions. To mitigate potential response bias and ensure validity and reliability, we conducted repetitive questionnaire designs and pilot experiments.

This study evaluated the factors influencing medical students’ satisfaction with their schools’ emergency management systems and responses in a city in Southwest China and examined the existing problems in emergency prevention and control of public health emergencies in colleges and universities. Students’ grades and the implementation of emergency management measures in schools were important factors affecting the evaluation of emergency management of public health emergencies in colleges and universities. Since today’s medical students will be tomorrow’s professionals entrusted with responding to public health emergencies, improving the medical schools’ management strategies for public health emergencies is vital.

Data availability

The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

Abbreviations

Corona Virus Disease 2019

Internet protocol address

Severe acute respiratory syndrome

Structural equation modeling

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Acknowledgements

The authors would like to thank all the participating organizations and participants.

This study was supported by the Key Project on Epidemics and Education in the 2020 “13th Five-Year Plan” of Chongqing Education Science (2020-YQ-04).And it was also supported by the Program for Youth Innovation in Future Medicine, Chongqing Medical University (W0063).

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XC collected and analyzed the data and wrote the manuscript; MZ, QB, and BT designed the study and collected data; DD designed the study and revised the manuscript. All authors have reviewed and approved the final manuscript.

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Chen, X., Zhang, M., Bu, Q. et al. Evaluation and associated factors of public health emergency management among medical college students in a city in Southwest China: a cross-sectional study. BMC Med Educ 24 , 314 (2024). https://doi.org/10.1186/s12909-024-05317-1

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Published on 25.3.2024 in Vol 26 (2024)

Mitigating Health-Related Uncertainties During Pregnancy: The Role of Smart Health Monitoring Technologies

Authors of this article:

• Max Tretter, Mag Theol  

Chair of Systematic Theology (Ethics), Seminar for Systematic Theology, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany

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Pregnancy is a time filled with uncertainties, which can be challenging and lead to fear or anxiety for expectant parents. Health monitoring technologies that allow monitoring of the vital signs of both the mother and fetus offer a way to address health-related uncertainties. But are smart health monitoring technologies (SHMTs) actually an effective means to reduce uncertainties during pregnancy, or do they have the opposite effect? Using conceptual reasoning and phenomenological approaches grounded in existing literature, this Viewpoint explores the effects of SHMTs on health-related uncertainties during pregnancy. The argument posits that while SHMTs can alleviate some health-related uncertainties, they may also create new ones. This is particularly the case when the abundance of vital data overwhelms pregnant persons, leads to false-positive diagnoses, or raises concerns about the accuracy and analysis of data. Consequently, it is concluded that the use of SHMTs is not a cure-all for overcoming health-related uncertainties during pregnancy. Since the use of such monitoring technologies can introduce new uncertainties, it is important to carefully consider where and for what purpose they are used, use them sparingly, and promote a pragmatic approach to uncertainties.Using conceptual reasoning and phenomenological approaches grounded in existing literature, the effects of SHMTs on health-related uncertainties during pregnancy are explored. The argument posits that while SHMTs can alleviate some health-related uncertainties, they may also create new ones. This is particularly the case when the abundance of vital data overwhelms pregnant persons, leads to false-positive diagnoses, or raises concerns about the accuracy and analysis of data. Consequently, it is concluded that the use of SHMTs is not a cure-all for overcoming health-related uncertainties during pregnancy. Since the use of such monitoring technologies can introduce new uncertainties, it is important to carefully consider where and for what purpose they are used, use them sparingly, and promote a pragmatic approach to uncertainties.

Introduction

Pregnancy is a time full of uncertainties [ 1 ], starting from uncertainties concerning the health of the fetus and pregnant person, to parental uncertainties about how life will change during pregnancy and after birth, to socioeconomic uncertainties [ 2 , 3 ]. These uncertainties can be very challenging and can cause fear and anxiety among those affected [ 4 ]. Smart health monitoring technologies (SHMTs) offer the possibility to continuously monitor the health of both the child and the mother, allowing parents to at least mitigate some health-related uncertainties, thereby alleviating associated stress and anxiety.

But are SHMTs actually an effective means to reduce uncertainties during pregnancy, or do they have the opposite effect? In this Viewpoint, I will explore this question at a conceptual level and argue that while SHMTs can indeed reduce some health uncertainties, their use may also introduce new ones.

The argument is developed as follows: First, I define the concept of uncertainty, drawing on relevant theories of uncertainty. Then, using conceptual reasoning supported by existing research, I theorize how pregnancy screenings can address certain uncertainties and how SHMTs can alleviate the remaining ones. Following this, I adopt a phenomenological approach to examine how the introduction of these technologies could create new uncertainties. This analysis is underpinned by key studies identified from database searches on PubMed, Embase, Web of Science, and Google Scholar using the keywords “pregnancy” and “uncertainty.” Finally, I reflect on the implications and limitations of these insights and provide practical recommendations based on pragmatic considerations.

Uncertainties in the Context of Pregnancy

Both in common sense and in the scientific discussion of this concept, uncertainty is largely understood as an epistemic state [ 5 , 6 ] in which individuals lack knowledge because they either lack information or the available information is inaccurate or incorrect [ 7 ]. Many people experience uncertainty as a challenge, which can lead to stress, anxiety, and fear [ 8 ]. A well-established method to navigate these uncertainties and alleviate the ensuing negative emotions involves bridging these knowledge gaps [ 9 ].

In the realm of health, uncertainty is nearly ubiquitous [ 10 - 12 ]. Even among those with a solid grasp of their bodily functions and biological processes, there remain gaps in knowledge and looming questions: What will my health look like tomorrow, next week, or a year from now [ 13 ]? What steps can I take to prolong my well-being? The same can be said for pregnancy [ 14 ], as pregnant women undergo significant physical and psychological changes and are constantly confronted with uncertainty [ 15 ] regarding whether the fetus is developing healthily, whether there are signs of potential health issues, whether they are behaving correctly, or whether they need to make changes to promote the healthy development of the fetus [ 3 ]. Pregnancy, an inherently stressful period, can be further complicated by these uncertainties, potentially escalating stress and anxiety levels in expectant mothers [ 15 ], which may adversely affect both the parent and child [ 16 , 17 ]. Therefore, it is crucial to mitigate these uncertainties where feasible, to minimize unnecessary stressors.

Pregnancy Screenings to Address Health-Related Uncertainties

Thankfully, expectant parents are not helpless in the face of these health-related uncertainties. Various prenatal tests and screenings routinely conducted throughout pregnancy can provide insight into the health of both the pregnant individual and the fetus, thereby helping to alleviate existing uncertainties.

Pregnancy screenings typically involve monitoring the vital signs of the pregnant person, including blood pressure, heart rate, and weight [ 18 ]. By tracking weight gain, health care providers can assess the health of both the pregnant person and fetus, as inadequate weight gain may be harmful to the fetus, while rapid or excessive weight gain may be a sign of health concerns [ 19 , 20 ], such as gestational diabetes [ 21 , 22 ] or pre-eclampsia [ 23 ]. A pregnant person’s heart rate and blood pressure can also provide valuable information, with a low maternal heart rate potentially negatively affecting fetal growth and birth weight of the fetus [ 24 , 25 ], while high blood pressure or an abnormal heart rate is associated with increased risks of gestational diabetes [ 26 ] and maybe a sign of future cardiovascular disease [ 27 , 28 ]. Monitoring these vital signs is crucial for safeguarding the health of both the pregnant person and fetus, enabling timely interventions if necessary, and ultimately reducing health-related uncertainties during pregnancy.

Smart Health Monitoring Technologies to Address These Uncertainties

Although pregnancy screenings are vital for ensuring the health of both the pregnant person and the fetus, weeks can pass between appointments. During this time, pregnant individuals may find themselves grappling with everyday uncertainties, such as the effects of dietary changes or physical activities on the fetus, and seeking reassurance about both their own well-being and that of their unborn child.

SHMTs such as smartwatches, smart rings, and fitness trackers, especially when integrated within an Internet of Things ecosystem [ 29 , 30 ], can offer a practical solution [ 31 - 33 ]. These devices enable parents to independently measure the vital signs of the pregnant person and, in some cases, the fetus at home. This data can be analyzed to provide parents with an assessment of their fetus’s health condition without needing to visit a doctor. The capability to ascertain the health status of their fetus from the comfort of home, or to receive timely alerts if the data points to potential health issues, could provide much-needed reassurance in between medical screenings and counter emerging uncertainties.

New Uncertainties Produced by the Use of Smart Health Monitoring Technologies

The widespread acceptance of SHMTs among expectant parents [ 34 ], coupled with the fact that their use is considered extremely feasible by them [ 35 ], as well as the empirical evidence suggesting that their use can have a positive impact on the health of pregnant persons [ 36 ] and can reduce their stress levels [ 37 ], should not obscure the fact that their use also brings some disadvantages. In addition to privacy and data protection issues [ 38 , 39 ], the use of SHMTs can also produce new health-related uncertainties.

First, new information can in itself produce new uncertainties [ 40 ], particularly when there are no medical personnel available to help interpret the additional data. In the absence of such guidance, every recorded irregularity, whether it be an irregular heartbeat, temporary high blood pressure, or a decrease in blood oxygen saturation, can cause pregnant persons to question their own health and that of their child. In extreme cases, these uncertainties can lead to unnecessary anxiety and stress symptoms [ 41 , 42 ], which can be detrimental to their mental and emotional well-being.

However, even in professional contexts, more data might produce new uncertainties. This happens, for example, when continuous health monitoring triggers false alarms [ 43 ], as, for instance, particular vital sign patterns are erroneously interpreted as symptoms of a specific disease or indicators of an emergency, despite being totally harmless. As Welch et al explain in their publication Overdiagnosed [ 44 ], the likelihood of such false-positive diagnoses inevitably increases with additional data collection, which can lead to unnecessary or even incorrect diagnoses and create additional health uncertainties.

Last, there is the uncertainty of whether health data are being collected accurately and analyzed correctly. Users of SHMTs must ask themselves if the sensors are properly attached, if smart devices are being used correctly, and if the data are being transmitted and analyzed correctly by the app’s algorithms [ 45 ]. Particularly for medical and technical “laypeople,” there is no way to verify this, and they must live with the uncertainty about the reliability of the data.

Ambivalent Effects of Pregnancy Monitoring Technologies

I have shown how SHMTs can mitigate the daily health uncertainties encountered during pregnancy. However, it is important to note that the use of SHMTs during pregnancy can also create new uncertainties as they make even the slightest abnormalities visible, increase the likelihood of false-positive results, and raise constant questions about the reliability of the data.

In summary, the use of SHMTs should be viewed as a double-edged sword. While they can help alleviate health uncertainties and reassure and relax pregnant persons, they also carry the risk of introducing new uncertainties, potentially exacerbating stress, anxiety, and fear.

Limitations and Opportunities for Further Research

The discussion regarding the correlation between SHMTs and uncertainties during pregnancy highlights 2 significant limitations. While these limitations require careful consideration, they do not invalidate the fundamental insights. Rather, they should be interpreted as avenues for further investigation.

First, I did not present original data to substantiate my arguments. Although I have incorporated recent literature to substantiate key assumptions, and empirical research on uncertainty in pregnancy [ 46 ] and on the impact of (health) technologies on uncertainty [ 47 ] support my findings, my contribution was strictly conceptual.

Second, the results do not explore the balance between the emergence of new uncertainties and the resolution of preexisting ones. Does the use of SHMTs produce more health uncertainties than it reduces, or vice versa? This question cannot be answered definitively, as shifts in uncertainty resulting from the use of such technologies need to be assessed on a case-by-case basis.

Practical Recommendations

In conclusion, the question arises of what practical recommendations can be derived from the insights gained regarding the use of SHMTs during pregnancy. Considering the preceding discussions, I recommend not to use SHMTs in terms of “the more the better,” as their increased use might also produce more uncertainties. Instead, it seems advisable to use them sparingly and only where constant monitoring is actually necessary [ 10 ], such as when abnormalities have been identified during pregnancy screening or when there are hereditary medical conditions. In cases where constant monitoring is not necessary, these technologies should only be used upon explicit request from parents and with appropriate training on their use and data interpretation.

Moreover, even if it may sound cynical at first, a pragmatic approach toward uncertainties in health care (not just during pregnancy) can be helpful and should be encouraged [ 11 , 48 - 51 ]. This involves acknowledging that not everything can be controlled and that sometimes it can be beneficial to simply let things “take their course” [ 52 , 53 ].

Acknowledgments

This work has been funded by Bundesministerium für Bildung und Forschung (grant 01GP2202B) and by the Deutsche Forschungsgemeinschaft (DFG, German Research Foundation)-SFB 1483, under project ID 442419336, EmpkinS. The author conveys his thanks to Hannah Bleher for her input and discussions, as well as to Isabella Auer, Fiona Bendig, and Tabea Ott. ChatGPT was used as a tool for idea generation in the early stages of this paper and for linguistically refining the final document. The content suggestions provided by ChatGPT were verified for accuracy and relevance by the author and were developed into a coherent manuscript by the author without the help of ChatGPT.

Conflicts of Interest

None declared.

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Abbreviations

Edited by A Mavragani; submitted 25.04.23; peer-reviewed by MDG Pimentel, E Baker; comments to author 11.01.24; revised version received 26.01.24; accepted 23.02.24; published 25.03.24.

©Max Tretter. Originally published in the Journal of Medical Internet Research (https://www.jmir.org), 25.03.2024.

This is an open-access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in the Journal of Medical Internet Research, is properly cited. The complete bibliographic information, a link to the original publication on https://www.jmir.org/, as well as this copyright and license information must be included.

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AI’s future in medicine the focus of Stanford Med LIVE event

Leaders of Stanford Medicine discuss artificial intelligence in health and medicine; its usefulness in research, education and patient care; and how to responsibly integrate the technology.

March 20, 2024 - By Hanae Armitage

Nigam Shah, Natalie Pageler, David Magnus and Sylvia Plevritis , with panel moderator Michael Pfeffer, discussed ways that artificial intelligence can improve patient care and lighten providers' workload. Dorin Greenwood

Artificial intelligence-powered health care, generative models in medical research and the ethics of broad AI integration were key topics at the March 18 Stanford Med LIVE event featuring experts from across Stanford Medicine.

Panelists at the event explored what AI is; why it’s poised to change the future; and how it can support practices in research, education and patient care. It was a precursor to the first RAISE Health Symposium coming in May and sets the table for further exploration of how this current wave of excitement, fueled by advancements in generative AI technology and access to massive amounts of data, can be applied to health care and medicine.

“Now, with an explosion in new AI capabilities, we are beginning to see the full promise of this technology — as a tool with the potential to transform patient outcomes, advance biomedical education and accelerate research,” said Lloyd Minor , MD, dean of the Stanford School of Medicine and vice president of medical affairs at Stanford University.

Minor also addressed the obligation institutions like Stanford Medicine face to deploy AI tools responsibly. In partnership with the Stanford Institute for Human-Centered Artificial Intelligence, Stanford Medicine launched the Responsible AI for Safe and Equitable Health Initiative — RAISE Health — in June 2023 to ensure AI is developed, used and evaluated in medicine following best practices and the highest ethical standards.

In recent years, Stanford Medicine has begun tapping into AI’s potential applications. “At Stanford Health Care, we already have more than 30 different technology applications that leverage AI, and we will see many more of these tools coming online in the not-too-distant future,” said David Entwistle , president and CEO at Stanford Health Care. “We’re entering an exciting era of AI innovation in health and medicine, and Stanford Medicine is uniquely poised to lead.”

But, as Stanford Medicine’s other key leader pointed out, it will be critical that AI models represent all populations fairly, equitably and without bias. “To date, AI systems in medicine have been primarily trained on data from adults, as there are special privacy considerations for the use and availability of pediatric patient data,” said Paul King , president and CEO of Stanford Medicine Children’s Health. “We are actively solving this challenge at Stanford Medicine so that even our youngest patients can benefit from the same technology advances, while maintaining the necessary robust protections.”

The panel discussion, moderated by Michael Pfeffer , MD, chief information officer for Stanford Health Care and the School of Medicine, featured four speakers from Stanford Medicine:

• David Magnus , PhD, professor of medicine, biomedical ethics and pediatrics and the Thomas A. Raffin Professor in Medicine and Biomedical Ethics
• Natalie Pageler , MD, chief medical information officer at Stanford Medicine Children’s Health and clinical professor of pediatrics and medicine
• Sylvia Plevritis , PhD, chair of biomedical data science and professor of radiology
• Nigam Shah , PhD, chief data scientist at Stanford Health Care, professor of medicine and associate dean for research

AI is having a moment

Simply put, Shah told the audience, AI is the application of data by an algorithm that performs a task on behalf of, or in assistance to, a human being. The use of AI has exploded as generative AI models, such as ChatGPT — which can assimilate existing data and information and apply it in a human-like fashion — have grabbed the world’s attention.

The panelists discussed how to harness that promise, honing the broader hullabaloo into something mission-driven, impact-focused and ethical. At Stanford Medicine, that implementation is surfacing in a variety of ways, from helping kids manage Type 1 diabetes, to solving challenges in data scarcity, to creating new drugs and therapeutics with higher efficiency and lower toxicity. Outside of research, Pfeffer also pointed to two uses that are poised to enhance clerical practices for clinicians: ambient listening tools that generate clinical notes for doctors and large language models that draft responses to patient messages.

As panelists shared sentiments of anticipation and excitement, all emphasized human-centric, responsible integration of AI. “There’s so much more to providing care than just what AI can provide,” Pageler said. “It’s important that we all learn to use it, but not to be worried about being replaced.”

Deploying AI in health care

The panelists acknowledged that AI’s success in health and medicine will largely depend on the thoughtfulness and fairness with which algorithms are folded into practice.

Algorithms are not inherently neutral, Magnus said. If the data is biased, the algorithm will be too. “AI is often just a mirror. Data reflects social determinants of health; it can reflect biases in physician behavior,” he said. “That can be a problem because the models that learn from that data can either reify those biases, or we can turn them around to combat the problems that already exist.”

The AI experts say it’s crucial to look at the downstream effects of adopting AI into something as complex as a health care system. That means seeking guidance from like-minded entities such as the Coalition for Health AI and tools such as the FURM (fair, useful, reliable model) assessment, a system spearheaded by Shah and others who seek to determine whether AI tools provide fair, useful and reliable model guided care. “The point is to look at the ripple effects of using a model,” Shah said, “to think beyond the model and look at the workflow impact on real people, like workforce, patients, IT staff or nursing staff.”

These are big challenges for those aiming to get AI right. Nonetheless, the Stanford Medicine panelists shared an optimism for the future they are helping craft — largely because of where they get to do it. “Not only do we have a fantastic medical center, but we have an entire university that’s within walking distance, and we connect every day with our colleagues from medicine, engineering, humanities and other specialties,” Plevritis said. “I feel like we’re on the precipice of new knowledge, and we’re truly on the best campus to see it through.”

For more news about responsible AI in health and medicine, sign up for the RAISE Health newsletter.

Register for the RAISE Health Symposium on May 14.

About Stanford Medicine

Stanford Medicine is an integrated academic health system comprising the Stanford School of Medicine and adult and pediatric health care delivery systems. Together, they harness the full potential of biomedicine through collaborative research, education and clinical care for patients. For more information, please visit med.stanford.edu .

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Your environment. your health., climate change and human health literature portal backcountry travel emergencies in arctic canada: a pilot study in public health surveillance, climate change and human health literature portal.

• Publisher http://dx.doi.org/10.3390/ijerph13030276
• PubMed https://www.ncbi.nlm.nih.gov/pubmed/26950137

Residents in the Canadian Arctic regularly travel in remote, backcountry areas. This can pose risks for injuries and death, and create challenges for emergency responders and health systems. We aimed to describe the extent and characteristics of media-reported backcountry travel emergencies in two Northern Canadian territories (Nunavut and Northwest Territories). A case-series of all known incidents between 2004 and 2013 was established by identifying events in an online search of two media outlets, Nunatsiaq News and Northern News Services. We identified 121 incidents; these most commonly involved young men, and death occurred in just over 25% of cases. The territories differed in the seasonal patterns. News media provides a partial source of data to estimate the extent and characteristics of backcountry emergencies. This information is needed to improve emergency preparedness and health system responsiveness in the Arctic.

Resource Description

weather or climate related pathway by which climate change affects health

resource focuses on specific type of geography

resource focuses on specific location

specification of health effect or disease related to climate change exposure

format or standard characteristic of resource

Sierra Leone Records Progress in Human Capital Development - But Requires Sustained Investments to Drive Economic Growth and Reduce Poverty

FREETOWN, March 25, 2024 – Sierra Leone has made commendable strides in improving human capital development with the government demonstrating a strong commitment to enhancing the well-being and productivity of its population through significant investments in health and education, according to a new World Bank report launched today in Freetown. The report also highlights the prioritization of social protection interventions like cash transfers to extremely vulnerable groups as a notable intervention aimed at reducing poverty and building human capital.

The Sierra Leone Human Capital Review: Maximizing Human Potential for Resilience and Inclusive Development , provides critical insights into the country's efforts to foster human capital development and economic growth. The report examines the current state of health, education, and social protection systems in the country and offers recommendations to enhance the effectiveness of human capital investments.

"The future socio-economic stability and prosperity of Sierra Leone is intrinsically linked to the well-being of its people," said Abdu Muwonge, World Bank Country Manager for Sierra Leone . "This report provides a roadmap for the government and its partners to strengthen human capital, which is essential for Sierra Leone to achieve its full economic potential and improve the livelihoods of its citizens."

‘Human Capital Development’ is the first Policy Cluster in the Government of Sierra Leone’s Medium-term National Development Plan (MTNDP) 2019–2023 with increased financing of inputs in key human development sectors such as health and education. The new MTNDP (2024-2030) also prioritizes human capital development among its five key pillars, with food security as the main flagship. This increased commitment towards social sectors has resulted in improvements in health and education outcomes. For example, maternal and under-5 mortality rates, adult survival rates, as well as expected years of schooling have all improved since 2005. The Free Quality Education, launched in 2018, helped to reduce barriers to accessing education with the Education Sector Plan (2022–2026) laying out the core priorities and presenting a road map to achieving the country’s education goals. There have also been improvements in social protection coverage – the flagship social protection initiative, ‘Ep Fet Po’ cash transfer program, financed through the World Bank-supported Social Safety Net (SSN) Project, provides direct financial support to the most vulnerable populations, thereby contributing to the development of a more resilient and capable workforce.

However, Sierra Leone still faces challenges related to low human development outcomes, high poverty rates, and limited access to basic services, the report notes. The country ranks 151 out of 157 countries on the Human Capital Index (HCI). The HCI value is lower than the region’s average, indicating significant challenges in human capital development. The report highlights that only around two-thirds of today’s 15-year-olds can be expected to survive to the age of 60, and about one-quarter of the country’s children are stunted due to chronic malnutrition. Additionally, the HCI measure predicts that a child born today in Sierra Leone can be expected to be only 35% as productive when he or she grows up as the child could have been if he or she had enjoyed complete education and full health.

"The government of Sierra Leone has demonstrated a strong commitment to human capital. This report makes the case that one of the best investments a country can make is investing in its people,” said Ali Ansari, World Bank Senior Economist and one of the lead authors of the report. "A healthy, educated and skilled population is the cornerstone of Sierra Leone's journey towards a resilient, prosperous and inclusive future."

As policy priorities over the short to medium-term, the report emphasizes the need to: (i) prioritize investments in high-impact interventions for foundational learning, health, youth skills and employability; (ii) improve workforce management; (iii) prioritize investments in ensuring a minimum social protection floor for Sierra Leone; (iv) strengthen governance and implementation capacity; and (v) improve national and local level coordination in human capital development. The report also identifies several cross-cutting areas that should be prioritized, including: (i) building resilient and adaptive human development systems; (ii) improving food security; (iii) leveraging technology to enhance service delivery; and (iv) targeting human capital interventions to vulnerable groups, especially adolescent girls, women, youth and the poorest.

The Sierra Leone Human Capital Review is part of the World Bank's broader commitment to supporting countries in their efforts to build strong human capital as a foundation for inclusive growth. This is in line with WBG’s vision of creating a world free of poverty on a livable planet. The report's findings will serve as a valuable resource for policymakers, development partners, and stakeholders working towards a prosperous future for Sierra Leone.

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