Determinants of tobacco-related health literacy: A qualitative study with early adolescents

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Abstract

Background

Today's adolescents are used to a constant information flow, but many face difficulties in processing health-related information due to low health literacy. There is still need for deeper understanding on the determinants of health literacy in relation to adolescents to guide the development of health literacy instruments and interventions.

Purpose

The purpose of this study was to explore, from the perspective of early adolescents, the determinants of health literacy in the context of tobacco-related health communication.

Design

A qualitative descriptive study.

Setting

Two schools located in the south of Finland. One school represented a typical Finnish public school with students following general curriculum and the other represented a Finnish public school with students with special educational needs.

Participants

Purposively selected sample of 10–13-year-old early adolescents (n = 39) from the two schools to obtain a varied group of early adolescents representing different kinds of literacy levels.

Methods

We conducted 10 focus groups with early adolescents and analyzed the data using the theoretical thematic analysis method. We used a combination of the determinants presented in three adolescent-specific health literacy models as the theoretical framework of deductive analysis. The remaining data extracts were coded inductively. We sorted the codes under sub-themes that represented different determinants of health literacy. These were further divided between three themes: “personal”, “external”, and “mediating” determinants. Finally, we named the themes with an expression that embodied the early adolescents’ views and experiences.

Results

Early adolescents’ descriptions revealed that the list of determinants presented in the three adolescent-specific health literacy models is not comprehensive enough. Early adolescents brought up how their motives, self-efficacy, and role expectations determine their health literacy in addition to the other personal determinants presented in the previous models. Their descriptions also suggest that external determinants include interpersonal relations with authorities, idols and random people, and the socio-cultural atmosphere as new factors. New mediating determinants that have a separate influence on health literacy were recognized based on early adolescents’ descriptions as well.

Conclusion

Our findings give a new, adolescent-oriented insight on the determinants of adolescents’ health literacy. Based on the findings, there are additional personal, external, and mediating determinants that are not included in the current adolescent-specific health literacy models. These newly found determinants require attention and further exploration. The acquired knowledge can be used for strengthening existing adolescent-specific health literacy models, and as a basis of health literacy instrument and intervention development.

Introduction

Digital technology has increased the amount of available health-related information. Today's adolescents are used to a constant information flow and are experienced users of mobile devices that offer instant access to the Internet (Lenhart et al., 2015). Adolescents use traditional health information sources alongside new technology. They value health information received from adults and peers (Gray et al., 2005a, Baheiraei et al., 2014). The role of parents has shown to be important, especially in younger groups (Baheiraei et al., 2014). Adolescents also prefer to have a variety of sources of health information, coming from different forms of media (Baheiraei et al., 2014). Moreover, schools and school health care have a central role in adolescents’ life as a source of health information (Lee, 2009).

Despite the growing amount of available health-related information, many adolescents have low health literacy. In other words, many face difficulties, for example, in accessing health information online, understanding the information, evaluating the relevance and credibility of the information, and applying the information to addressing personal health concerns (Gray et al., 2005b). This lack of health literacy is a growing public health concern (Sørensen et al., 2012).

It has been shown that both adolescents’ and their parents’ literacy are associated with health outcomes (DeWalt and Hink, 2009). It has been presented that health literacy may be a key strategy in reducing health behavior-related disparities between socio-economic groups (Bennett et al., 2009). Health literacy is also recognized (Nutbeam, 2008) as an asset from a health promotion perspective. It is assumed to not only lead to personal benefits but more widely to social actions as well. For these reasons, actions toward the promotion of health literacy already need to be taken during childhood and adolescence (DeWalt and Hink, 2009).

Tobacco use is one of the public health concerns that has been connected to the widening health disparity gap between socio-economic groups (Pampel et al., 2010). In 2012, the tobacco-use rates in adolescents aged 13–15 varied between eight percent on average among girls globally to over 20 percent on average among boys in South-East Asia and Mediterranean regions (WHO, 2015a). Higher tobacco prevalence is correlated with lower income levels (WHO, 2011).

Despite the decreasing trend in tobacco use and political actions taken worldwide to curb tobacco use, tobacco use remains the leading preventable cause of death (WHO, 2015b). In 2005, the World Health Organization's Framework Convention on Tobacco Control (WHO FCTC) presented measures to reduce the demand and supply of tobacco products and protect the public from exposure to tobacco smoke (WHO, 2015b). Today, 180 countries have already committed to these actions, tightened legislation, and taken steps toward tobacco-free environments (WHO, 2015b). All tobacco-preventive actions are particularly important among young target groups, as tobacco use that starts during adolescence often continues into adulthood (Paavola et al., 2004).

Interest in health literacy has increased, but the majority of research examines health literacy from the adult perspective (DeWalt and Hink, 2009). There is still a conceptual debate and lack of knowledge on what exactly health literacy is when used in reference to children and adolescents (Ormshaw et al., 2013). According to the World Health Organization (WHO), health literacy, in general, refers to “the cognitive and social skills which determine the motivation and ability of individuals to gain access to, understand and use information in ways which promote and maintain good health” both at personal and community levels (WHO, 1998). Nutbeam (2000) further divides health literacy into three levels. In his non-age-specific, three-level model, functional health literacy refers to improved knowledge on health risks and health services, and compliance regarding instructions, interactive health literacy covers the personal capacity, motivation, and self-confidence to act on the advice received, and critical health literacy refers to the improved capacity to take individual, social, and political actions to change the social and economic determinants of health (Nutbeam, 2000).

Manganello (2008), Paek et al. (2011), and Wharf Higgins et al. (2009) have presented three different adolescent-specific conceptual models to clarify and recognize the determinants of health literacy among adolescents. Of these three models, the model of Wharf Higgins et al. (2009), examines health literacy from a socioecological perspective and the model of Paek et al. (2011) examines it from a health socialization perspective. The definitions of health literacy used as the core of the models also differ slightly. By health literacy, Manganello (2008) refers to functional, interactive, and critical literacy, as defined by Nutbeam (2000). She also includes media literacy (“the ability to critically evaluate media messages”) to the definition. Wharf Higgins et al. (2009) refer to Kickbusch (2007), and Rootman and Gordon-El-Bihbety (2008), and define health literacy as “the ability to make sound health decisions in the context of everyday life.” They consider health literacy as a strategy that increases individuals’ control over their health, and the ability to search for, access, understand, evaluate, and communicate information. They also add that health literacy increases an individual's ability to take responsibility in ways that “promote, maintain and improve health in a variety of settings across the life course.” The definition used by Paek et al. (2011) is the most concise. They follow the definition of the Institute of Medicine (2004) and define health literacy as an “individual's capacity to acquire and use new information.”

These models of Manganello (2008), Wharf Higgins et al. (2009), and Paek et al. (2011) present several different determinants of adolescents’ health literacy (Table 3). Only five of the determinants (gender, parents/family, peers, school, and media) are included in all three models. The models of Manganello (2008) and Paek et al. (2011) lean largely on previous models developed for the adult population. Wharf Higgins et al. (2009) also partly explored the perspective of 16–17-year-old adolescents when developing their model.

It has been stated that health education, general education, and community-based interventions are possible contexts for the promotion of the health literacy of young individuals (Sanders et al., 2009). School health nurses and other school personnel are in central positions regarding health literacy – promoting actions (Lee, 2009). However, clarification of the concept of health literacy and its determinants in relation to adolescents is needed to guide the development of health literacy instruments and interventions (Ormshaw et al., 2013). Our goal was to gain early adolescent-oriented insight into the area of interest. Thus, the purpose of this study was to explore, from the perspective of early adolescents, the determinants of health literacy in the context of tobacco-related health communication. We used Nutbeam's (2000) definition of health literacy in this study. This study is part of a larger multidisciplinary research project (No! To Smoking).

Section snippets

Study design and data gathering method

We used qualitative description (Sandelowski, 2000) as a design and focus groups (Krueger and Casey, 2009) for information gathering to explore early adolescents’ views and experiences on the topic. We chose focus groups, because with this method it is possible to acquire valuable data in terms of both consensus and diversity of views among participants (Morgan, 1996). The group dynamic and interaction that takes place in the focus groups potentially also enriches the conversation and offers

Results

Early adolescents’ descriptions suggest that health literacy is a result of a more multidimensional combination of different determinants than presented in the previous models of Manganello (2008), Wharf Higgins et al. (2009), and Paek et al. (2011). The newly recognized personal determinants, based on early adolescents’ descriptions, include motives, self-efficacy, and role expectations. Moreover, new external determinants contain interpersonal relations with authorities, idols and random

Discussion

We learned from early adolescents that health literacy development is a result of a multidimensional combination of different determinants. These determinants cover a wide range of personal and external factors, and also interpretation of the health messages, balancing the personal and external determining factors, and level of capacity to process conflicting messages as mediating determinants. We suggest some additions to list of different determinants of adolescents’ health literacy (Table 3).

Conclusion

According to early adolescents, health literacy is, in the context of tobacco-related health communication, a result of a multidimensional combination of different determinants. Based on the findings, there are additional personal, external, and mediating determinants that are not included in the current adolescent-specific health literacy models. We argue that the personal determinants of adolescents’ health literacy cover their age, knowledge and access to health information, media use,

Conflict of interest

None declared.

Funding

This research was funded by research funding from The Research Foundation of the Pulmonary Diseases and The Finnish Association of Nursing Research.

Ethical approval

Ethical pre-approval specifying no objections to the study was obtained from the Ethical Board of the University of Turku.

Acknowledgements

We would like to thank all the early adolescents who participated in the focus groups and school personnel who collaborated during implementation of the study.

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