Early Adolescents Perceptions of Health and Health Literacy

RE S E A R C H AR T I C L E

Early Adolescents Perceptions of Healthand Health Literacy*

STEPHEN L. BROWN, PhDa

JAMES A. TEUFEL, MPHb

DAVID A. BIRCH, PhD, CHESc

ABSTRACT

BACKGROUND: Health illiteracy is a societal issue that, if addressed successfully,

may help to reduce health disparities. It has been associated with increased rates of

hospital admission, health care expenditures, and poor health outcomes. Because of

this, much of the research in the United States has focused on adults in the health

care system. This study investigated the effect of aspects of health literacy on the

motivation to practice health-enhancing behaviors among early adolescents.

METHODS: Measures were generally based on 3 National Health Education Stand-

ards for grades 5-8. Data were obtained from 1178 9- to 13-year-old students visiting

11 health education centers in 7 states. Students responded via individual electronic

keypads.

RESULTS: Multivariate logistic regression revealed that, in addition to age, difficulty

understanding health information and belief that kids can do little to affect their

future health, decreased the likelihood for interest in and desire to follow what they

were taught about health. Further, low interest independently decreased motivation to

follow what was taught. Girls were more likely to turn to school, parents, and medical

personnel for health information. Older students were more likely to turn to school

and to the Internet.

CONCLUSIONS: Programs and curricula should be designed to increase student

interest in health issues and their self-efficacy in controlling their own health destinies.

Educators should also teach students to more effectively use nonconventional health

information sources such as the Internet, parents, and medical professionals.

Keywords: health literacy; early adolescents.

Citation: Brown SL, Teufel JA, Birch DA. Early adolescents perceptions of health and

health literacy. J Sch Health. 2007; 77: 7-15.

aAssistant Professor, ([email protected]), Department of Health Education, Southern Illinois University Carbondale, Carbondale, IL 62901-4632.bDoctoral Student, ([email protected]), Department of Health Education, Southern Illinois University Carbondale, Carbondale, IL 62901-4632.cProfessor and Chair ([email protected]), Department of Health Education, Southern Illinois University, Carbondale, Carbondale, IL 62901-4632.

Address correspondence to: Stephen L. Brown, ([email protected]), Professor, Department of Health Education, Southern Illinois University Carbondale,Carbondale, IL 62901-4632.

This study was completed with funding help from the National Association of Health Education Centers and KidsHealth (the Nemours Foundation’s Center forChildren’s Health Media).

Timeframe: Data collection took place in a 3-week period in November 2004.

*Article is available for CHES CECH. Complete the exam at the back of this issue or go to: www.ashaweb.org/continuing_education.html

Journal of School Health d January 2007, Vol. 77, No. 1 d ª 2007, American School Health Association d 7

Health literacy is defined in Healthy People 2010

as ‘‘The degree to which individuals have the

capacity to obtain, process, and understand basic

health information and services needed to make

appropriate health decisions.’’1 Much of the health

literacy research in the United States has focused on

adults in the health care system. Lower levels of

health literacy have been associated with increased

rates of hospital admission, increased health care ex-

penditures, and worse health outcomes.2-4 The issue

of health illiteracy also presents ethical and societal

concerns because it may be linked to health dispar-

ities in the United States.1,5

However, the conventional research perspective is

functionally too narrow because health literacy in-

volves more than the ability to navigate the health

care system or follow doctors’ directions.6 As sug-

gested by the Institute of Medicine, health literacy

should be seen in an ecological framework that in-

cludes 3 systemic influences: (1) the health care sys-

tem, (2) culture or society, and (3) the educational

system.3 Adult medical health literacy research pri-

marily focuses on only 1 of these categories of influ-

ence and needs to be supplemented with other types

of research, especially research on younger samples.

Adult Health LiteracyBecause literacy skills are a key component in the

development of health literacy,3,7 adult health liter-

acy in the United States has been primarily assessed

with the Health Activities Literacy Scale (HALS). The

HALS includes literacy assessments across 5 domains—

health promotion, health protection, disease preven-

tion, health care and maintenance, and systems navi-

gation.7 However, the Joint Committee on National

Health Education Standards and others have reasoned

that health literate individuals need to do more than

comprehend written language as assessed by the

HALS. They should also be able to verbally communi-

cate (speaking, as well as listening) and to analyze

and evaluate health information, skills, and sources.3,8

If these additional requirements (ie, verbal communi-

cation, analysis, and evaluation) are added as requi-

sites for an individual to be categorized as health

literate, then the HALS assessment is likely an under-

estimate of real health illiteracy in the United States.

Early Adolescent Health LiteracyEducation is recognized as an important influence

on both general literacy and health literacy skills.3,7

Although there is a breadth of research regarding

early adolescent literacy skills (reading, writing, and

quantifying), relatively few large studies have

focused on early adolescent health literacy. Most of

the work related to health literacy in K-12 educa-

tional setting use the National Health Education

Standards (NHES) as a framework for research and

discussion.8 The NHES highlights specific proficien-

cies for school-age children and early adolescents

that are assumed to be essential in the development

and maintenance of a functionally health literate

individual. According to the NHES, these proficien-

cies are (1) critical thinking and problem solving, (2)

responsibility and productivity, (3) self-directedness,

and (4) effective communication.8

The School Health Policies and Programs Study of

2000 found that the majority of states use the NHES

as a guide for their health education curricula and

that most elementary and middle schools offer some

type of health education. However, there were dis-

crepancies among schools regarding the content,

consistency, and durations of health education.9

KidsHealth KidsPoll of Health LiteracySurveying early adolescents using questions based

on the NHES could provide data that could be used

to improve the delivery of health education designed

to increase health literacy. For the KidsHealth Kids-

Poll, questions were developed to measure the

degree to which students understand, are interested

in, and apply health information. Students were also

asked their opinions of various sources of health

information. Although not specifically written to

measure the performance indicators, the questions

generally addressed 3 NHES for grades 5-8 (Table 1).

Early adolescents were polled regarding their ability

to comprehend concepts related to health promotion

and disease prevention (questions 1, 6-7: NHES stan-

dard 1 in general), access valid health information

Table 1. Matching of NHES With Survey Questions

NHES Standards Questions

Standard 1: Studentswill comprehend conceptsrelated to health promotionand disease prevention

Most of what I hear abouthealth is: very easy tovery hard to understand

ANDHow much can a kid do to growup to be a healthy adult?

Standard 2: Studentswill demonstrate the abilityto access validhealth information . . .

From which of these do youlearn the most about health?

ANDIf you had an importantquestion about health,where would you go firstfor information?

ANDWhich of these gives the mostwrong information about health?

Standard 7, indicator 2:Students will expressinformation and opinionsabout health issues

Process of participatingin the survey

8 d Journal of School Health d January 2007, Vol. 77, No. 1 d ª 2007, American School Health Association

(questions 2-4: NHES standard 2, indicators 1-3),

and, as a process of participating in this poll, demon-

strate the ability to advocate for health by sharing

information (NHES standard 7, indicator 2).

Questions were also similar to other polls of adults

and early adolescents using self-report of or opinions

of health.10-12 For this study, early adolescents re-

ported the source from which they learn most about

health, as well as the source they would go to first if

they had an important question about health. Further,

their interests in learning about health and their per-

ceptions of their own health status were also assessed.

Studies have consistently demonstrated that early

adolescents in the Untied States and elsewhere can

validly and reliably self-report their own emotional,

behavioral, psychological, and somatic health.13-15

METHODS

SampleWe obtained data from 1178 adolescents, aged

9-13 years, who attended programs at 11 health edu-

cation centers in the United States. These centers, all

members of the National Association of Health Educa-

tion Centers, are located in 7 states: Illinois, Indiana,

Michigan, North Carolina, Ohio, Pennsylvania, and

Wisconsin. The centers, which are not affiliated with

schools, are similar to youth science centers, except

that they have the primary goal of teaching about

health and the human body.

Following university institutional review board

approval, center staff contacted officials at each

school, prior to the school’s scheduled trip to the

center, to arrange permission to give the survey dur-

ing the visit. Parental permission for the survey was

passive and was given with the permission to attend

the field trip. Class selection was convenient to the

classes scheduled for visits during the study period

in November 2004 and to the schools extending per-

mission. Staffs at each center were instructed to solicit

enough 4th- through 8th- grade classes to include

100-200 respondents per center. To further facilitate

intracenter variability, centers recruited no more than

2 classes from the same grade and no more than 2

classes from the same school. Center staff invited, but

did not require, all students in a selected class to par-

ticipate. Classes from 35 schools participated.

ProceduresData were collected using computer systems

(Classroom Response System or Audience Response System)

that combine data from multiple students responding

via individual electronic keypads. Preceding or fol-

lowing a health education program on an unrelated

topic, center staff explained the purpose of the study

and taught the selected classes to use the handheld

keypads. Trained staff read to the students the in-

structions for the survey and then read each ques-

tion and answer choice as they simultaneously

appeared on a large screen in the front of the room.

Participating students indicated their choices by

pressing corresponding letters on their keypads.

Participation was voluntary, and all respondents re-

mained anonymous.

MeasuresWe collected data at 2 levels: student and school.

We obtained student-level data from individual stu-

dents via handheld keypads. The students were

given 2 demographic questions (age and gender) and

8 questions dealing with aspects of health literacy.

Based on literature review and previous surveys at

these centers, a research advisory team and the au-

thors developed a large pool of original questions and

a survey script related to 3 of the NHES for grades 5-8.

Content and face validity were established by the

advisory team, which included researchers with ex-

pertise in health literacy. The advisory team consisted

of a child psychologist, parents, 2 center directors, a

pediatrician, 2 researchers with topic expertise, and

the authors.

We piloted the survey with 2 classes at 1 health

education center. Following each pilot, center staff

asked a sample of the adolescents who took the survey

and the teachers and other adults present for qualita-

tive responses regarding the appropriateness, wording,

and answer choices of the survey. We shortened and

revised the survey and script based on the pilots and

qualitative feedback. Due to the method of data collec-

tion, remote keypads, all of the questions were closed-

end with a maximum of 5 answer choices. Therefore,

the answer choices for the questions addressing infor-

mation sources were each limited to the 5 answers

given most often during pilot testing. Answer choices

for questions referring to information sources were

presented in the same order for every question.

Center staff also recorded the size of each class

and the school and school district to which the class

belonged. From this information, we were able to

obtain, from the National Center for Education Sta-

tistics (NCES),16 school-level data for all the schools.

Among other statistics, the NCES reports school size,

urban-to-rural locale code, ethnic/racial proportions,

and proportions participating in free or reduced-

lunch programs.

AnalysisWe calculated proportions for each demographic,

personal belief, and personal behavior variable. We

also evaluated differences in these variables by re-

spondent characteristics (gender and age) by chi-square

tests. Through multiple logistic regression analyses,

we examined associations between predictor variables


(gender, age, beliefs, and behaviors) and outcome

variables (interest in learning about health and desire

to follow what is taught). For these analyses, we re-

coded responses to each outcome into dichotomous

categories: interested versus uninterested and try to

follow most or all the time versus sometimes or less.

As a measure of effect, we present crude odds ratios

and 95% confidence intervals (CIs). Next, we used

multivariate logistic regression to examine the associ-

ation between each dichotomous outcome and the 6

predictor variables simultaneously. We report these

effects as adjusted odds ratios with associated 95%

CIs. A CI that includes the value ‘‘1’’ indicates a non-

significant association (p . .05). Finally, we ran

a nominal logistic regression of gender and age on 3

categorical responses (source learned the most from,

first source sought with a question, and source with

most wrong information). For the nominal logistic

regression, we recoded age into bivariate categories: 9-

11 and 12-13. From the nominal logistic regression

analysis, we report the results of the likelihood ratio

tests and the parameter estimates to show whether

gender and age, in a simultaneous model, affect the

likelihood of giving various responses to these poly-

chotomous categorical items.

In addition, we calculated average proportions

across schools for school-level variables (ethnicity,

reduced-lunch participation, and locale code). We

must note that these variables do not represent the

individual student but the school that the student at-

tends. For example, a high score for reduced-lunch

participation means that the student attended a

school where a large percentage of the students

received reduced lunch, not necessarily that that

student received reduced lunch.

RESULTS

DemographicsThe schools participating were relatively diverse

across population locales, school size, ethnicity, and

income (represented by reduced-lunch participation;

Table 2). As a group, the schools sampled also

approximated NCES national averages on the re-

ported measures,17 with a few exceptions. Our sam-

ple (1) included a smaller proportion of schools from

midsize central cities, (2) represented schools with

slightly more white and slightly fewer Asian stu-

dents, and (3) had fewer students from very large

schools. Boys and girls were nearly equal in the

sample. Average participant age was 10.5 years, with

10- and 11-year-olds overrepresented.

ResponsesTable 3 includes responses of all participants. Over

90% of the participants considered themselves ‘‘very

or sort of’’ healthy, and nearly two thirds of partici-

pants believed there is ‘‘a lot’’ a kid can do to grow

up to be a healthy adult. Almost two thirds of partic-

ipants also reported that they try to follow what

they are taught about health ‘‘all or most of the

time.’’ More than 40% of participants reported that

they were very interested in learning about health,

another third of participants reported that they were

sort of interested, and about a quarter of participants

reported they were uninterested in learning about

health. The majority of participants said that most of

what they hear about health is easy to understand,

but nearly 1 in 4 responded that what they hear was

hard to understand.

Participants reported that school (49%) and medi-

cal personnel (29%) were the sources from which

they learned the most about health. When asked

where they would go first if they had an important

question about health, nearly equal numbers (31%

and 29%) of participants reported parents and medi-

cal personnel. These responses were followed by

school (21%). Friends and television were consid-

ered to have the greatest potential for ‘‘wrong infor-

mation about health,’’ with more than a third of

participants naming each.

Logistic Regression AnalysesIn the presence of other predictors, gender was

not a significant predictor of interest in or motiva-

tion to follow what is taught about health (Table 4).

Table 2. School-Level Data—Proportion of Participants FromSchools in Each Category (N = 1178)

Current study NCES averages2001 (%)n (%)

School city sizeLarge city center 247 (21) (15)Large city fringe 271 (23) (17)Midsize city center 200 (17) (31)Midsize city fringe 130 (11) (8)Small city 94 (8) (13)Rural 246 (21) (16)

School size [Mean = 551] [Mean = 477]0-300 165 (14) (9)300-750 836 (71) (46)750-1500 153 (13) (30)15001 23 (2) (14)

School ethnicityWhite na (66) (61)Black na (15) (17)Hispanic na (17) (17)Asian/Pacific Islander na (1) (4)Native American na (1) (1)

School lunch participationFree or reduced lunch na (39) (45)

NCES averages = National Center for Educational Statistics 2001 Report;

na = not applicable.


Table 3. Frequencies of Responses by Gender and Age

TotalBoys (%) Girls (%) 9 (%) 10 (%) 11 (%) 12 (%) 13 (%)n (%)

Total 48.3 51.7 27.9 28.8 15.4 13.1 14.81. Most of what I hear abouthealth is:*,†

Very easy to understand 397 (37.1) 42.0 32.4 38.3 41.8 35.4 29.9 30.8Sort of easy to understand 438 (41.0) 35.5 46.1 36.0 43.8 44.9 43.8 38.5Sort of hard to understand 164 (15.3) 14.0 16.5 17.4 11.4 13.9 19.7 19.9Very hard to understand 70 (6.5) 8.6 5.0 8.3 3.0 5.7 6.6 10.9

2. From which of these do youlearn the most about health?*,†

The Internet 85 (8.5) 9.9 6.9 8.4 5.9 10.2 10.0 8.6School 403 (40.2) 35.3 42.9 26.6 40.3 43.3 52.3 55.7Parents 124 (12.4) 11.3 14.0 10.3 14.3 14.2 9.2 10.0A doctor or nurse 295 (29.4) 31.3 28.8 41.1 32.6 22.0 21.5 15.0Some other way 96 (9.6) 12.1 7.5 13.7 7.0 10.2 6.9 10.7

3. If you had an important questionabout health, where would you gofirst for information?†

The Internet 129 (12.0) 14.0 10.1 7.7 8.4 14.5 20.6 19.4School 225 (21.0) 19.1 21.2 20.4 21.2 16.7 19.8 20.0Parents 327 (30.5) 28.4 33.7 29.9 32.3 37.7 31.3 31.0A doctor or nurse 313 (29.2) 30.7 27.9 32.7 32.3 26.8 22.1 23.9Some other way 77 (7.2) 7.8 7.0 9.2 5.7 4.3 6.1 5.8

4. Which of these gives the mostwrong information about health?†

The Internet 65 (6.2) 6.3 6.3 7.5 6.6 7.3 3.9 3.9TV 373 (35.5) 37.2 33.5 42.3 38.9 37.2 21.1 21.3School 53 (5.0) 6.3 3.9 3.6 3.5 7.3 3.1 10.3Friends 383 (36.4) 34.3 38.6 26.3 34.4 37.2 56.3 47.7I‘m not sure 178 (16.9) 15.9 17.7 20.3 16.7 10.9 15.6 16.8

5. I try to follow what I’m taughtabout health:†

All the time 368 (33.4) 35.2 31.6 45.6 41.3 28.0 21.6 13.5Most of the time 361 (32.8) 30.4 35.7 31.4 35.9 34.4 37.4 29.0Sometimes 209 (19.0) 17.6 20.7 13.1 14.4 22.3 28.1 31.0Hardly ever 57 (5.2) 5.5 3.6 2.8 3.0 5.7 4.3 7.1Never 107 (9.7) 11.3 8.4 7.1 5.4 9.6 8.6 19.4

6. How much can a kid do to growup to be a healthy adult?*,†

A lot 709 (63.5) 61.8 65.0 69.0 67.1 63.4 58.4 57.6Some 187 (16.7) 15.1 18.8 8.7 17.4 17.4 29.9 17.1A little 42 (3.8) 4.8 2.2 4.9 2.3 2.5 2.9 1.3Almost nothing 23 (2.1) 3.8 0.6 1.0 1.3 3.7 0.0 3.8I don‘t know 156 (14.0) 14.5 13.4 16.4 11.8 13.0 8.8 20.3

7. How interested are you inlearning about health?*,†

Very interested 471 (41.9) 40.7 43.5 63.6 41.5 32.5 25.4 18.8Sort of interested 422 (37.5) 37.5 39.1 25.4 44.1 45.0 47.9 39.0Sort of uninterested 90 (8.0) 6.2 9.0 3.8 6.9 9.4 12.7 14.3Very uninterested 142 (12.6) 15.7 8.3 7.2 7.5 13.1 14.1 27.9

8. I consider myself to be:†

Very healthy 656 (58.8) 58.5 58.5 73.4 63.2 45.6 50.0 42.4Sort of healthy 381 (34.1) 33.1 35.7 22.5 30.3 43.1 43.6 49.6Sort of unhealthy 34 (3.0) 3.8 2.4 2.0 2.9 3.1 2.9 4.3Very unhealthy 45 (4.0) 4.6 3.4 2.0 3.6 8.1 3.6 3.6

*v2 tests statistically significant for gender (p , .05), †v2 tests statistically significant for age (p , .05); N = 1125.


Interest in and motivation to follow what is taught

about health decreased with age (Table 4). For

example, 9- and 10-year-olds were much more

likely (3.5-4.13) than the referent age of 13 years to

report that they try to follow what they were taught

about health and even more likely than the referent

age to say they were interested in learning about

health (5.4-8.53).

Beyond age, the greatest predictor of both interest

in and motivation to follow what is taught about

health was a belief that kids can influence their own

future health (Table 4). Those who perceived that

they have at least some control over future health

outcomes were 3-4 times as likely to be interested in

health (3.43) and to say they try to follow what

they were taught (4.23). Moreover, those that per-

ceived that they have ‘‘a lot’’ of control were much

more likely to report both interest in (3.63) and at-

tempts to follow (7.03) what they were taught

about health. Interest in health was, in turn, a pri-

mary predictor of attempts to follow what is taught

(3.4-6.73; Table 4).

Adolescents who considered themselves at least

somewhat healthy were 3-4 times more likely to be

interested in health (3.6-4.33) and to attempt to fol-

low what they were taught (3.63) than those who

considered themselves unhealthy (Table 4). Finally,

those who reported that most of what they hear

about health is hard to understand were less likely

to be interested in learning about or following what

they were taught about health (Table 4).

Nominal Logistic Regression AnalysesGender was not a significant predictor of where

students would go to first if they had an important

health question or of the sources that students

believe give the most wrong information (Table 5).

However, girls were more likely than boys to report

that they learn the most about health from parents

(2.23), school (2.13), or a doctor/nurse (1.73) com-

pared to the referent category ‘‘some other way.’’

Older students, 12-13 years of age, were also

more likely (1.73) to name school as the source

they learn the most about health compared to the

referent category (Table 5). Additionally, older stu-

dents were more likely than younger students

(2.33) to report that they would go to the Internet

first with a health question than to the referent cate-

gory, some other place (Table 5). They were also

Table 4. CRO and ARO (With 95% CI) for Interest in Learning About Health and Try to Follow What Is Taught About Health (Most orAll of the Time)—for Gender, Age, and Personal Beliefs

Interested in LearningAbout Health

Try to FollowWhat Is Taught About Health

COR (CI) AOR (CI) COR (CI) AOR (CI)

GenderGirls 1.1 (0.8-1.7) 1.1 (0.7-1.7) 1.0 (0.7-1.4) 0.9 (0.6-1.4)Boys 1.0 1.0 1.0 1.0

Age (years)9 7.1* (3.5-14.7) 8.5* (3.9-18.4) 4.8* (2.7-8.6) 3.5* (1.8-6.8)10 5.5* (3.0-10.0) 5.4* (2.8-10.3) 5.2* (3.0-9.0) 4.1* (2.3-7.7)11 3.9* (1.9-7.9) 4.8* (2.2-10.4) 2.0* (1.1-3.7) 1.6 (0.8-3.0)12 2.0* (1.1-3.6) 2.0* (1.1-3.9) 1.4 (0.8-2.5) 1.2 (0.7-2.3)13 1.0 1.0 1.0 1.0

Most of what I hear about health isVery easy to understand 5.0* (2.2-11.7) 3.6* (1.3-9.5) 3.9* (1.7-8.9) 2.9* (1.0-8.1)Sort of easy to understand 4.9* (2.1-11.3) 3.5* (1.3-9.2) 2.6* (1.2-5.8) 1.9 (0.7-5.3)Sort of hard to understand 3.2* (1.3-8.2) 2.4 (0.8-7.0) 2.9* (1.2-7.1) 2.4 (0.8-7.3)Very hard to understand 1.0 1.0 1.0 1.0

How much can a kid do to grow up to be a healthy adult?A lot 4.7* (2.2-10.1) 3.6* (1.4-9.3) 8.5* (3.7-19.7) 7.0* (2.6-18.6)Some 3.5* (1.5-8.3) 3.4* (1.2-9.5) 4.3* (1.8-10.6) 4.2* (1.5-12.1)Little to nothing 1.0 1.0 1.0 1.0

Consider self to be:Very healthy 4.9* (2.4-10.0) 4.3* (2.0-9.5) 4.5* (2.2-8.9) 3.6* (1.6-8.0)Sort of healthy 3.0* (1.5-6.2) 3.6* (1.6-8.2) 3.0* (1.5-6.0) 3.6* (1.6-8.1)Unhealthy 1.0 1.0 1.0 1.0

Interest in learning about healthVery interested na na 12.4* (6.3-24.2) 6.7* (3.2-14.1)Sort of interested na na 5.9* (3.1-11.2) 3.7* (1.8-7.5)Sort of uninterested na na 3.4* (1.5-7.6) 3.4* (1.4-8.2)Very uninterested na na 1.0 1.0

COR, crude odds ratio; AOR, adjusted odds ratio; na = not applicable.

*p , .05; N = 638.


more likely than younger students to believe that

school (2.13) or friends (1.93) and less likely to

believe television (0.63) gives the most wrong infor-

mation compared to the referent category ‘‘I’m not

sure’’ (Table 5).

DISCUSSION

Measuring indicators for health education stand-

ards that are intended to increase health literacy can

provide a benchmark for degrees of health literacy

among adolescents. Although all the standards pro-

vide some indication of achievement of health liter-

acy, this study generally focused on standards 1-2

and aspects of standard 7 as a function of partici-

pating in this survey (Table 1). For this study, health

literacy was defined simply as the ability to under-

stand health information and to understand that ac-

tions taken in youth affect health later in

life, combined with the ability to access valid health

information. Answers to these questions were

used to predict interest in learning about health and

motivation to follow what is learned, both of which

are needed before a student can demonstrate the

ability to practice health-enhancing behaviors.

Level of health literacy, as it is defined in this

study, appears to have significant influence on cer-

tain health-related attitudes and perceptions. This

study shows that early adolescents who either did

not believe or did not understand that their behav-

iors and decisions as adolescents can affect their

health as adults were less interested in health infor-

mation and, in turn, less likely to follow what they

were taught about staying healthy. Additionally,

those who found health messages difficult to under-

stand were less likely to be interested in or to follow

what they are taught. Additional research may be

needed to discover why one fourth of students sur-

veyed say it is hard to understand most of what they

hear about health. This may require a more detailed

understanding of the mix of health information

sources these particular students are referring to and

of whether they find all or only some of these sour-

ces difficult to understand. For example, they may

be referring to sources that were intended for older

audiences. This may also highlight the need to

involve the students, for whom the information is

intended, in the development and review of the

health messages from various levels and sources. In

addition to testing readability or word selection, stu-

dents may help those who develop programs and

Table 5. Nominal Regression of Gender and Age on 3 Categorical Questions

Gender Age

Likelihood Ratio Tests v2 df sig. v2 df sig.

Learn the most about health 13.6** 4 0.01 36.1** 16 0.00Go to first with a question 8.4 4 0.08 20.7** 12 0.01Gives the most wrong information 4.0 4 0.41 47.6** 12 0.00

Girls (vs Boys) Age 12-13 (vs Age 9-11)

Parameter Estimates Exp (B) (CI) Exp (B) (CI)

Learn the most about health

Internet 1.2 (0.6-2.3) 1.5 (0.8-3.0)School 2.1* (1.3-3.4) 1.7* (1.0-2.9)Parents 2.2* (1.2-3.9) 0.8 (0.4-1.6)Doctor/nurse 1.7* (1.0-2.7) 0.6 (0.3-1.1)Some other way 1.0 1.0

Go to first with a question

Internet 0.7 (0.4-1.3) 2.3* (1.2-4.6)School 1.2 (0.7-2.2) 1.1 (0.6-2.1)Parents 1.3 (0.7-2.2) 1.0 (0.5-1.8)Doctor/nurse 1.0 (0.5-1.8) 0.8 (0.4-1.5)Somewhere else 1.0 1.0

Gives the most wrong information

Internet 0.8 (0.5-1.6) 0.7 (0.3-1.5)TV 0.9 (0.6-1.3) 0.6* (0.4-0.9)School 0.6 (0.3-1.1) 2.1* (1.1-4.1)Friends 1.0 (0.7-1.4) 1.9* (1.3-2.9)I’m not sure 1.0 1.0

*p , .05; **p , .01; N = 1178.


curricula identify the types of topics most students at

given ages find interesting or potentially confusing.

This research may also point to personal or social

factors that make these particular students unique.

In this study, students were more likely to report

difficulty understanding health information if

they came from schools with more ethnic minorities

(v2(1) = 5.7, p , .019), or more lower-income fami-

lies, as represented by free-lunch participation

(v2(1) = 34.1, p , .001). Further research is needed

to determine whether this is due to personal, famil-

ial, community, or school variables. For instance,

there may be differences in the resources available,

the cultural appropriateness of the information

delivered at school, or the absence of supporting

messages in the community. This type of research

may help to redesign programs to meet the needs of

these particular students. This type of focus should

also help to increase students’ interest in health edu-

cation, but other efforts may also be necessary, such

as tailoring messages to different learning styles.

Additionally, this research could focus on the best

instrumental approaches to affect behavior early. It

may also be useful to simply investigate the topics

students find most interesting and why.

This study also highlighted issues associated with

ability to access health information (standard 2). For

example, is the finding that school was listed so often

as an information source among older students due

to the fact that students are exposed to more health

education in higher grades or to developmental

maturity? Additionally, parents as a primary source

of health information was surprisingly low even

among younger children. Parents may be missing an

opportunity to reinforce topics about which they are

particularly concerned. If schools are devoting mini-

mal time to health issues and kids do not see parents

as a principal source for health information, they

may be turning to other sources, such as friends or

the Internet, that were not intended to supply them

this information. This low mention of parents may

also be associated with the fact that some schools

may not be using a formal method to reach out to

parents to get them more involved in their child’s

health education. If not currently in place, schools

should consider programs that train parents to

deliver health education and then cast parents in the

roles of important health educators to their children.

There was a surprisingly high mention of medical

personnel as sources of health information. We have

also seen this halo effect with other health topics at

these centers. Schools could take advantage of this

effect by preparing such professionals to be involved

in or to reinforce school programs and curricula.

Additionally, parents could partner with doctors and

nurses by asking them to reinforce, during clinical

visits, messages they are trying to teach their chil-

dren. These practitioners may need additional train-

ing on how to be proactive health educators within

the constraints of a clinical setting and minimal time

per patient.

The Internet also seems to be an important

source, especially for older children; yet few said

that the Internet is a primary source of wrong infor-

mation. As children increasingly use the Internet at

younger ages for all types of information, training

on how to use the Internet to obtain health informa-

tion is becoming more crucial. Curricula at lower

levels should be designed to teach children to distin-

guish valid and poor online information that deals

with health issues.

The limitations of this study warrant consider-

ation. Cross-sectional design prevents causal inferen-

ces due to potential threats to internal validity, and

nonrandom sampling also limits the generalizability

of results. However, the sample did approximate

national demographic characteristics of students in

the United States and was spread across multiple

states. Additionally, limiting answers to 1 of 5 closed-

end options (the 5 most cited during pilot tests) and

the order the answer options were presented also

may have influenced student responses and possibly

attenuated some associations.

Prevention efforts need to start earlier and may be

strengthened by addressing subjective beliefs and by

including an understanding of the perspectives and

preferences of those for whom the programs are

developed. Efforts should extend beyond conven-

tional methods by soliciting and coordinating help

from other potential information sources such as pa-

rents, medical professionals, and health education

centers. Utilizing adolescents as active participants in

health literacy research not only provides important

information to program planners but also may

potentially help to empower or increase the ‘‘buy-

in’’ of some adolescents, thereby increasing their

interest in health information.

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Documents

Early Adolescents Perceptions of Health and Health Literacy