DOI: 10.1542/peds.

2009-1162D
2009;124;S282 Pediatrics
Dina L.G. Borzekowski
Considering Children and Health Literacy: A Theoretical Approach

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Considering Children and Health Literacy: A
Theoretical Approach
abstract
The theoretical approaches of Paulo Freire, Jean Piaget, and Lev
Vygotsky frame the consideration of children and health literacy. This
article includes a general discussion of literacy from the Freirian per-
spective. A denition of health literacy is then presented; rst, the
established meaning is introduced, but then a Freirian extension is
proposed. Next, the theories of cognitive development by Piaget and
Vygotsky are discussed, and examples related to childrens health lit-
eracy are given. Finally, there is a discussion of why it is important to
encourage and enable health literacy among children and adolescents.
Pediatrics 2009;124:S282S288
AUTHOR: Dina L. G. Borzekowski, EdD
Department of Health, Behavior and Society, Johns Hopkins
Bloomberg School of Public Health, Baltimore, Maryland
KEY WORDS
Freire, Piaget, Vygotsky, health literacy, children
ABBREVIATION
ZPDzone of proximal development
The views presented in this article are those of the author, not
the organizations with which she is afliated.
www.pediatrics.org/cgi/doi/10.1542/peds.2009-1162D
doi:10.1542/peds.2009-1162D
Accepted for publication Jul 20, 2009
Address correspondence to Dina L. G. Borzekowski, EdD, Johns
Hopkins Bloomberg School of Public Health, Department of
Health, Behavior and Society, 624 N Broadway, 745, Baltimore,
MD 21205. E-mail: dborzeko@jhsph.edu
PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).
Copyright 2009 by the American Academy of Pediatrics
FINANCIAL DISCLOSURE: The author has indicated she has no
nancial relationships relevant to this article to disclose.
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An inuential educational theorist and
Brazilian educator, Paulo Freire dis-
cussed and wrote about literacy. He
felt that the attainment of literacy was
inextricably linked to personal, social,
and political liberation. Becoming liter-
ate occurred within the specic lives
and culture of the people attaining lit-
eracy. The true purpose of education
and literacy, according to Freire, was
to liberate people so that they could
achieve their full potential.
1
As background, Freire believed that
many of the worlds inequities were
perpetuated by existing educational
systems. Such systems withheld the
tools that would allow certain groups
to attain power. For example, the
ways that some societies conceived
of and taught literacy kept people, es-
pecially those from more marginalized
groups, politically powerless. Offering
only rote learning and discouraging
critical thinking skills helped to immo-
bilize large population groups. Socio-
political power would remain in the
hands of the few when vulnerable peo-
ples could not obtain the tools to chal-
lenge inadequate literacy education.
In a Freirian literacy program, the
teacher and student develop through
the act of dialogue and reection. The
teacher does not hold a superior posi-
tion, nor does the student accept a
passive role. A successful interaction
involves the teacher developing an
awareness of the learners world. The
student increases the inherent control
over his or her life by taking control in
the educational environment. Teachers
and students engage in a mutually bene-
cial relationshipa partnership.
Literacy, according to Freire, is more
than the learning of text. One is literate
when he or she can read the word as
well as the world.
2
People achieve
higher literacy levels when they can
critically decipher obstacles (which
Freire terms limit situations) in their
personal and social lives. Conscious-
ness of these situations, regardless of
whether reading or writing is involved,
can be a tool toward gaining personal
freedom.
1
Individuals who may be un-
familiar with text or writing can be ex-
tremely literate in the environments
they inhabit but also cultivate.
2
For ex-
ample, in an agrarian community, a
woman who cannot read or write text
may be an expert with various plant
species and social types. She might be
able to read the resource to increase
production in a range of situations.
A Freirian educational process results
in personal and social transformation.
Education and literacy allow students
to clarify goals and desires and recog-
nize how they can bring about these
changes. This occurs when students
not only read the world and word but
also write the word and the world.
2
A
personal level of ownership and em-
powerment can stimulate changes on
a public level.
Freirian thought provides an interest-
ing lens through which to think about
health literacy in general and its devel-
opment among children and adoles-
cents more specically. Similar to ed-
ucational systems that perpetuate
unequal power relationships, one
could assert that certain medical
environments are responsible for
keeping groups powerless. The ab-
sence of problem-solving skills related
to health literacy renders people, es-
pecially vulnerable groups such as
children, unable to improve their
health on their own. Furthermore, the
relationship that Freire describes be-
tween the teacher and the student
might be comparable to the relation-
ship between the health provider and
the patient. A partnership would facili-
tate a young child to have more control
over his or her own health and behav-
iors. Lastly, a broader denition of
health literacy may be necessary. Al-
though a child or adolescent may be
unable to read and dene medical
texts, that same person might under-
stand healthy behaviors or medical
management in his or her home envi-
ronment and actively participate in
decision-making regarding his or her
own health care. In fact, the child or
adolescent may be more skilled at
reading the world to determine the
best path toward healthy behaviors
than the medical provider. Freirian
philosophy suggests that we address a
broader meaning of health literacy
and attempt to understand how chil-
dren and adolescents may achieve it.
The rest of this article is organized in
the following way. First, we present a
traditional denition of health literacy,
and then we describe howFreirian phi-
losophy can extend our thinking about
health literacy. Next, we offer a brief
description of Jean Piagets and Lev
Vygotskys theories on child develop-
ment. Finally, we discuss how Piaget-
ian, Vygotskian, and Freirian thought
contribute to emerging health literacy.
THE DEFINITION AND MEANING OF
HEALTH LITERACY
Various media and interpersonal chan-
nels convey important health messages.
An individuals ability to receive, com-
prehend, integrate, and act on those
messages makes up their level of
health literacy. True health literacy re-
quires understanding different mes-
sage types and using the conveyed
messages in appropriate ways. Such
literacy can be extremely complex and
varied. Consider the following 3 situa-
tions, all which involve individuals hav-
ing higher functioning levels of health
literacy.
A teenaged girl or young woman ips
through a magazine and comes across
an article that describes different
birth-control options. She reads and
ags them, with the intention of
e-mailing her health provider and ask-
ing whether she can adopt any of these
options. In this example, the young
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woman is exposed to messages and
decides to follow-up with an electronic
conversation with her physician.
A mother hears on the radio a recruit-
ment advertisement for a research
study on childrens sleep habits. She
goes to the study site and receives a
packet of information. After reading
the parental consent form, the mother
realizes that her child might be at
higher risk if he participates, because
his current medication might interfere
with the protocol. The mother refuses
consent and does not allowher child to
join the study.
A child wakes up in the middle of the
night with a fever. Her father remem-
bers that the family recently pur-
chased some over-the-counter fever
medication that is in the medicine cab-
inet. He reads the dosage-by-weight
and age information on the label and
determines that his 35-lb 3-year-old
daughter needs just 1 teaspoon of the
medicine. He administers it, and they
both go back to sleep.
The Healthy People 2010 report dened
health literacy 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.
3
Health literacy is not just the ability to
read health text; rather, it is a set of
skills that involves recognizing, pro-
cessing, integrating, and acting on in-
formation from a variety of platforms.
To be health literate, an individual
must be able to develop functional, in-
teractive, and interpretive skills. In ad-
dition, media-literacy skills seem es-
sential, especially when we consider
health literacy in todays media-rich
environment.
Besides acquiring knowledge, health
literacy includes interactive and crit-
ical health literacy.
4
Interactive
health literacy requires social skills
that help individuals interact in
health-promoting ways, whereas criti-
cal health literacy involves the ability
to analyze and apply knowledge to
function and be in more control.
4
Community and societal factors affect
health literacy. As an example, when it
becomes necessary to include more in-
formation on over-the-counter medica-
tion instructions, from either govern-
mental or population-wide demands,
text becomes smaller, more dense,
and harder to read. This, of course, af-
fects health literacy. As another exam-
ple, disease management nowinvolves
connecting with more subspecialists
across facilities and institutions.
Decision-making about care now re-
quires an awareness and under-
standing of complex systems, includ-
ing not only scheduling but also
receiving and paying for services.
From decreasing font size to increas-
ing complexity of health systems,
environmental factors can help or
hinder access and use of health
information.
Besides systemic issues, individual fac-
tors relate to and inuence health liter-
acy. Poor health literacy is strongly and
signicantly correlated to limited gen-
eral literacy skills. Such decits result
from weak or lacking educational op-
portunities, suboptimal support for lit-
eracy within the family, and/or learn-
ing and cognitive disabilities. The
elderly (aged 65 years), minority
populations, immigrant populations,
low-income groups, and people with
chronic mental and/or physical health
conditions are considered to be at
much higher risk for poor literacy.
5
It is intriguing to think that children
and adolescents were not mentioned
when describing vulnerable groups.
Although recommended initiatives to
improve health literacy often include
primary and secondary school teach-
ers, nurses, and librarians, the popula-
tions with whom these professionals
work are hardly ever mentioned.
CHILDRENS HEALTH AND
DEVELOPMENT
Why do we care about childrens health
literacy? In the United States, there are
74 million children under the age of
18 (almost 25% of the national popula-
tion).
6
Reportedly, most US children
are in very good or excellent health;
however, 10% lack any health insur-
ance coverage. Injury is the main
cause of death for those aged 1 to 14
years, and chronic illnesses remain a
problem for many.
7
In a 2006 survey,
5% of children had reportedly missed
11 or more days of school in the previ-
ous year; this rate was twice as high
for children in the lowest income
bracket or from single-mother house-
holds.
8
Currently, 16% of children and
adolescents are overweight, and 34%
are at risk of being overweight.
9
Ap-
proximately 14% of US children have
been diagnosed with asthma, and 9%
to 12% suffer from different types of
respiratory allergies.
8
It is estimated
that among children aged 3 to 17
years, 8% have a learning disability
and 7% suffer from attention-decit/
hyperactivity disorder.
8
CHILD DEVELOPMENT
Besides physical growth, childhood is
a time of tremendous cognitive, social,
and emotional development. Two
20th-century theoristsPiaget and
Vygotskyoffered important obser-
vations and concepts to consider in our
thinking of healthy child development.
Although other researchers and theo-
rists have contributed to current
thinking, it is Piagets theories that
form the foundation and much of our
understanding of child development.
Drawing on early interests in biology
and philosophy, Piaget tried to answer
a fundamental question: How does
knowledge evolve?
Piagetian theory suggests that chil-
dren move along a linear course
of development; Table 1 summarizes
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the different stages.
10
First is the sen-
sorimotor period, which characterizes
the time from birth through approxi-
mately the second birthday. Infants in
this stage move from reexive behav-
iors to habits. A 4-month-old may pick
up a rattle and learn that shaking the
object causes a sound. The child will
recognize that a personal action re-
sults in a manipulative outcome. From
the ages of 2 through 6 years, most
children are in the preoperational pe-
riod. During this stage, childrens rec-
ognition of symbolic thinking emerges,
mental reasoning grows, and the use
of concepts increases. A 4-year-old
child in this stage will recognize a
stop sign and know that it means
that mommy must stop the car when
she sees it.
The concrete-operation period follows,
typically from the age of 7 through 11
years. This stage is characterized by
the active and appropriate use of logic.
Despite changes in situations, children
learn to apply general and known rules
in a consistent way. Children can take
multiple aspects of a newenvironment
into account, an ability known as de-
centering. The child is no longer the
center of the world and can consider
that others have preferences and per-
spectives. In the next stage, the formal
operational period, those aged 11 years
and older develop the ability to think ab-
stractly. Hypothetico-deductive resound-
ing is used, in which individuals start
with a general theory about what pro-
duces a particular outcome and then
they deduce explanations for what has
brought about that outcome.
10
Central to Piagetian thought are 3 ma-
jor developmental processes: assimi-
lation, accommodation, and equilibra-
tion.
10
Assimilation is the means by
which children interpret incoming in-
formation to make it understandable
within their existing stage of cognitive
development and way of thinking. Ac-
commodation refers to the ways in
which children change their thinking
in response to new experiences, stim-
uli, or events. Equilibration is a 3-stage
process that integrates accommoda-
tion and assimilation. First, children
are in a state of equilibrium. Then, fail-
ure to assimilate new information
leads to their becoming aware of
short-comings in their current think-
ing. Finally, their mental structure ac-
commodates to incorporate the new
information in a way that creates a
more advanced equilibrium. These
processes allow cognitive develop-
ment and movement from 1 stage to
the next to occur.
To further illustrate the Piagetian
stages, it is interesting to consider
how children of different ages might
understand illness.
1113
A child younger
than 2 years might know illness as
something associated with feeling
poorly. He or she may not be able to
use the appropriate language to ex-
plain; however, his or her understand-
ing and thoughts about being sick may
be enough to evoke tears. Like the
younger child, the preschool-aged
child will associate illness with a vague
emotion (eg, it makes you feel sad), but
also this child may explain illness with
physical appearance or observable ac-
tion. For example, a 5-year-old girl
might explain being sick as when you
have bumps on your body or when
you throw up. A child in the next
stage associates illness with particu-
lar behaviors and consequences. A
9-year-old may not be capable of de-
scribing why a child has a fever, but he
or she would certainly be able to tell
you that such a child has to stay in bed
and cannot go to school for several
days. Those who are slightly older and
in the formal operational stage could
hypothesize, on the basis of subtle
clues, that certain environments might
put someone at risk for illness. It is
interesting to note that some recent
research on childrens understanding
of health and illness provided evidence
that comprehension may not be as lim-
ited as the Piagetian theory would sug-
gest.
12,13
For example, children younger
TABLE 1 Piagetian Stages of Cognitive Development
Stage Approximate
Age, y
Children in This Stage . . . Example
Sensory motor Birth to 2 Acquire knowledge through physical manipulation and
ones senses.
A child will learn about a rattle by sucking on it or
shaking it.
Preoperational 27 Develop symbolic thought and consider the world
from an egocentric perspective; everyone and
everything share the childs point of view.
A child says that his teddy bear only likes to eat the
foods that the boy likes to eat.
Concrete operational 711 Develop understanding if they are able to manipulate
a physical object. In the latter part of this stage,
abstract symbols can represent objects and be
manipulated instead of the objects themselves. The
child considers the perspectives of others.
A child can create a map of her neighborhood with
blocks and show the path she likes to use to walk to a
friends house.
Formal operational 1116 Can think abstractly, logically, and in terms of
organized systems.
When facing a choice of 2 activities (eg, doing homework
versus watching a movie), a child or adolescent can
think of the possible outcomes and hypothesize what
would be the optimal solution.
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than those in the formal operational
stage can provide sophisticated and ac-
curate descriptions of abstract pro-
cesses (eg, what might occur if one did
not brush his or her teeth).
13
Although Piaget and other theorists
formed a foundation for thinking about
childrens development, it was the Rus-
sian psychologist Vygotsky who broad-
ened our thinking to include ideas
about how social interactions and cul-
tural factors could greatly affect a
childs cognitive development.
14
Chil-
dren, in partnership with peers and
adults, learn within established cultural
and social institutions. Two concepts
advanced by Vygotsky that pertain to
the discussion of children and health
literacy are the zone of proximal de-
velopment (ZPD) and scaffolding.
A childs abilities are more likely to in-
crease if they are presented within the
childs ZPD. The ZPD is dened as the
difference between what a child can do
with assistance and what a child can
do on his or her own. Independently, a
child may not comprehend something
or be unable to perform a task, but
with assistance or scaffolding, he or
she can master a new topic or skill.
Across different cultures, scaffolding
occurs in practically every successful
learning situation.
15
An optimal learn-
ing environment is one that challenges
the child just at the edge of his or her
current understanding. Peers and
adults aide the child in gaining new
knowledge, and in fact, these relation-
ships promote faster and better com-
prehension. Vygotsky saw develop-
ment as learning-specic and general
tasks; such learning would always be
more successful in social and cooper-
ative settings.
Dynamic assessment, proposed Vy-
gotsky, should be used to measure
ones intelligence and abilities. Instead
of looking at cognitive processes that
are fully developed, those that are be-
ing developed need to be considered.
In practical terms, this means that one
should not test children in isolation to
measure what they know and can do;
rather, a better assessment would
take into consideration how they per-
formwhen helped by peers and adults.
This has clear implications for chil-
drens health literacy and what and
how we should communicate to them,
as well as what role they should have in
managingtheir ownhealthandillness. In
contrast to developmental surveillance,
inwhicha childs actions are considered
in isolation, the pediatrician should do
a dynamic assessmentnoting how a
childadheres tohis or her medical treat-
ment with a parents assistance
because this is how medical self-
management would occur in the childs
natural environment.
CHILDREN AND HEALTH LITERACY
Given these notions of child develop-
ment, at what age should an individual
become responsible for his or her own
health? When should an individual try
to gain health-literacy skills? And how
might one assess a childs level of
health literacy?
Answers to these questions must start
with how one perceives the relation-
ship between the individual and medi-
cal system. Traditionally, it has been
the physician who has dened the
needs of the patient. It has been ar-
gued that that an unbridgeable com-
petence gap exists between physicians
and lay people, and because this
wealth of knowledge is impossible to
share, patients must accept the word
of the physician on faith.
16,17
Others be-
lieve that established relationships
and interactions persist to keep pa-
tients from challenging physicians
high status and societal standing,
contesting medical conduct, second-
guessing decisions, and even detect-
ing medical errors.
16
Parents and chil-
dren would adhere to rather than
challenge their pediatricians advice
and instructions.
We know that such medical paternal-
ism is obsolete. Especially in todays
world of patient- and family-centered
care, physicians need and want indi-
viduals to be health literate. With new
technology, more accessible health
information, and the sometimes-
transitory relationship between physi-
cians and patients, the patients under-
standing is fundamental for health.
There is a growing movement among
pediatricians and adolescent health
specialists for improving the health lit-
eracy of their patients, encouraging
even young children to become knowl-
edgeable consumers of health infor-
mation and environments.
Piaget and Vygotsky
If we expect the relationship between
patients and health providers to be
more balanced and we want children
and adolescents to be more involved in
their own health, then it is essential to
develop health literacy skills at an
early age. Piagetian and Vygotskian
theories can inform when and how
children can achieve certain levels of
health literacy. Considering age-
related developmental stages, even
young children can recognize icons
and images that convey health infor-
mation. Those who are slightly older
might be able to read and understand
health recommendations printed on a
Web site and incorporate these rules
into their daily activities. Quite likely, a
preadolescent could read a label on an
over-the-counter medication, consider
his or her age and weight, and mea-
sure the correct dosage. An adoles-
cent might see a theatrical production
about drug abuse, recognize the rele-
vant themes, and realize that the les-
sons learned by the on-stage charac-
ters might inform his or her own
engagement in risky behaviors. Vy-
gotskian theory could suggest that so-
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cial support, from family, friends, or
health providers, might facilitate the
learning of more difcult health con-
cepts at a younger age. Early elemen-
tary school-aged children with diabe-
tes might learn to monitor their own
blood sugar levels if given assistance,
even if they are at a cognitive stage
that would suggest that they cannot
handle the measurement activities. A
diabetic preadolescent, if in a social
cohort with other diabetics, might bet-
ter understand the more abstract im-
plications of his or her behaviors if
slightly older peers helped to clarify the
pertinent issues. When health concepts
and behaviors are culturally relevant
and part of the childs environment, a
child may understand their importance
at an earlier-than-expected age. To date,
studies examining these approaches do
not appear in the published literature;
empirical evidence is needed to show
that such approaches can lead to im-
proved health behaviors in children.
It is important to be familiar with de-
velopmental stages when creating
health materials and programs; how-
ever, boundaries should not be seen as
barriers. Imagine designing a televi-
sion program with the purpose of
conveying useful injury-prevention in-
formation to a preschool-aged child.
Through recognizable storylines, char-
acters could encounter familiar and less
familiar safety symbols (eg, cross-walk
signs, poisonsymbols) intheir neighbor-
hoods. More advanced thought and un-
derstanding might be achieved if the
producers recommend that children
watch the program with their older
siblings or parents or as part of a pre-
school experience. Learning at levels
even higher than expected would also
be achieved if, after watching the pro-
gram, the program instructed older
viewers to walk around and point out
these symbols within the childs own
neighborhood.
Freire
Children and adolescents who may be
marginalized by current health prac-
tices could be taught to take on a more
active role in health care practice. Par-
ents may discuss the content of a med-
ical examination or test results with
the health provider without including
the child or adolescent, perhaps want-
ing to protect the child or adolescent
from the negative aspects of the con-
versation. Even the selection of medi-
cations and medical or surgical proce-
dures may occur without the child or
adolescent being present and part of
the conversation. Fostering more par-
ticipatory strategies, however, can
encourage greater responsibility for
learning and well-being; this, in turn,
alters patterns of dependence.
16
When
children are provided with and rein-
forced to have empowering experi-
ences, youth become agents of change,
for personal as well as community
health. When children are more aware
of the health issues facing them and
their peers, they may take action to im-
prove their health.
Health literacy skills should be encour-
aged at a very young age. First, chil-
dren and adolescents are increasingly
involved in their own health care man-
agement; young people see and regu-
larly interact with health messages, in-
terventions, and health practitioners.
Healthy literacy skills can alter exist-
ing and future behaviors; with greater
health literacy, children and adoles-
cents can take more control and own-
ership of their own habits and deci-
sions. When children take more
control of their own health, it is possi-
ble that they might adopt and build on
health-promoting lifestyles. Second,
children already make decisions that
affect their current health. A 7-year-old
may or may not put on a helmet when
riding his or her scooter to school. An
11-year-old has a choice when offered
to try a cigarette. A pregnant 17-year-
old resolves to terminate or continue a
pregnancy. Finally, health attitudes and
behaviors formed during childhood
greatly predict adult healthpatterns. For
example, childrens food preferences
andmediabehaviorsaresignicantly re-
lated to being overweight or at risk for
obesity in adulthood.
18
As promoted in the Freirian literacy
program, emerging health literacy
should involve dialogue. When the
health provider or health system is
more aware of the learners world,
then the experience is better for all
participants. Children should not be
placed in a passive role when learning
about health; interaction should be en-
couraged so that a partnership occurs
to promote better understanding and
more healthy behaviors. An optimal
learning experience requires growth
not only by the student but also by the
teacher. Likewise, an optimal medical
experience should involve patients as
well as health educators learning from
the particular circumstance or en-
counter. Imagine a pediatric nurse
explaining to a 7-year-old child who
suffers from asthma how to use
an inhaler. Improved compliance is
achieved when the child actively lis-
tens to the nurse but also when the
nurse knows the environmental barri-
ers that keep the child from using the
inhaler. As another example, consider
a Web-based intervention that encour-
ages physical activity among middle
school students. The site might be
more effective if designers evaluate
and modify the online experience so
that greater interactivity occurs.
To date, most tools that assess health
literacy focus on the reading of
health text.
19
No instruments have fo-
cused on measuring health literacy
related behaviors that involve deci-
phering obstacles and symptoms in
ones own personal environment. A
child may be unfamiliar with letters,
numbers, or graphic representations;
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however, he or she might be able to
identify or react to specic hazards
that compromise the health of commu-
nity members. For example, even a
very young child can recognize a nox-
ious odor coming from a container.
Despite the fact that the child cannot
read the label hazardous waste, he
or she might still avoid the container
and get an adult to help alleviate the
immediate predicament. The child
can also be taught to understand the
pictogram or symbol for poison on
containers.
With literacy, Freire believed that per-
sonal and social transformation was
possible. Similarly, the development of
health literacy will enhance both indi-
vidual and public health. Teaching
youth to recognize, use, and interact
with different resources for personal
health will empower themto engage in
health-promoting activities, leading to
personal and societal changes.
CONCLUSIONS
This consideration of Freire, Piaget,
and Vygotsky suggests that even the
youngest child is able to gain the nec-
essary skills on a path toward health
literacy. Those between the ages of
3 and 18 can seek, comprehend, eval-
uate, and use health information, espe-
cially if materials are presented in
ways that are age appropriate, cul-
turally relevant, and socially sup-
ported. The development of health
literacy among children and adoles-
cents can empower this vulnerable
and marginalized group to be more
engaged, more productive, and
healthier.
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2009;124;S282 Pediatrics
Dina L.G. Borzekowski
Considering Children and Health Literacy: A Theoretical Approach

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