essay about childrens health

Lifelong Health

Health in the earliest years — beginning with the future mother’s well-being before she becomes pregnant — strengthens developing biological systems that enable children to thrive and grow up to be healthy adults. Positive early experiences provide children with a foundation for building sturdy brain architecture , which supports a broad range of skills and learning capacities throughout the lifespan.

See the latest from the Center on lifelong health:

• Working Paper: Connecting the Brain to the Rest of the Body: Early Childhood Development and Lifelong Health Are Deeply Intertwined
• InBrief: Connecting the Brain to the Rest of the Body
• Infographic: What Is Inflammation? And Why Does it Matter for Child Development?

Why Does Early Health Matter?

The biology of health explains how experiences and environmental influences “get under the skin” and interact with genetic predispositions.

“Early experience literally is built into our bodies, for better or for worse.” InBrief: The Foundations of Lifelong Health

The resulting physiological adaptations or disruptions affect lifelong outcomes in learning, behavior, and both physical and mental well-being. Science tells us:

• Early experiences are built into our bodies , creating biological “memories” that shape development, for better or for worse.
• Toxic stress caused by significant adversity can undermine the development of the body’s stress response systems, and affect the architecture of the developing brain, the cardiovascular system, the immune system, and metabolic regulatory controls.
• These physiological disruptions can persist far into adulthood and lead to lifelong impairments in both physical and mental health.

The Three Foundations of Lifelong Health

Extensive scientific research has identified three basic foundations of lifelong health that are laid down in early childhood.

• A stable and responsive environment of relationships. These provide young children with consistent, nurturing, and protective interactions with adults , which help them develop adaptive capacities that promote learning and well-regulated stress response systems.
• Safe and supportive physical, chemical, and built environments. These provide children with places that are free from toxins and fear, allow active and safe exploration, and offer their families opportunities to exercise and form social connections.
• Sound and appropriate nutrition. This includes health-promoting food intake and eating habits, beginning with the future mother’s preconception nutritional status.

Caregiver and Community Capacities that Promote Health

Ensuring that children have a healthy start to life requires the support of family members, early childhood program staff, neighborhoods, voluntary associations, and parent workplaces. The caregiver and community capacities that enable adults to strengthen the foundations of child health can be grouped into three categories:

• Time and commitment. This includes the nature and quality of time caregivers spend with children and how communities assign and accept responsibility for monitoring child health. It also includes how communities pass and enforce legislation and regulations that affect child well-being.
• Financial, psychological, and institutional resources. These include caregivers’ ability to purchase goods and services, their physical and mental health, and their child-rearing skills. Also important are the availability of community services and organizations that promote children’s healthy development, as well as supportive structures such as parks, child care facilities, schools, and afterschool programs.
• Skills and knowledge. Caregivers’ education, training, interactions with child-related professionals, and personal experiences affect their capacity to support children. Similarly, the political and organizational capabilities of communities affect their ability to build systems that work for children and families.

Policies and Programs that Improve Health Outcomes

Nearly any policy or program that touches the lives of children and families is an opportunity to improve lifelong health outcomes.  

“People like to say that children’s health is our nation’s wealth, but until we really start to act on these ideas…we will not get to being a healthier population and a more prosperous society.” InBrief: The Foundations of Lifelong Health

Within both the public and private sectors, policies and programs can benefit children by enhancing the capacities of their caregivers as well as the communities in which they develop. Relevant policies include legislative and administrative actions that affect public health, child care and early education, child welfare, early intervention, family economic stability, community development, housing, environmental protection, and primary health care. The private sector can also play an important role in strengthening the capacities of families to raise healthy and competent children, particularly through supportive workplace policies.

Health Graphic Description

The graphic shows a series of four arrows, one after the other, each pointing right, moving from left to right. Each arrow represents a facet of policy or programming innovation to help enhance children’s lifelong health. The arrows exist in a larger oval labeled “Settings” which describe where these innovations can take place. The oval includes the following labels as examples of settings: “Workplace,” “Programs,” “Neighborhood,” and “Home.” The last of the arrows points to a circle labeled “Health and Development Across the Lifespan.” Within the circle are listed stages of life, moving from Preconception to Prenatal to Early Childhood to Middle Childhood to Adolescence and finally to Adulthood. The labels on the four arrows are as follows, in order from left to right:

Policy and Program Levers for Innovation

• Primary Health Care
• Public Health
• Child Care and Early Education
• Child Protection and Social Welfare
• Economic and Community Development
• Private Sector Actions

Caregiver and Community Capacities

• Time and Commitment
• Financial, Psychological, and Institutional Resources
• Skills and Knowledge

Foundations of Health

• Stable, Responsive Relationships
• Safe, Supportive Environments
• Appropriate Nutrition

Biology of Health

• Cumulative Over Time
• Embedded During Sensitive Periods

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National Research Council (US); Institute of Medicine (US). Children’s Health, The Nation’s Wealth: Assessing and Improving Child Health. Washington (DC): National Academies Press (US); 2004.

Children’s Health, The Nation’s Wealth: Assessing and Improving Child Health.

• Hardcopy Version at National Academies Press

1 Introduction

Children are vital to the nation’s present and its future. Parents, grandparents, aunts, and uncles are usually committed to providing every advantage possible to the children in their families, and to ensuring that they are healthy and have the opportunities that they need to fulfill their potential. Yet communities vary considerably in their commitment to the collective health of children and in the resources that they make available to meet children’s needs. This is reflected in the ways in which communities address their collective commitment to children, specifically to their health.

In recent years, there has been an increased focus on issues that affect children and on improving their health. Children have begun to be recognized not only for who they are today but for their future roles in creating families, powering the workforce, and making American democracy work. Mounting evidence that health during childhood sets the stage for adult health not only reinforces this perspective, but also creates an important ethical, social, and economic imperative to ensure that all children are as healthy as they can be. Healthy children are more likely to become healthy adults.

Within this context, it is reasonable to ask what it means for children to be healthy and whether the United States is adequately assessing and monitoring the health of its children. Do available surveillance and monitoring approaches provide the information necessary to ensure that common priorities and shared resources are aligned with children’s needs and deployed to optimize their health? Are there ways to improve methods to better guide policies and practices designed to make children healthier? This report addresses these questions.

Children are generally viewed as healthy when they are assessed by adult standards, and there has been a great deal of progress in reducing childhood death and diseases. But the country should not be blinded by these facts—several indicators of children’s health point to the need for further improvement, children in the United States do not fare as well as their European counterparts on many aspects of health, and there are marked disparities in health among children in the United States. Recent improvements in children’s health need to be sustained and further efforts are needed to optimize it. To accomplish this, the nation must have an improved understanding of the factors that affect health and effective strategies for measuring and using information on children’s health. This chapter starts with what is known about the health of children. It then moves to a discussion of why measuring children’s health is important. The chapter concludes with an examination of why critical differences between children and adults establish the need for children’s health to be held to a standard different from that used for adults.

• CHILDREN AND THE STATE OF THEIR HEALTH

Dramatic improvements have occurred over the past several decades in such areas as reducing infant mortality, reducing mortality and morbidity from many infectious diseases and accidental causes, increasing access to health care, and reducing environmental contaminants, such as lead ( Centers for Disease Control and Prevention, 1999b , 2000a ). There have been steady increases in the proportion of immunized children, and both acute mortality and long-term disabilities resulting from certain infectious diseases have been greatly reduced. Learning how environmental exposure to lead adversely affects children’s development contributed to great reductions in ambient lead and significantly reduced childhood blood lead levels ( Lanphear, Dietrich, and Berger, 2003 ). Average concentrations of lead in the blood of children younger than 5 years dropped 78 percent between 1976–1980 and 1992–1994 ( U.S. Environmental Protection Agency, 2000a ). Fewer adolescents are having babies—in 1999, the teenage pregnancy rate reached the lowest recorded rate since 1976 ( Child Trends, 2003 ). Daily cigarette use fell by over 50 percent (from 10 to 5 percent) among 8th grade students between 1996 and 2002, and by over two-fifths (from 18 to 10 percent) among 10th grade students ( Child Trends, 2003 ).

Yet despite these improvements, some national indicators raise questions about the health of the nation’s children and point to the need for continued progress. The children behind each of these statistics face serious barriers to healthy childhoods and healthy, productive adult lives. For example, 12–19 percent of children in the United States have chronic health conditions ( Newacheck, Hung, and Wright, 2002 ; Stein and Silver, 2002 ), an estimated 15 percent of children and adolescents ages 6–19 years are overweight ( National Center for Health Statistics, 2002b ), and 1 in 10 children have significant mental health conditions that cause some form of impairment ( Satcher, 2001 ). Despite the country’s great wealth, some children are not surviving past childhood. Even with recent improvements in child mortality, approximately 7 out of 1,000 children die before the age of 1 ( Federal Interagency Forum on Child and Family Statistics, 2003 ), and 44 percent of deaths of children between the ages of 1 and 19 are caused by unintentional injuries ( Anderson and Smith, 2003 ).

Children, particularly poor and minority children, are not faring as well as the public might think. The current and future prospects of these children, and the prospects of the nation as a whole, are reduced as a result. The nation needs to consider the significance of statistics such as these and adopt prudent policies to improve children’s health if it is to successfully maximize the potential of all its children and ensure the future health of the nation.

Even more distressing than the absolute numbers are the sustained and marked disparities between white children and racial and ethnic minority children, and between children in poorer families and wealthier families. For example, blacks have higher infant mortality ( Centers for Disease Control and Prevention, 2002d ) and adolescent mortality rates, with the death rate for adolescent males increasing from 1985 to 2000 (125 to 130), while the rate for white adolescents males decreased (105 to 86) ( Federal Interagency Forum on Child and Family Statistics, 2003 ). Teenage pregnancy rates have fallen but blacks still have higher rates than other population groups ( Ventura et al., 2003 ). Hispanic children are more likely than both black children and white children to lack health insurance ( Institute of Medicine and National Research Council, 1998 ) and twice as likely to drop out of school ( Martinez and Day, 1999 ). These and other substantial disadvantages for some groups of children during childhood have major effects both on child health and on adult health outcomes and subsequent health care costs and productivity. These discrepancies are particularly disturbing given projected population changes over the next several decades. While the proportion of children is projected to stay relatively constant (24 percent), the non-Hispanic white child population is projected to decrease from 64 to 55 percent by 2020, while the percentage of Hispanic children is projected to increase from 16 to 22 percent ( U.S. Department of Health and Human Services, 2001b ).

The health of the U.S. population generally, and children’s health in particular, lags behind that of many Western industrialized countries ( Shi and Starfield, 2000 ). For example, while the infant mortality rate has decreased by more than 50 percent in the past two decades, the United States still has an infant mortality rate that is higher than all but 5 other Organisation for Economic Co-operation and Development (OECD) nations (Hungary, Mexico, Poland, the Slavic Republic, and Turkey) ( Organisation for Economic Co-operation and Development, 2002 ). While this might be partly attributable to the more inclusive definition of live birth used in the United States, data suggest that this is not the only factor. An in-depth comparison involving 13 industrialized nations in the mid-1990s showed that the United States ranked worst (13th) in rates of low birthweight. Similar poor rankings for postneonatal mortality (11th) indicate that the poor infant mortality ranking is not a result solely of the high percentage of low-birthweight infants. Postneonatal mortality is less sensitive to low birthweight and more sensitive to receipt of good basic (primary) care ( Starfield, 2000b ).

In another international comparison, the United States ranked lowest among major industrialized nations on equity of child survival (to age 2) and had the highest probability of dying before age 5 ( World Health Organization, 2000 ). The United States also ranks poorly (23rd) in child (ages 1–14) death rates from injuries among 26 OECD countries (1992–1995 data). Among a subset of 15 of these countries (including Mexico, a developing country by OECD standards), the United States ranks in the worst 5 on 3 of the 5 categories of injury deaths: 11th for motor vehicle injury deaths, 15th for deaths resulting from fire, and 14th for deaths due to homicide ( United Nations Children’s Fund, 2001 ).

WHY MEASURING AND USING CHILDREN’S HEALTH DATA ARE IMPORTANT

Measurement and appropriate use of data on children’s health and influences on health can help ensure that federal, state, and local policies are based on good information and are designed to enhance the health of children. This will reap benefits for both today’s children and the adults they will become. The use of child health reporting systems can improve awareness among policy makers and other stakeholders about the complex needs of children and their families ( Halfon, Newacheck, Hughes, and Brindis, 1998 ). Good measurement and reporting of data as well as judicious integration of data help to target public expenditures and interventions toward identified problem areas and identify areas for further research. Comprehensive tracking systems can help to identify changes in patterns in children’s health and to develop appropriate public health responses. For example, recognition of obesity and asthma as significant public health issues might have been facilitated by more comprehensive data collection and monitoring systems that identified changes and the likely correlates of these changes.

At the state and local levels, combining data from multiple sources can increase planning efficiency and provide a more useful picture of children’s health. States and localities have used child health tracking systems to target public health insurance enrollment activities ( Box 6-4 is one example), to increase immunization rates and receipt of other preventive health services, to identify areas with particularly high incidence of such diseases as cancer, to facilitate case management among the many medical and other service providers sometimes involved in children’s lives, and to improve communication across agencies and with legislators and other policy makers ( Association of State and Territorial Health Officals, 2003 ). Measurement systems that consider the relationship of various factors in the family, community, and physical environments also serve as early warning systems about things like toxic neighborhoods, risky family situations, and poor school environments. Monitoring of such influences can help identify the need for policy or other interventions early and, if implemented, avoid potential long-term negative consequences.

Good measurement systems also allow comparison within and across jurisdictions. They facilitate identification of specific geographic areas where health problems are concentrated. The establishment of state and local data systems allows these areas to compare their progress with that of other comparable areas and to identify areas that need improvement. Finally, good data systems at the local, state, and national levels provide early evidence of failures and successes so that more rapid and more targeted modifications can be made in interventions and public policies.

THE COMMITTEE’S STUDY

In 2000, Congress responded to concerns raised about risks to children’s health by directing the U.S. Department of Health and Human Services 1 to fund a study by the National Academies. Congress requested the National Academies to conduct “an evaluation on children’s health [that would] assess the adequacy of currently available methods for assessing risks to children, identify scientific uncertainties associated with these methods, and develop a prioritized research agenda to reduce such uncertainties and improve risk assessment for children’s health and safety.”

The Board on Children, Youth, and Families of the National Research Council and Institute of Medicine in consultation with the Department of Health and Human Services and expert advisers developed a statement of task that expanded this basic charge. The Committee on Evaluation of Children’s Health : Measures of Risk, Protective, and Promotional Factors for Assessing Child Health in the Community was formed to examine key issues regarding the definition and measurement of children’s health, influences that affect children’s health, and the optimal use of data on children’s health. Specifically, the committee was charged with considering these questions:

• How is children’s health defined? Are these definitions appropriate? If not, what is an appropriate definition of children’s health?
• What data and methods are being used to assess and monitor children’s health at the federal, state, and local levels? Are these data and methods adequate and appropriate? If not, what types of data and methods are needed and what are the strategies for their development and application? How could new technologies be used to link individual, family, community, and clinical data to assess and monitor children’s health? What are the technical challenges and limitations for linking such data?
• What are the risk, protective, and promotional factors to children’s health, safety, and well-being? What data and methods are used to assess and monitor these factors? Are these data and methods adequate and appropriate? What new assessment tools or methods are needed and what are the strategies for their development and application?
• Ideally, how should data be used to inform both policy and practice to ensure children’s health, safety, and well-being? What are the ethical considerations in obtaining such data and in their application?

The study committee included 13 members with expertise in key areas related to children’s health. The committee heard from a range of stakeholders active in various aspects of the field to benefit from a wider range of viewpoints and to obtain input on our charge. The committee’s first tasks were to (1) define what is meant by children; health, safety, and well-being; and risk, protective, and promotional factors and (2) determine how to approach the task of reviewing federal, state, or local data and methods.

The committee adopted the term “children” to refer to groups of individuals from the time of birth to their 18th birthday. Surveys and other data sources employ differing age ranges, and the committee recognizes that, from a developmental perspective, there is no exact age at which childhood definitively ends. Numerous factors can affect the timing of one’s transition from adolescence to adulthood and, as a result, individuals transition from child to adult roles at different rates. For some, adult roles are assumed during adolescence, while for others this does not occur until the middle of the third decade of life. Nevertheless, many datasets and systems consider individuals before and after they reach legal majority, so the committee has chosen age 18 as a minimum age for ending childhood. However, while the committee asserts that data on children’s health should extend at least to that point, collection of data for those older than 18 should be an important data collection priority for the nation. The committee also recognizes that myriad factors affect the developing fetus prior to birth that impinge on and influence the health of children at birth. In this report these prenatal factors are considered and discussed as influences on children’s health.

Although the terms “youth” or “adolescents” are often used to refer to older children and the terms “infants” and “toddlers” refer to very young children, for ease of reference, this report uses the term “children” to encompass all these groups. If a statement is intended to refer to a subset of the child population (e.g., infants, adolescents) the relevant descriptive term is used in the text.

Children’s Health, Safety, and Well-Being

The committee was asked to assess definitions of health and questions related to children’s health, safety, and well-being. This section provides a brief overview of the committee’s approach to children’s health and outlines how safety and well-being were considered in the report. Chapter 2 discusses these issues in more detail.

Health: Most available definitions or conceptualizations of health have been developed for adults. In the committee’s view, these approaches do not account for issues particularly salient for children and do not reasonably transfer to children’s health. Definitions of children’s health must account for their special characteristics, particularly rapid development during childhood. They also must consider multiple influences that interact over time in different ways as children develop and change. The committee proposes a new definition of children’s health that embraces health conditions, functioning, and health potential in a new conceptual model that considers multiple interrelated factors as influences.

Safety : Safety generally refers to aspects of the environment that contribute to health, including the physical environment (e.g., absence of toxins or pollutants in ground water, use of car seats and bicycle helmets), social environment (e.g., low neighborhood crime rates, low rates of risky behaviors either by the children or adults), and psychological environment (e.g., the perception of not being in personal danger). Some environmental and behavioral influences might be conceptualized as contributing to less safe situations, while others might be viewed as health-promoting, safety-related, or protective.

At any given moment in time, children are exposed to a range of risk and protective influences. To the extent that one or the other predominates (assuming this could be determined), it may be possible to characterize children’s social or biological environments as relatively safer, health-promoting, or risky. More often it is possible to characterize an environment as risky or safe with respect to a single influence or single set of variables. Such factors can be used to make statements about the likely current or future health of a given population and, in effect, are often used as “proxies” for the actual health of a given population. In this report, children’s safety is considered to be those influences that result in an environment that contributes positively to health and is discussed primarily in Chapter 3 .

Well-Being: Well-being is commonly considered to be the sense of self as appraised by the individual. Concepts such as quality of life, fulfillment, and ability to contribute constructively to society and one’s own family are important aspects of well-being. Well-being inherently involves comparisons with how one feels one should be, given one’s age, preexisting health status or the health status of other persons in the social network, and physical status. For example, some children with attention deficit disorder and asthma that is controlled by medication, who are able to participate in a range of extracurricular activities and have many friends, may perceive themselves as healthy and fortunate, whereas others may not. Or children with no obvious physical illness but a subjective sense of poor well-being might be conceived to be in good physical health but potentially in compromised psychological health or in physical peril. Thus, one’s sense of well-being is an important component of overall health that has been shown to affect one’s overall functioning and prognosis, at least in adult health ( Berkman and Syme, 1979 ).

In the developmental literature, well-being is often considered to be a state broader than health that incorporates social, psychological, educational, behavioral, and economic dimensions. The term “health and well-being” is used to recognize that aspects of children’s life beyond traditional health considerations are important to both their current condition and to their future potential as adults, as well as to capture positive aspects of health. The committee contends that behavioral, psychological, and social well-being are core aspects of health and has incorporated these within the domain of health termed “health potential,” discussed in the next chapter. As used in this report, the term “health” therefore inherently embraces health-related aspects of well-being.

Risk, Protective, and Promotional Factors (Influences on Children’s Health)

A multitude of biological, behavioral, and environmental factors can either pose a risk to children’s health or act in a protective or health-promoting capacity. For example, children’s social environments can be characterized by a number of influences that can be viewed as safe, health-promoting, risky, or detrimental. Many factors (e.g., peers) can be either a risk to health or a protective factor, depending on the specific circumstances. Given this uncertainty, the committee adopted the term “influences on children’s health” to refer to risk, protective, and promotional factors.

The distinction between health and influences on health is usually straightforward. In a few instances, however, the distinction is ambiguous. For example, risk behaviors are considered an influence in this report, although a strong case could be made that daily alcohol use by an adolescent indicates poor health in terms of functioning. Likewise, an individual’s genetic endowment is considered an influence because in most instances gene expression interacts with other factors before it causes disease or impairment in functioning.

The committee recognizes that children’s health is the result of a dynamic set of factors. In a few cases, randomized, controlled trials or experimental studies (or both) have demonstrated a causal link between a particular influence and health. In other cases, while there is evidence to suggest a link between the influence and health, a direct causal link has not been established. In determining whether to include a given influence in this report, the committee included factors that meet at least two of these three criteria: (1) the existence of randomized control trials or experimental studies that demonstrate a causal link; (2) longitudinal prospective studies plus other nonexperimental or quasi-experimental evidence that supports a link; and (3) observational studies, plausible theory, or animal studies that support a link. Furthermore, inclusion required a substantial body of evidence with replicated studies and multiple, independent laboratories or researchers reaching the same conclusions.

Typically, current research assesses the effect of a single or a small set of influences but does not allow an assessment of the relative importance of multiple influences in relation to one another. In the committee’s view, the relative lack of research on children’s health generally, and the interaction of various influences specifically, precludes a reliable ranking of influences. Instead, we have included all factors that meet a defined threshold of evidence and excluded those that, while plausible, do not yet have sufficient evidence to support their effect. The committee calls for research to allow refinement of the influences and their relative effect.

Data and Methods

Numerous federal, state, and local surveys and administrative data sources are used to inform policy and programmatic decisions. In specifying available data sources, the committee chose to focus on national data sources or state-level sources that are available in all or most states. Conducting a comprehensive review of the innumerable data sources that measure children’s health or a component of it in individual states or localities was not feasible. Instead, the committee highlights state or local examples to illustrate strategies proposed in the report.

THE COMMITTEE’S PREMISES

The committee approached its charge based on several underlying assumptions related to the importance of measuring and using data on children’s health:

• children are vital assets of society;
• critical differences between children and adults warrant special attention to children’s health;
• children’s health has effects that reach far into adulthood;
• the manifestations of health and definitions and causes of ill health vary for different communities and different cultures; and
• the tracking of data on children’s health and its influences is an essential part of efforts to improve children’s health and the health of the adults they will become.

Children Are Vital Assets of Society

Children have intrinsic value in their own right. In the committee’s view, fully protecting the health and growth of children is one of society’s primary responsibilities. Optimal health and development are necessary preconditions to provide the opportunity for all children to reach their inherent potential. The reality that some children do not have the opportunity to grow up healthy and become productive members of their communities and the nation has enormous ramifications for all. Failure to optimize the health and development of children will result in future burdens of dependence that come from an unhealthy and unskilled workforce and dysfunctional families. Furthermore, growing scientific evidence demonstrates that disparities in health have their origins in early childhood and, if not addressed, are compounded over the life course ( Ben-Shlomo and Kuh, 2002 ; Hardy, Kuh, Langenberg, and Wadsworth, 2003 ; Halfon and Hochstein, 2002 ; Institute of Medicine, 2001b ). Therefore, the committee undertook its task with the conviction that it is important for the whole of society to be committed to ensuring that children are as healthy as possible and that all children are afforded an opportunity to optimize their individual health and development. In the committee’s view, maximizing children’s health will provide immediate benefits to them as well as determine their capacity to contribute to society and the common good over the long term.

Critical Differences Between Children and Adults

Many other reports have examined issues related to the health of Americans generally. Thus, a legitimate question is: Why should a report focus specifically on the health of children? The answer is that there are many differences between children and adults. Therefore, it is inappropriate to assume that what enhances or impedes adult health translates directly into children’s health. While many factors may be relevant to both child and adult health, a wide range of factors affect them differentially.

Developmental Differences

Children’s physiology and behavior differ in ways that require a different view of their health that is sensitive to rapid developmental change and unique developmental considerations. The particular patterns of gene expression, the relative sizes and growth of children’s organs, the injuries to which they are susceptible, and the manner in which they interact with their environments differ in many ways from adults. For example, the surface area of their skin and lungs is proportionately greater in comparison to their weight than at any other time of life. This makes children more vulnerable than adults to certain types of environmental exposures ( National Research Council, 1993 ). Children’s behavior also differs in significant ways from that of adults. Children are by nature exploratory and many of their exploratory behaviors, hand-to-mouth behaviors, crawling, climbing, testing the limits of their capacity, and experimentation involve activities that are not normative for adults. As a result, children have greater exposure to a number of hazards in their physical world. In addition, they lack the cognitive mastery and behavioral inhibitions that are normally associated with adults and consequently they may exhibit behaviors that place them at significant risk for negative long-term consequences.

In addition, children grow more rapidly, most notably during the early years and again during adolescence, and change body and organ sizes and proportions at faster rates than at any other time of life. Furthermore, development occurs at different rates in individual children, and it is heavily influenced by a wide range of factors, from nutrition and nurturance to experiences and opportunities for learning ( National Research Council and Institute of Medicine, 2000 ). The manner in which a child grows cognitively, emotionally, socially, and physically are key components of children’s health that are not routinely part of assessments of adult health. As a result, indicators of a healthy 6-week-old, 6-month-old, and 6-year-old will be different. Given these dynamic elements, in general, it is necessary to look at changes over time, rather than a point assessment to distinguish among different levels of health.

Childhood is characterized by children’s dependency on their families and communities ( Jameson and Wehr, 1994 ; Halfon, Inkelas, Wood, and Schuster, 1996 ). A newborn infant cannot survive without adult caregivers. Children are not free agents who can access services, determine diets, or change the environments in which they are raised. They lack voice and control of their own destiny. While autonomy increases with growth and development, during most of their childhood children are fundamentally dependent on the adults in their environment for the prevention of disease and the promotion and protection of their health and development.

Different Manifestations of Poor Health

The distribution of disease in childhood and the nature and types of health threats that affect children are different than in adults. Children have a lower prevalence than adults of chronic illnesses that require expensive, high-tech interventions and a higher prevalence of repeated acute illness. They also experience an array of congenital problems and inborn errors of metabolism that may not be seen in adults. What especially distinguishes the majority of children from adults is their greater resilience, less rapid biological deterioration, and continued ability to develop and grow in the face of negative health conditions. As a result, in many cases, interventions are more possible and more effective with children than with adults.

Childhood Has a Long Reach

What happens to children early in their lives can have profound implications for later health and well-being during adulthood ( Wadsworth, 1999 ). A great deal of information is emerging on the high degree to which early events and conditions of childhood serve as precursors of adult disease. From Neurons to Neighborhoods , a recent report of the National Academies, states: “What happens during the first months and years of life matters a lot, not because this period of development provides an indelible blueprint for adult well-being, but because it sets either a sturdy or fragile stage for what follows” ( National Research Council and Institute of Medicine, 2000 , p. 5). Experiences early in life establish a physical, psychological, and social foundation on which future development and adult health are based. This can include prenatal and perinatal insults as well as exposures in childhood that lead to negative adult health outcomes. For example, early exposure to ultraviolet light has implications for the development of melanoma in adulthood. Habits and behaviors developed during childhood can also lead to health problems in adulthood. Diet and exercise habits acquired in early childhood have been shown to have cumulative effects that alter adult health outcomes in the absence of appropriately targeted interventions.

Both positive and negative influences early in life not only have direct effects on health during childhood, but also act to influence future health at each stage of development. Both negative and positive factors and health disparities compound their effects over a lifetime. At each stage, previous health affects current and future health, and the cumulative effects of early differences in health may result in profound differences in later health (see Keating and Hertzman, 1999 ).

Failure to influence children’s health in a positive way may result in later excessive morbidity. The later consequences may be even more difficult and expensive to change than might prevention efforts put forth earlier in life. The capacity of an adult to contribute as a productive member of society may also be dramatically affected by poor health experienced as a child. This also means that there is often a long lag time between the measurable effects of interventions in childhood and changes in health later in life. This in turn makes it much more difficult to assess whether health is improving in both the short and the long run.

Community and Cultural Variation

Although there are some absolute notions of health (e.g., absence of disease), the manifestations of health differ across social and cultural groups. This is reflected in the differing notions of health across human societies and within societies over time. Common and technical use of terms like “disease,” “illness,” and “impairment” is embedded in a cultural context, which will determine whether certain symptoms, signs, or disease manifestations are considered normal or worthy of distinction in either a positive or negative way. For example, notions of normal body size differ substantially in different parts of the world and over generations. Aspects of health, social, and cultural norms influence concepts of health as well as understanding of the causes and consequence of the variety of its aspects. When these notions translate into individual and group behaviors and attitudes, they can have a major effect on health.

Culture also provides a framework for the use of home remedies. For example, in some Hispanic and Asian communities, health is a balance between “hot” and “cold,” and an imbalance in favor of one can cause illness necessitating a remedy from the other to restore harmony ( Risser and Mazur, 1995 ). Other cultural variations that can be misconstrued are the traditional practices of cupping and coining, which can be mistaken for child abuse ( Hansen, 1998 ), and home remedies for such folk illnesses as caída de mollera (fallen fontanelle), mal ojo (evil eye), and empacho (intestinal blockage).

In addition, social or cultural views on health, as well as the circumstances of a given community, may affect the priorities of that community in terms of what is considered important. It is therefore critical for specific societies and communities to define the measures they deem most salient to their local circumstances and for those working to improve health to take into account cultural differences and the priorities of that community. For example, a low-income community in which food is scarce and healthy children are defined by carrying extra weight may not consider obesity a priority health problem compared with reducing other more immediate threats to health, such as crime.

Use of Data to Improve Children’s Health

How can the nation assess whether movement toward the goal of optimizing children’s health society-wide is being achieved? Without the capacity to measure and monitor progress, there is no way to know whether changes in policy make a difference toward improving children’s health. Lack of valid and reliable information impedes comparisons across time or place or in response to interventions. Without data to measure and monitor children’s health, the effect of changes in the social, cultural, and physical environment will remain unknown.

What is measured is often what gets attention. Conversely, aspects that are more difficult to assess are more likely be ignored. This report addresses the questions of whether what is measured is what ought to be measured; whether it is being measured in an appropriate manner; and whether information is being used in a way that will optimize children’s health.

THE COMMITTEE’S VISION

Although the committee views the findings in this report as relevant to multiple audiences, federal, state, and local decision makers are considered to be the primary audience. The committee proposes strategies to address gaps in knowledge about children’s health and influences on it, tools available to measure both, and ways to use data about children’s health and influences on children’s health to inform policy decisions. The committee’s recommendations aim to focus on action and results, address future health measurement needs, and improve understanding of children’s health and influences on children’s health through specific research priorities.

To make the report as practical as possible and facilitate its use, the committee focuses on feasible next steps such as integrating existing datasets, and outlines strategies by which children’s health might be improved. The definition of children’s health and the conceptual framework presented in this report have important policy implications for the ultimate health of the nation, as well as the health of the nation’s economy, its workforce, and its viability as a future leader among nations.

Given the rapid strides in the development of new technologies, such as electronic information systems and the Human Genome Project, the committee has addressed future information needs both in terms of specific types of indicators as well as the types of systems and infrastructures necessary to make better data available at national, state, and local levels.

Where indicators, measurement tools, and measurement systems are not available, the committee has identified research to address gaps in knowledge. Research to examine the interaction of multiple influences and improve understanding of the dynamic nature of children’s health is also identified.

• STRUCTURE OF THE REPORT

This report has seven chapters. The next chapter focuses on our definition and conceptualization of children’s health. It outlines a definition of children’s health that reflects the committee’s view that children’s health is a developmental, multifaceted state that is socially and culturally defined and specifies its components. The chapter presents the conceptual framework adopted by the committee for thinking about both the internal and external influences that affect children’s health.

Chapter 3 reviews the scientific evidence pertaining to the ways in which various influences have been shown to affect children’s health. It outlines influences specific to children including their biology (their genetic make-up and internal biological environment), and the behaviors they exhibit as they interact with their surroundings. The chapter also outlines influences external to the child, including the family, community, culture, and physical environments as well as policy environments and services systems.

Chapter 4 outlines the available tools and data for measuring children’s health and the adequacy of these methods, including specifying gaps based on the committee’s definition of health. Chapter 5 provides a similar review of tools, data, and gaps for measuring the influences discussed in Chapter 3 . Chapters 4 and 5 focus primarily on available national data.

Chapter 6 discusses data systems, outlines the value of data integration, and presents strategies to begin to develop improved data systems, including discussion of the ethical, technical, and political challenges inherent in these strategies. This chapter introduces the potential value to state and local policymakers of improved use of available state-level data.

Chapter 7 presents the committee’s conclusions and recommendations. This chapter focuses on what can be done at the federal, state, and local levels to improve children’s health by advancing efforts to measure and use information on children’s health and its influences. This final chapter also outlines the committee’s recommendations aimed at improving knowledge of how various factors interact to affect health and their relative importance.

Finally, several appendixes follow the body of the report. Appendix A provides short descriptions of existing core datasets for measuring children’s health and compares them based on periodicity, age, and geographic level surveyed. Appendix B examines the extent to which current major surveys capture data on children’s health and its influences and provides a comparison across surveys in both narrative and tabular form. Appendix C presents information on national-level syntheses that use secondary data to track multiple indicators over time and examples of the indicators they track. The glossary in Appendix D defines frequently used terms, Appendix E identifies acronyms referred to in the text, and Appendix F provides biographical sketches of the committee members and staff responsible for the report.

The Consolidated Appropriations Act 2001 (P.L. 106–554).

• Cite this Page National Research Council (US); Institute of Medicine (US). Children’s Health, The Nation’s Wealth: Assessing and Improving Child Health. Washington (DC): National Academies Press (US); 2004. 1, Introduction.
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Expert Commentary

The health effects of screen time on children: A research roundup

This research roundup looks at the effects of screen time on children’s health.

Republish this article

This work is licensed under a Creative Commons Attribution-NoDerivatives 4.0 International License .

by Chloe Reichel, The Journalist's Resource May 14, 2019

This <a target="_blank" href="https://journalistsresource.org/education/screen-time-children-health-research/">article</a> first appeared on <a target="_blank" href="https://journalistsresource.org">The Journalist's Resource</a> and is republished here under a Creative Commons license.<img src="https://journalistsresource.org/wp-content/uploads/2020/11/cropped-jr-favicon-150x150.png" style="width:1em;height:1em;margin-left:10px;">

This research roundup, originally published in May 2019, has been updated to include a recent systematic review and meta-analysis looking at the effects of screen time on academic performance.

Gone are visions of idyllic childhoods spent frolicking in fields and playing in pastures; for many kids, green grass has been replaced with smartphone screens.

In fact, recent research finds that 63% of kids in the U.S. spend over two hours a day on recreational screen time .

This is in spite of official guidelines from the American Academy of Pediatrics, which recommends less than one hour per day of screen time for children between the ages of 2 and 5, and, for older children, “consistent limits” on screen time and prioritization of sleep, physical activity and other healthy behaviors over media use. Just last month the World Health Organization issued guidelines on the subject, stressing that children between the ages of 2 and 4 should have no more than one hour of screen time per day.

The ubiquity of screens and their prominence in everyday life has drawn criticism and concerns, with Microsoft veteran and philanthropist Melinda Gates writing about not being “prepared for smartphones and social media” as a parent and news headlines questioning whether smartphones have “ destroyed a generation .”

But what does the research say? This roundup looks at the effects of screen time on children’s health. Studies range from childhood to adolescence and focus on topics including sleep, developmental progress, depression and successful interventions to reduce screen time.

Screen-Time is Associated with Inattention Problems in Preschoolers: Results from the CHILD Birth Cohort Study Tamana, Sukhpreet K.; et al. PLOS ONE , April 2019.

This study analyzes parent-reported data about screen time and behavioral issues such as inattention and aggressiveness for a sample of 2,322 Canadian preschool-age children. Researchers found that over 13% of kids in the sample were exposed to over two hours of screen time each day including watching TV and DVDs, playing video games or using a computer, tablet or mobile device. The effects: Kids who were exposed to more screen time “showed significantly increased behavior problems at five-years,” the authors write. “Briefly, children who watched more than 2 hours of screen time/day had increased externalizing [e.g., attention and behavior], internalizing [e.g., anxiety and depression], and total behavior problems scores compared to children who watched less than 20 minutes.” Attention problems in particular were apparent in children who had over two hours of screen time each day.

Mobile Media Device Use is Associated with Expressive Language Delay in 18-Month-Old Children van den Heuvel, Meta; et al. Journal of Developmental & Behavioral Pediatrics , 2019.

Toddlers who use mobile devices daily are more likely to experience speech delays, according to an analysis of parent-reported data on 893 children in the greater Toronto area of Canada. While 78% of parents said their kids spent no time on mobile devices, the other 22% reported a range of 1.4 to 300 minutes daily, with a median of 15.7 minutes.

In total, 6.6% of parents reported expressive speech delays (i.e., late to begin talking). The prevalence of other communication delays, such as lack of use of gestures and eye gaze, was 8.8%. The researchers found a positive association between mobile device use and expressive speech delays. “An increase in 30 minutes per day in mobile media device use was associated with a 2.3 times increased risk of parent-reported expressive speech delay,” the authors write. Other communication delays were not linked to device use. The researchers suggest the connection between device use and expressive speech delays might be explained by the fact that past research has shown infants “have difficulty applying what they learn across different contexts.” An alternate explanation is that these children who spend more time with devices might have less exposure to speech from caregivers.

Association Between Screen Time and Children’s Performance on a Developmental Screening Test Madigan, Sheri; et al. JAMA Pediatrics , March 2019.

Is screen time detrimental to child development? This study looks at data collected from 2,441 mothers and children in Canada at three different time points – when the children were 2, 3 and 5 years old. The researchers were interested in the total number of hours the children spent looking at screens each week as well as their progress in various developmental areas such as fine motor skills, communication and problem solving. The average amount of screen time for the age groups in the study: 17, 25 and 11 hours of television per week for 2-, 3-, and 5-year olds, respectively.

The researchers found that kids who spent more time watching screens at ages 2 and 3 did worse on developmental tests at the subsequent time points of 3 and 5 years. “To our knowledge, the present study is the first to provide evidence of a directional association between screen time and poor performance on development screening tests among very young children,” the authors write.

The researchers suggest that excessive screen time leads to developmental delays, rather than the other way around – negating the notion that children with developmental delays might receive more screen time to manage their behavior.

The three phase data capture supports this explanation because children with greater screen time at one time point go on at the next time point to have poorer developmental progress, but children with poor developmental performance at an earlier time point do not receive increased screen time at later time points.

Association Between Screen Media Use and Academic Performance Among Children and Adolescents Adelantado-Renau, Mireia; et al. JAMA Pediatrics , September 2019.

This publication consists of both a systematic review and meta-analysis of research on the relationship between screen time and academic performance. The authors identified 58 studies to include in the systematic review, which provides a summary of the qualitative effects of screen time; 30 of these studies were included in the subsequent meta-analysis, which the authors used to calculate the effect size of screen time on academic performance.

The 58 studies in the systematic review included 480,479 participants ranging from four to 18 years of age. The articles were published between 1958 and 2018 and represent the efforts of researchers around the world. The studies looked at computer, internet, mobile phone, television and video game use individually, as well as overall screen time. Outcomes of interest included school grades, performance on academic achievement tests, academic failure data, or self-reported academic achievement or school performance.

The key finding from the systematic review was that in most of the papers reviewed, as time spent watching television increased, academic performance suffered. Relationships were less clear-cut for other types of screen use.

The meta-analysis, which focused on a subset of 106,653 participants from the larger sample, did not find an association between overall screen time and academic performance. When the authors analyzed the data by type of activity, they found television watching was linked to poorer overall academic performance as well as poorer language and mathematics performance, separately. Time spent playing video games was negatively linked with composite academic performance scores, too. Analyzing the data further by age, the authors found that time spent with screens had a larger negative association with academic performance for adolescents than children.

“The findings from this systematic review and meta-analysis suggest that each screen-based activity should be analyzed individually because of its specific association with academic performance,” the authors conclude. “This study highlights the need for further research into the association of internet, computer, and mobile phone use with academic performance in children and adolescents. These associations seem to be complex and may be moderated and/or mediated by potential factors, such as purpose, content, and context of screen media use.”

The authors suggest that educators and health professionals should focus screen time reduction efforts on television and video games for their negative connections to academic performance and potential health risks due to their sedentary nature.

Screen Time Is Associated with Adiposity and Insulin Resistance in Children Nightingale, Claire M.; et al. Archives of Disease in Childhood , July 2017.

This study looks at the relationship between screen time and Type 2 diabetes risk factors, like being severely overweight, among 4,495 schoolchildren in the United Kingdom between the ages of 9 and 10. The short of it: Kids who spent over three hours daily on screen time were less lean and more likely to show signs of insulin resistance, which can contribute to the development of Type 2 diabetes, compared with their peers who reported one hour or less of screen time each day. Black children were more likely to spend over three hours daily on devices compared with their white and south Asian peers – 23% of black children fell into that group, compared with 16% of white children and 16% of south Asian children.

Digital Media and Sleep in Childhood and Adolescence LeBourgeois, Monique K.; et al. Pediatrics , November 2017.

This report summarizes 67 studies looking at associations between screen time and sleep health – adequate sleep length and quality — in children and adolescents. The main takeaways: A majority (90%) of the studies included in a systematic review of research on screen time in children and teenagers found adverse associations between screen time and sleep health – primarily because of later bedtimes and less time spent sleeping. Delving deeper, underlying mechanisms include “time displacement” (think scrolling Instagram for an hour that might otherwise be spent sleeping), psychological stimulation from content consumed and impacts of screen light on sleep patterns. The upshot? These kids are tired. The previously cited research review also indicates that a majority of studies saw a relationship between tiredness and screen time.

Prevalence and Likelihood of Meeting Sleep, Physical Activity, and Screen-Time Guidelines Among US Youth Knell, Gregory; et al. JAMA Pediatrics , April 2019.

This study analyzes data from the 2011, 2013, 2015 and 2017 cycles of a nationally-administered, school-based survey on various health-related behaviors related to the leading causes of death and disability in the U.S. The researchers were interested in whether respondents met the recommendations for time spent on sleep, physical activity and screen time in a given day. A total of 59,397 adolescents were included in the data set.

The findings indicate that only 5% of adolescents surveyed met all three guidelines – that is, getting the recommended amount of sleep and physical activity and limiting screen time to less than two hours per day. There were disparities among the sample in terms of the odds of meeting all of the recommendations: 16- and 17-year-olds were less likely than those aged 14 and younger to meet all the guidelines; black, Hispanic/Latino and Asian participants were less likely to meet the three guidelines than white participants; overweight and obese participants were less likely to meet the guidelines than normal weight participants; participants who reported marijuana use were less likely to meet the guidelines than those who did not. Participants who reported depressive symptoms were also less likely to meet all the guidelines.

Associations Between 24 Hour Movement Behaviors and Global Cognition in US Children: A Cross-Sectional Observational Study Walsh, Jeremy J.; et al. The Lancet Child & Adolescent Health , November 2018.

This study looks at the same three outcomes examined above, but adds another component – “global cognition.” This is an overall cognition score assessed by the National Institutes of Health Toolbox – an iPad-based neuro-behavioral screening tool. The assessment measures various cognitive functions including memory, attention, vocabulary and processing speed. The sample included 4,520 participants between the ages of 8 and 11. Only 5% of participants met all three recommendations – and they were the better for it. “Compared with meeting none of the recommendations, associations with superior global cognition were found in participants who met all three recommendations, the screen time recommendation only, and both the screen time and the sleep recommendations,” the authors write.

Increases in Depressive Symptoms, Suicide-Related Outcomes, and Suicide Rates Among U.S. Adolescents After 2010 and Links to Increased New Media Screen Time Twenge, Jean M.; et al. Clinical Psychological Science , January 2018.

This study looks at the relationship between screen time and depression and suicide rates in 506,820 adolescents in the U.S. between 2010 and 2015. The data on screen time use and mental health issues came from two nationally representative surveys of students in grades 8 through 12. Suicide rates were calculated from national statistics collected by the Centers for Disease Control and Prevention’s Fatal Injury Reports.

The analysis finds a “clear pattern linking screen activities with higher levels of depressive symptoms/suicide-related outcomes [suicidal ideation — that is, thinking about suicide — and attempts] and nonscreen activities with lower levels.” Among participants who used devices for over five hours each day, nearly half – 48% — reported at least one suicide-related outcome. In comparison, 29% of those who used devices for just an hour per day had at least one suicide-related outcome.

Overall, during the time studied, suicide rates, depressive symptoms and suicide-related outcomes increased. Girls accounted for most of the rise – they were more likely to experience depressive symptoms and suicide-related outcomes than boys; they also experienced stronger effects of screen time on mental health. In particular, girls, but not boys, had a significant correlation between social media use and depressive symptoms.

Interventions Designed to Reduce Sedentary Behaviors in Young People: A Review of Reviews Biddle, Stuart J.H.; Petrolini, Irene; Pearson, Natalie. British Journal of Sports Medicine , 2014.

This review looks at 10 systematic reviews and meta-analyses of research on interventions to reduce sedentary behaviors such as screen time among children and adolescents. The authors found that all of the included reviews determined “some level of effectiveness in reducing time spent in sedentary behavior.” Effects, however, were small. Interventions tended to be more successful among children younger than 6 years old. Strategies that were effective included restricting access to television through TV monitors, systems that use TV as a reward for physical activity and behavioral interventions such as setting goals and developing schedules for screen time.

For more research on the effects of screen time, check out our write ups of research that shows how smartphones make people unhappy and how they’re distracting even when they aren’t in use .

About The Author

Chloe Reichel

Child Healthcare: Importance and Challenges Essay

Children are the future. This is an immutable fact. Every society has the mandate and responsibility of caring and providing for them. United Nations member states passed the famous Millennium Development Goals in the year 2000. Some of the practices seek to improve the overall child’s health and the health condition of mothers ( Reduce Child Mortality).

Child healthcare faces many challenges amid laws and regulations passed by State and Federal governments. Pediatricians and health practitioners experience challenges that are beyond their control. Clinical experts express optimism citing that implementation of Clinical Advocacy will improve on children’s condition and the overall family’s situation.

Inadequate infrastructure is an enormous impediment to child care for the disabled. Before the period 1990, most health facilities lacked ample parking for the handicapped. The US Congress passed the Americans with Disability Act to ensure that children and parents with disabilities were offered protection from discrimination in the provision of services ( ADA National Network ).

A language barrier is another setback limiting service delivery in the child care unit. In a survey conducted by the Medicine National Institute of Health, it was observed that 84% of patients who visited health facilities spoke English. The rest of the patients mostly spoke Chinese, Russian and Spanish. The report warns that non-English speakers had higher adjusted odds of readmission (Gannon 1).

Hospital management has come up with measures that aim to solve the prevalent language barrier. For instance, a hospital in Boston paid for the services of an interpreter, a Jewish, to translate for the Russian patient admitted to the child care unit (Palfrey 90).

The treatment for children has become expensive to most parents. In the year 2013, a report compiled by Child Poverty Action Group has indicated that the UK incurs a total of 29 billion pounds yearly due to child poverty. Out of this, 20.5 billion pounds translate into a direct cost to the government.

To overcome the issue of child poverty, clinicians encourage parents to obtain health insurance cover for their children. As such, some clinics can refuse to offer treatment in the event that the patient fails to produce an insurance cover. Medical practitioners, however, blame the state terming that the process of acquiring health insurance cover is hindered by the strict administrative bottlenecks that the government has put in place (Palfrey 92).

Time is another barrier that limits service delivery. Pediatricians have developed ways that can help reduce the time spent on asking questions. Clinicians are encouraged to ask open-ended questions, which patients quickly understand. It will as well help organize the doctor’s schedule (Palfrey 98).

Children have the right to play. Research done in the US warns that children who are not playful are likely to suffer physical fitness in the future. The United Nations Convention on the Right of the Child entitles children with the right to engage in recreational activities and play (Forbes 45).

Accident is another significant risk to children’s health. According to the report published by Royal Society for the Prevention of Accidents, over one million children below the age of 15 are involved in various accidents yearly. Although it warned that most of the accidents happened in the living room, it was alleged that fatal injuries occured in the kitchen. The figure of children hurt in the kitchens estimated at 67000 yearly ( Accident to Children ). Safety agencies in various states offer education for both drivers and the students. The measure aims at inculcating road safety measure and the importance of observing road signs. For instance, in the city of Osage, Kansas, the Ministry of Transportation supports driver’s safety event for secondary students. Local police stations in Cambridge, Massachusetts, inspect car seats free of costs. Sinai Hospital in Chicago donates infant car seat to every mother who has attended the facility more than two times (Palfrey 110).

Coordination, accessibility, family centeredness, compassionate delivery and culturally active understanding are the fundamental pillars of change. Clinical Advocacy Principal lobbies for child’s well-being by embracing the above pillars (Palfrey 118).

Works Cited

“Accidents to Children.” RoSPA Home Safety RSS . Web. 2015.

“ADA National Network.” Welcome to the Americans With Disabilities Act National Network . Web. 2015.

Forbes, Ruth. Beginning to Play Young Children from Birth to Three , Buckingham: Open University Press, 2004. Print.

Gannon, Frank. “Language Barriers.” EMBO Reports . Web. 2015.

Palfrey, Judith. Child Health in America Making a Difference through Advocacy . Baltimore: Johns Hopkins UP, 2006. Print.

“Reduce Child Mortality.” Millennium Development Goal 4 .Web. 2015.

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• Health and child development

All children, including those with developmental delays and disabilities, have the right to lead healthy lives.

• Child and adolescent health and well-being

To reach their full potential, children need high-quality health care and services – especially in life’s early moments.

The time between pregnancy and age 3, when the brain is most susceptible to environmental influences, is critical for a child’s growth and development . All children – including those with disabilities and developmental delays, those living in poverty or deprivation, and those affected by conflict or displacement – need nurturing care and health services to survive and thrive.

But millions do not receive them.

In many places, health systems are not equipped to support routine health interactions among children, families and caregivers. Without regular monitoring, some children miss out on specialized health services and developmental support that could help them fulfil their potential.

Early interventions are especially crucial to children with developmental delays and disabilities, but many do not have access to primary health care systems that provide them.

Globally, 93 million children 14 years old and younger experience moderate or severe developmental delays or disabilities.

Because children with developmental delays and disabilities are more likely to be invisible in government statistics, they are often excluded from policy decisions that could improve their well-being. As a result, the quality of the health services they receive can be severely compromised – largely due to limited capacity, inadequate training of service providers, or lack of coordination between public authorities and community practitioners.

UNICEF’s response

In 2018, UNICEF co-led the creation of the Nurturing Care Framework for Early Childhood Development . This framework outlines relevant policies, interventions and strategies needed across sectors – including health, nutrition, education and child protection – to strengthen early childhood development and monitor progress towards associated goals.

The health sector plays a critical role in galvanizing Governments and partners to support children’s holistic health and well-being. It also serves as a platform for policy makers and practitioners across sectors to reach mothers, families and children with crucial early interventions.

UNICEF works around the world to support key components of nurturing care and seek opportunities to advance nurturing care through routine health interactions among children, families and caregivers.

We also focus on early identification and early interventions of developmental delays and disabilities among children, particularly during the first three years of life, while promoting universal coverage of responsive caregiving and early learning.

UNICEF, alongside the World Health Organization, develops global goods, disseminates learning, and convenes Governments and partners at global, regional and country levels to support the development of action plans, the mobilization of resources and the training of health-care professionals to ensure all children receive the nurturing care they need to thrive. 

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Child Health, Safety and Nutrition CDCG 110 5-8-2012 What did I learn from this course? Health, safety and nutrition are three of the most important factors to consider when raising a child. In other words, every child should be raised with proper nutrition, good health and safety as possible, allowing him or her to grow with a great well-being. Something that I've learned about this class is that in today’s fast-paced world where the child’s safety and health issues are rapidly growing, more than fifty sites online present health and safety guidelines for the public to consider. These websites given to us has really opened up a door for me to look into my own life as well as my child's development. Another thing I've learned …show more content…

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• 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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University of Suffolk, Ipswich, UK

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University of Education, Freiburg i.Br, Germany

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Katholische Hochschule Nordrhein-Westfalen, Paderborn, Germany

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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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• Health Literacy
• Health Competencies
• Young People
• Adolescents
• Definitions
• Conceptual Models
• Literature Review

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Children and youth’s perceptions of mental health—a scoping review of qualitative studies

• Linda Beckman 1 , 2 ,
• Sven Hassler 1 &
• Lisa Hellström 3  

BMC Psychiatry volume  23 , Article number:  669 ( 2023 ) Cite this article

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Recent research indicates that understanding how children and youth perceive mental health, how it is manifests, and where the line between mental health issues and everyday challenges should be drawn, is complex and varied. Consequently, it is important to investigate how children and youth perceive and communicate about mental health. With this in mind, our goal is to synthesize the literature on how children and youth (ages 10—25) perceive and conceptualize mental health.

We conducted a preliminary search to identify the keywords, employing a search strategy across electronic databases including Medline, Scopus, CINAHL, PsychInfo, Sociological abstracts and Google Scholar. The search encompassed the period from September 20, 2021, to September 30, 2021. This effort yielded 11 eligible studies. Our scoping review was conducted in accordance with the PRISMA-ScR Checklist.

As various aspects of uncertainty in understanding of mental health have emerged, the results indicate the importance of establishing a shared language concerning mental health. This is essential for clarifying the distinctions between everyday challenges and issues that require treatment.

We require a language that can direct children, parents, school personnel and professionals toward appropriate support and aid in formulating health interventions. Additionally, it holds significance to promote an understanding of the positive aspects of mental health. This emphasis should extend to the competence development of school personnel, enabling them to integrate insights about mental well-being into routine interactions with young individuals. This approach could empower children and youth to acquire the understanding that mental health is not a static condition but rather something that can be enhanced or, at the very least, maintained.

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Introduction

In Western society, the prevalence of mental health issues, such as depression and anxiety [ 1 ], as well as recurring psychosomatic health complaints [ 2 ], has increased from the 1980s and 2000s. However, whether these changes in adolescent mental health are actual trends or influenced by alterations in how adolescents perceive, talk about, and report their mental well-being remains ambiguous [ 1 ]. Despite an increase in self-reported mental health problems, levels of mental well-being have remained stable, and severe psychiatric diagnoses have not significantly risen [ 3 , 4 ]. Recent research indicates that understanding how children and youth grasp mental health, its manifestations, and the demarcation between mental health issues and everyday challenges is intricate and diverse. Wickström and Kvist Lindholm [ 5 ] show that problems such as feeling low and nervous are considered deep-seated issues among some adolescents, while others refer to them as everyday challenges. Meanwhile, adolescents in Hellström and Beckman [ 6 ] describe mental health problems as something mainstream, experienced by everyone at some point. Furthermore, Hermann et al. [ 7 ] point out that adolescents can distinguish between positive health and mental health problems. This indicates their understanding of the complexity and holistic nature of mental health and mental health issues. It is plausible that misunderstandings and devaluations of mental health and illness concepts may increase self-reported mental health problems and provide contradictory results when the understanding of mental health is studied. In a previous review on how children and young people perceive the concept of “health,” four major themes have been suggested: health practices, not being sick, feeling good, and being able to do the desired and required activities [ 8 ]. In a study involving 8–11 year olds, children framed both biomedical and holistic perspectives of health [ 9 ]. Regarding the concept of “illness,” themes such as somatic feeling states, functional and affective states [ 10 , 11 ], as well as processes of contagion and contamination, have emerged [ 9 ]. Older age strongly predicts nuances in conceptualizations of health and illness [ 10 , 11 , 12 ].

As the current definitions of mental health and mental illness do not seem to have been successful in guiding how these concepts are perceived, literature has emphasized the importance of understanding individuals’ ideas of health and illness [ 9 , 13 ]. The World Health Organization (WHO) broadly defines mental health as a state of well-being in which the individual realizes his or her abilities, can cope with the normal stresses of life, work productively and fruitfully and make a contribution to his or her community [ 14 ] capturing only positive aspects. According to The American Psychology Association [ 15 ], mental illness includes several conditions with varying severity and duration, from milder and transient disorders to long-term conditions affecting daily function. The term can thus cover everything from mild anxiety or depression to severe psychiatric conditions that should be treated by healthcare professionals. As a guide for individual experience, such a definition becomes insufficient in distinguishing mental illness from ordinary emotional expressions. According to the Swedish National Board of Health and Welfare et al. [ 16 ], mental health works as an umbrella term for both mental well-being and mental illness : Mental well-being is about being able to handle life's difficulties, feeling satisfied with life, having good social relationships, as well as being able to feel pleasure, desire, and happiness. Mental illness includes both mild to moderate mental health problems and psychiatric conditions . Mild to moderate mental health problems are common and are often reactions to events or situations in life, e.g., worry, feeling low, and sleep difficulties.

It has been argued that increased knowledge of the nature of mental illness can help individuals to cope with the situation and improve their well-being. Increased knowledge about mental illness, how to prevent mental illness and help-seeking behavior has been conceptualized as “mental health literacy” (MHL) [ 17 ], a construct that has emerged from “health literacy” [ 18 ]. Previous literature supports the idea that positive MHL is associated with mental well-being among adolescents [ 19 ]. Conversely, studies point out that low levels of MHL are associated with depression [ 20 ]. Some gender differences have been acknowledged in adolescents, with boys scoring lower than girls on MHL measures [ 20 ] and a social gradient including a positive relationship between MHL and perceived good financial position [ 19 ] or a higher socio-economic status [ 21 ].

While MHL stresses knowledge about signs and treatment of mental illness [ 22 ], the concern from a social constructivist approach would be the conceptualization of mental illness and how it is shaped by society and the thoughts, feelings, and actions of its members [ 23 ]. Studies on the social construction of anxiety and depression through media discourses have shown that language is at the heart of these processes, and that language both constructs the world as people perceive it but also forms the conditions under which an experience is likely to be construed [ 24 , 25 ]. Considering experience as linguistically inflected, the constructionist approach offers an analytical tool to understand the conceptualization of mental illness and to distinguish mental illness from everyday challenges. The essence of mental health is therefore suggested to be psychological constructions identified through how adolescents and society at large perceive, talk about, and report mental health and how that, in turn, feeds a continuous process of conceptual re-construction or adaptation [ 26 ]. Considering experience as linguistically inflected, the constructionist approach could then offer an analytical tool to understand the potential influence of everyday challenges in the conceptualization of mental health.

Research investigating how children and youth perceive and communicate mental health is essential to understand the current rise of reported mental health problems [ 5 ]. Health promotion initiatives are more likely to be successful if they take people’s understanding, beliefs, and concerns into account [ 27 , 28 ]. As far as we know, no review has mapped the literature to explore children’s and youths’ perceptions of mental health and mental illness. Based on previous literature, age, gender, and socioeconomic status seem to influence children's and youths’ knowledge and experiences of mental health [ 10 , 11 , 12 ]; therefore, we aim to analyze these perspectives too. From a social constructivist perspective, experience is linguistically inflected [ 26 ]; hence illuminating the conditions under which a perception of health is formed is of interest.

Therefore, we aim to study the literature on how children and youth (ages 10—25) perceive and conceptualize mental health, and the specific research questions are:

What aspects are most salient in children’s and youths’ perceptions of mental health?

What concepts do children and youth associate with mental health?

In what way are children's and youth’s perceptions of mental health dependent on gender, age, and socioeconomic factors?

Literature search

A scoping review is a review that aims to provide a snapshot of the research that is published within a specific subject area. The purpose is to offer an overview and, on a more comprehensive level, to distinguish central themes compared to a systematic review. We chose to conduct a scoping review since our aim was to clarify the key concepts of mental health in the literature and to identify specific characteristics and concepts surrounding mental health [ 29 , 30 ]. Our scoping review was conducted following the PRISMA-ScR Checklist [ 31 ]. Two authors (L.B and L.H) searched and screened the eligible articles. In the first step, titles and abstracts were screened. If the study included relevant data, the full article was read to determine if it met the eligibility criteria. Articles were excluded if they did not fulfill all the eligibility criteria. Any uncertainties were discussed among L.B. and L.H., and the third author, S.H., and were carefully assessed before making an inclusion or exclusion decision. The software Picoportal was employed for data management. Figure  1 illustrates a flowchart of data inclusion.

PRISMA flow diagram outlining the search process

Eligibility criteria

We incorporated studies involving children and youth aged 10 to 25 years. This age range was chosen to encompass early puberty through young adulthood, a significant developmental period for young individuals in terms of comprehending mental health. Participants were required not to have undergone interviews due to chronic illness, learning disabilities (e.g., mental health linked to a cancer diagnosis), or immigrant status.

Studies conducted in clinical settings were excluded. For the purpose of comparing results under similar conditions, we specifically opted for studies carried out in Western countries .

Given that this review adopts a moderately constructionist approach, intentionally allowing for the exploration of how both young participants and society in general perceive and discuss mental health and how this process contributes to ongoing conceptual re-construction, the emphasis was placed on identifying articles in which participants themselves defined or attributed meaning to mental health and related concepts like mental illness. The criterion of selecting studies adopting an inductive approach to capture the perspectives of the young participants resulted in the exclusion of numerous studies that more overtly applied established concepts to young respondents [ 32 ].

Information sources

We utilized electronic databases and reached out to study authors if the article was not accessible online. Peer-reviewed articles were exclusively included, thereby excluding conference abstracts due to their perceived lack of relevance in addressing the review questions. Only research in English was taken into account. Publication years across all periods were encompassed in the search.

Search strategy

Studies concerning children’s and youths’ perceptions of mental health were published across a range of scientific journals, such as those within psychiatry, psychology, social work, education, and mental health. Therefore, several databases were taken into account, including Medline, Scopus, CINAHL, PsychInfo, Sociological abstracts, and Google Scholar, spanning from inception on September 20, 2021 to September 30, 2021. We involved a university librarian from the start in the search process. The combinations of search terms are displayed in Table 1 .

Quality assessment

We employed the Quality methods for the development of National Institute for Health Care Excellence (NICE) public health guidance [ 33 ] to evaluate the quality of the studies included. The checklist is based on checklists from Spencer et al. [ 34 ], Public Health Resource Unit (PHRU) [ 26 , 35 ], and the North Thames Research Appraisal Group (NTRAG) [ 36 ] (Refer to S2 for checklist). Eight studies were assigned two plusses, and three studies received one plus. The studies with lower grades generally lacked sufficient descriptions of the researcher’s role, context reporting, and ethical reporting. No study was excluded in this stage.

Data extraction and analysis

We employed a data extraction form that encompassed several key characteristics, including author(s), year, journal, country, details about method/design, participants and socioeconomics, aim, and main results (Table 2 ). The collected data were analyzed and synthesized using the thematic synthesis approach of Thomas and Harden [ 37 ]. This approach encompassed all text categorized as 'results' or 'findings' in study reports – which sometimes included abstracts, although the presentation wasn’t always consistent throughout the text. The size of the study reports ranged from a few sentences to a single page. The synthesis occurred through three interrelated stages that partially overlapped: coding of the findings from primary studies on a line-by-line basis, organization of these 'free codes' into interconnected areas to construct 'descriptive' themes, and the formation of 'analytical' themes.

The objective of this scoping review has been to investigate the literature concerning how children and youth (ages 10—25) conceptualize and perceive mental health. Based on the established inclusion- and exclusion criteria, a total of 11 articles were included representing the United Kingdom ( n  = 6), Australia ( n  = 3), and Sweden ( n  = 2) and were published between 2002 and 2020. Among these, two studies involved university students, while nine incorporated students from compulsory schools.

Salient aspects of children and youth’ perceptions of mental health

Based on the results of the included articles, salient aspects of children’s and youths’ understandings revealed uncertainties about mental health in various ways. This uncertainty emerged as conflicting perceptions, uncertainty about the concept of mental health, and uncertainty regarding where to distinguish between mild to moderate mental health problems and everyday stressors or challenges.

One uncertainty was associated with conflicting perceptions that mental health might be interpreted differently among children and youths, depending on whether it relates to their own mental health or someone else's mental health status. Chisholm et al. [ 42 ] presented this as distinctions being made between ‘them and us’ and between ‘being born with it’. Mental health and mental illness were perceived as a continuum that rather developed’, and distinctions were drawn between ‘crazy’ and ‘diagnosed.’ Participants established strong associations between the term mental illness and derogatory terms like ‘crazy,’ linking extreme symptoms of mental illness with others. However, their attitude was less stigmatizing when it came to individual diagnoses, reflecting a more insightful and empathetic understanding of the adverse impacts of stress based on their personal realities and experiences. Despite the initial reactions reflecting negative stereotypes, further discussion revealed that this did not accurately represent a deeper comprehension of mental health and mental illness.

There was also uncertainty about the concept of mental health , as it was not always clearly understood among the participating youth. Some participants were unable to define mental health, often confusing it with mental illness [ 28 ]. Others simply stated that they did not understand the term, as in O’Reilly [ 44 ]. Additionally, uncertainty was expressed regarding whether mental health was a positive or negative concept [ 27 , 28 , 40 , 44 ], and participants associated mental health with mental illness despite being asked about mental health [ 28 ]. One quote from a grade 9 student illustrates this: “ Interviewer: Can mental health be positive as well? Informant: No, it’s mental” [ 44 ]. In Laidlaw et al. [ 46 ], with participants ranging from 18—22 years of age, most considered mental health distinctly different from and more clinical than mental well-being. However, Roose et al. [ 38 ], for example, the authors discovered a more multifaceted understanding of mental health, encompassing emotions, thoughts, and behavior. In Molenaar et al.[ 45 ], mental health was highlighted as a crucial aspect of health overall. In Chisholm et al. [ 42 ], the older age groups discussed mental health in a more positive sense when they considered themselves or people they knew, relating mental health to emotional well-being. Connected to the uncertainty in defining the concept of mental health was the uncertainty in identifying those with good or poor mental health. Due to the lack of visible proof, children and youths might doubt their peers’ reports of mental illness, wondering if they were pretending or exaggerating their symptoms [ 27 ].

A final uncertainty that emerged was difficulties in drawing the line between psychiatric conditions and mild to moderate mental health problems and everyday stressors or challenges . Perre et al. [ 43 ] described how the participants in their study were uncertain about the meaning of mental illness and mental health issues. While some linked depression to psychosis, others related it to simply ‘feeling down.’ However, most participants indicated that, in contrast to transient feelings of sadness, depression is a recurring concern. Furthermore, the duration of feeling depressed and particularly a loss of interest in socializing was seen as appropriate criteria for distinguishing between ‘feeling down’ and ‘clinical depression.’ Since feelings of anxiety, nervousness, and apprehension are common experiences among children and youth, defining anxiety as an illness as opposed to an everyday stressor was more challenging [ 43 ].

Terms used to conceptualize mental health

When children and youth were asked about mental health, they sometimes used neutral terms such as thoughts and emotions or a general ‘vibe’ [ 27 ], and some described it as ‘peace of mind’ and being able to balance your emotions [ 38 ]. The notion of mental health was also found to be closely linked with rationality and the idea of normality, although, according to the young people, Armstrong et al. [ 28 ], there was no consensus about what ‘normal’ meant. Positive aspects of mental health were described by the participants as good self-esteem, confidence [ 40 ], happiness [ 39 , 43 ], optimism, resilience, extraversion and intelligence [ 27 ], energy [ 43 ], balance, harmony [ 39 , 43 ], good brain, emotional and physical functioning and development, and a clear idea of who they are [ 27 , 41 ]. It also included a feeling of being a good person, feeling liked and loved by your parents, social support, and having people to talk with [ 27 , 39 ], as well as being able to fit in with the world socially and positive peer relationships [ 41 ], according to the children and youths, mental health includes aspects related to individuals (individual factors) as well as to people in their surroundings (relationships). Regarding mental illness, participants defined it as stress and humiliation [ 40 ], psychological distress, traumatic experiences, mental disorders, pessimism, and learning disabilities [ 27 ]. Also, in contrast to the normality concept describing mental health, mental illness was described as somehow ‘not normal’ or ‘different’ in Chisholm et al. [ 42 ].

Depression and bipolar disorder were the most often mentioned mental illnesses [ 27 ]. The inability to balance emotions was seen as negative for mental health, for example, not being able to set aside unhappiness, lying to cover up sadness, and being unable to concentrate on schoolwork [ 38 ]. The understanding of mental illness also included feelings of fear and anxiety [ 42 ]. Other participants [ 46 ] indicated that mental health is distinctly different from, and more clinical than, mental well-being. In that sense, mental health was described using reinforcing terms such as ‘serious’ and ‘clinical,’ being more closely connected to mental illness, whereas mental well-being was described as the absence of illness, feeling happy, confident, being able to function and cope with life’s demands and feeling secure. Among younger participants, a more varied and vague understanding of mental health was shown, framing it as things happening in the brain or in terms of specific conditions like schizophrenia [ 44 ].

Gender, age, socioeconomic status

Only one study had a gender theoretical perspective [ 40 ], but the focus of this perspective concerned gender differences in what influences mental health more than the conceptualization of mental health. According to Johansson et al.[ 39 ], older girls expressed deeper negative emotions (e.g., described feelings of lack of meaning and hope in various ways) than older boys and younger children.

Several of the included studies noticed differences in age, where younger participants had difficulty understanding the concept of mental health [ 39 , 44 ], while older participants used more words to explain it [ 39 ]. Furthermore, older participants seemed to view mental health and mental illness as a continuum, with mental illness at one end of the continuum and mental well-being at the other end [ 42 , 46 ].

Socioeconomic status

The role of socioeconomic status was only discussed by Armstrong et al. [ 28 ], finding that young people from schools in the most deprived and rural areas experienced more difficulties defining the term mental health compared to those from a less deprived area.

This scoping review aimed to map children's and youth’s perceptions and conceptualizations of mental health. Our main findings indicate that the concept of mental health is surrounded by uncertainty. This raises the question of where this uncertainty stems from and what it symbolizes. From our perspective, this uncertainty can be understood from two angles. Firstly, the young participants in the different studies show no clear and common understanding of mental health; they express uncertainty about the meaning of the concept and where to draw the line between life experiences and psychiatric conditions. Secondly, uncertainty exists regarding how to apply these concepts in research, making it challenging to interpret and compare research results. The shift from a positivistic understanding of mental health as an objective condition to a more subjective inner experience has left the conceptualization open ranging from a pathological phenomenon to a normal and common human experience [ 47 ]. A dilemma that results in a lack of reliability that mirrors the elusive nature of the concept of mental health from both a respondent and a scientific perspective.

“Happy” was commonly used to describe mental health, whereas "unhappy" was used to describe mental illness. The meaning of happiness for mental health has been acknowledged in the literature, and according to Layard et al. [ 48 ], mental illness is one of the main causes of unhappiness, and happiness is the ultimate goal in human life. Layard et al. [ 48 ] suggest that schools and workplaces need to raise more awareness of mental health and strive to improve happiness to promote mental health and prevent mental illness. On the other hand, being able to experience and express different emotions could also be considered a part of mental health. The notion of normality also surfaced in some studies [ 38 ], understanding mental health as being emotionally balanced or normal or that mental illness was not normal [ 42 ]. To consider mental illness in terms of social norms and behavior followed with the sociological alternative to the medical model that was introduced in the sixties portraying mental illness more as socially unacceptable behavior that is successfully labeled by others as being deviant. Although our results did not indicate any perceptions of what ‘normal’ meant [ 28 ], one crucial starting point to the understanding of mental health among adolescents should be to delineate what constitutes normal functioning [ 23 ]. Children and youths’ understanding of mental illness seems to a large extent, to be on the same continuum as a normality rather than representing a medicalization of deviant behavior and a disjuncture with normality [ 49 ].

Concerning gender, it seemed that girls had an easier time conceptualizing mental health than boys. This could be due to the fact that girls mature verbally faster than boys [ 50 ], but also that girls, to a larger extent, share feelings and problems together compared to boys [ 51 ]. However, according to Johansson et al. [ 39 ], the differences in conceptualizations of mental health seem to be more age-related than gender-related. This could be due to the fact that older children have a more complex view of mental health compared to younger children.. Not surprisingly, the older the children and youth were, the more complex the ability to conceptualize mental health becomes. Only one study reported socioeconomic differences in conceptualizations of mental health [ 28 ]. This could be linked to mental health literacy (MHL) [ 18 ], i.e., knowledge about mental illness, how to prevent mental illness, and help-seeking behavior. Research has shown that disadvantaged social and socioeconomic conditions are associated with low MHL, that is, people with low SES tends to know less about symptoms and prevalence of different mental health problems [ 19 , 21 ]. The perception and conceptualizations of mental health are, as we consider, strongly related to knowledge and beliefs about mental health, and according to von dem Knesebeck et al. [ 52 ] linked primarily to SES through level of education.

Chisholm et al. [ 42 ] found that the initial reactions from participants related to negative stereotypes, but further discussion revealed that the participants had more refined knowledge than at first glance. This illuminates the importance of talking to children and helping them verbalize their feelings, in many respects complex and diversified understanding of mental health. It is plausible that misunderstandings and devaluations of mental health and mental illness may increase self-reported mental health problems [ 5 ], as well as decrease them, preventing children and youth from seeking help. Therefore, increased knowledge of the nature of mental health can help individual cope with the situations and improve their mental well-being. Finding ways to incorporate discussions about mental well-being, mental health, and mental illness in schools could be the first step to decreasing the existing uncertainties about mental health. Experiencing feelings of sadness, anger, or upset from time to time is a natural part of life, and these emotions are not harmful and do not necessarily indicate mental illness [ 5 , 6 ]. Adolescents may have an understanding of the complexity of mental health despite using simplified language but may need guidance on how to communicate their feelings and how to manage everyday challenges and normal strains in life [ 7 ].

With the aim of gaining a better understanding of how mental health is perceived among children and youth, this study has highlighted the concept’s uncertainty. Children and youth reveal a variety of understandings, from diagnoses of serious mental illnesses such as schizophrenia to moods and different types of behaviors. Is there only one way of understanding mental health, and is it reasonable to believe that we can reach a consensus? Judging by the questions asked, researchers also seem to have different ideas on what to incorporate into the concept of mental health — the researchers behind the present study included. The difficulties in differentiating challenges being part of everyday life with mental health issues need to be paid closer attention to and seems to be symptomatic with the lack of clarity of the concepts.

A constructivist approach would argue that the language of mental health has changed over time and thus influence how adolescents, as well as society at large, perceive, talk about, and report their mental health [ 26 ]. The re-construction or adaptation of concepts could explain why children and youth re struggling with the meaning of mental health and that mental health often is used interchangeably with mental illness. Mental health, rather than being an umbrella term, then represents a continuum with a positive and a negative end, at least among older adolescents. But as mental health according to this review also incorporates subjective expressions of moods and feelings, the reconstruction seems to have shaped it into a multidimensional concept, representing a horizontal continuum of positive and negative mental health and a vertical continuum of positive and negative well-being, similar to the health cross by Tudor [ 53 ] referred to in Laidlaw et al. [ 46 ] A multidimensional understanding of mental health constructs also incorporates evidence from interventions aimed at reducing mental health stigma among adolescents, where attitudes and beliefs as well as emotional responses towards mental health are targeted [ 54 ].

The contextual understanding of mental health, whether it is perceived in positive terms or negative, started with doctors and psychiatrists viewing it as representing a deviation from the normal. A perspective that has long been challenged by health workers, academics and professionals wanting to communicate mental health as a positive concept, as a resource to be promoted and supported. In order to find a common ground for communicating all aspects and dimensions of mental health and its conceptual constituents, it is suggested that we first must understand the subjective meaning ascribed to the use of the term [ 26 ]. This line of thought follows a social-constructionist approach viewing mental health as a concept that has transitioned from representing objective mental descriptions of conditions to personal subjective experiences. Shifting from being conceptualized as a pathological phenomenon to a normal and common human experience [ 47 ]. That a common understanding of mental health can be challenged by the healthcare services tradition and regulation for using diagnosis has been shown in a study of adolescents’ perspectives on shared decision-making in mental healthcare [ 55 ]. A practice perceived as labeling by the adolescents, indicating that steps towards a common understanding of mental health needs to be taken from several directions [ 55 ]. In a constructionist investigation to distinguish everyday challenges from mental health problems, instead of asking the question, “What is mental health?” we should perhaps ask, “How is the word ‘mental health’ used, and in what context and type of mental health episode?” [ 26 ]. This is an area for future studies to explore.

Methodological considerations

The first limitation we want to acknowledge, as for any scoping review, is that the results are limited by the search terms included in the database searches. However, by conducting the searches with the help of an experienced librarian we have taken precautions to make the searches as inclusive as possible. The second limitation concerns the lack of homogeneous, or any results at all, according to different age groups, gender, socioeconomic status, and year when the study was conducted. It is well understood that age is a significant determinant in an individual’s conceptualization of more abstract phenomena such as mental health. Some of the studies approached only one age group but most included a wide age range, making it difficult to say anything specific about a particular age. Similar concerns are valid for gender. Regarding socioeconomic status, only one study reported this as a finding. However, this could be an outcome of the choice of methods we had — i.e., qualitative methods, where the aim seldom is to investigate differences between groups and the sample is often supposed to be a variety. It could also depend on the relatively small number of participants that are often used in focus groups of individual interviews- there are not enough participants to compare groups based on gender or socioeconomic status. Finally, we chose studies from countries that could be viewed as having similar development and perspective on mental health among adolescents. Despite this, cultural differences likely account for many youths’ conceptualizations of mental health. According to Meldahl et al. [ 56 ], adolescents’ perspectives on mental health are affected by a range of factors related to cultural identity, such as ethnicity, race, peer and family influence, religious and political views, for example. We would also like to add organizational cultures, such as the culture of the school and how schools work with mental health and related concepts [ 56 ].

Conclusions and implications

Based on our results, we argue that there is a need to establish a common language for discussing mental health. This common language would enable better communication between adults and children and youth, ensuring that the content of the words used to describe mental health is unambiguous and clear. In this endeavor, it is essential to actively listen to the voices of children and youth, as their perspectives will provide us with clearer understanding of the experiences of being young in today’s world. Another way to develop a common language around mental health is through mental health education. A common language based on children’s and youth’s perspectives can guide school personnel, professionals, and parents when discussing and planning health interventions and mental health education. Achieving a common understanding through mental health education of adults and youth could also help clarify the boundaries between everyday challenges and problems needing treatment. It is further important to raise awareness of the positive aspect of mental health—that is, knowledge of what makes us flourish mentally should be more clearly emphasized in teaching our children and youth about life. It should also be emphasized in competence development for school personnel so that we can incorporate knowledge about mental well-being in everyday meetings with children and youth. In that way, we could help children and youth develop knowledge that mental health could be improved or at least maintained and not a static condition.

Availability of data and materials

All data generated or analyzed during this study are included in this published article [and its supplementary information files].

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Beckman, L., Hassler, S. & Hellström, L. Children and youth’s perceptions of mental health—a scoping review of qualitative studies. BMC Psychiatry 23 , 669 (2023). https://doi.org/10.1186/s12888-023-05169-x

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Essay on Health Education for Students and Children

500 words essay on health education.

We all know that health education has become very important nowadays. It refers to a career where people are taught about healthcare . Professionals teach people how to maintain and restore their health. In other words, health does not merely refer to physical but also mental, social and sexual health. Health education aims to enhance health literacy and develop skills in people which will help them maintain good health.

Importance of Health Education

Health education is very essential for enhancing the condition of the overall health of different communities and people. It will also help in improving the health of the whole nation. You can also say that the economy of a country is directly proportional to health education. In other words, it means that the higher the life expectancy the better will be the standard of living.

Health education is given to people by professionals in the field known as health educators. They are qualified and certified enough to talk about these issues. Furthermore, they undergo training related to health and hygiene for educating people.

Similarly, health education is very important as it improves the health conditions of the people. It does so by teaching them ways on how to remain healthy and prevent diseases. Moreover, it also makes them responsible enough as a whole community.

The developing nations especially are in dire need of health education. It not only conveys basic knowledge about health but also shapes their habits and way of living. Most importantly, it not only focuses on physical health but also addresses other issues like mental illnesses, sexual well-being and more.

Methods to Improve Health Education

Although health education is very important, we often see how it is not given the importance it deserves. The poor condition of the prevalent health education in many countries is proof of this statement. We need to improve the state of public health education in the world, especially in developing countries.

As the developing countries have many remote areas, the necessary help does not reach there. We must emphasis more on conveying this education to such people. The villagers especially must be made aware of health education and what role it plays in our lives. We can organize these programs which will attract more audience like fares or markets, which already has a gathering.

Moreover, as most of the audience will be illiterate we can make use of visuals like plays, folk shows and more to convey the message in a clear manner. Subsequently, we must also make the most of the opportunity we get at hospitals. The patients coming in to get checked must be made conscious of their health conditions and also be properly educated on these matters.

Similarly, we must target schools and inculcate healthy habits amongst children from an early age. This way, students can spread this knowledge better to their homes and amongst their friends. Therefore, we must enhance the state of health education in the world to help people become healthier and maintain their vitality and dynamism.

FAQs on Health Education

Q.1 Why is Health Education important?

A.1 Health education is very important as it improves the health standards of the country. It further helps in preventing diseases and making people more aware of their health conditions. Most importantly, it not only focuses on physical health but also mental health and others.

Q.2 How can we improve health education?

A.2 We can improve health education by making the people of remote areas more aware. One can organize programs, camps, plays, folk shows and more plus teach it properly at schools too.

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The National Survey of Children's Health

The National Survey of Children’s Health (NSCH) provides rich data on multiple, intersecting aspects of children’s lives—including physical and mental health, access to and quality of health care, and the child’s family, neighborhood, school, and social context. The National Survey of Children's Health is funded and directed by the Health Resources and Services Administration (HRSA)   Maternal and Child Health Bureau (MCHB) . A revised version of the survey was conducted as a mail and web-based survey by the Census Bureau in 2016, 2017, 2018, 2019, 2020, 2021 and 2022. Among other changes, the 2016 National Survey of Children’s Health started integrating two surveys: the previous NSCH and the National Survey of Children with Special Health Care Needs (NS-CSHCN) .  See the  MCHB website  for more information on the 2016, 2017, 2018, 2019, 2020, 2021 and 2022 National Survey of Children's Health administration, methodology, survey content, and data availability.   The previous version of the NSCH was conducted three times between 2003 and 2012. In 2003, 2007, and 2011/12, the NSCH was conducted using telephone methodology, and was conducted by the National Center for Health Statistics at the Centers for Disease Control under the direction and sponsorship of the federal Maternal and Child Health Bureau  (MCHB).

The 2016, 2017, 2018, 2019, 2020, 2021 and 2022 NSCH public-use files (PUF) are available on the Census Bureau's NSCH page . Additionally, national and state estimates for over 300 Child and Family Health Measures and Title V National Performance Measures (NPMs) and National Outcome Measures (NOMs) from the 2016, 2017, 2018, 2019, 2020, 2021, 2022, combined 2016-2017, 2017-2018, 2018-2019, 2019-2020, 2020-2021 and 2021-2022 NSCH are available on the interactive data query . All NSCH survey data shown on the DRC website, including constructed National Performance and Outcome Measures, child and family health measures, and demographic variables are available as SAS, SPSS, and Stata datasets on the DRC  Dataset Request Page .

Attention! The Maternal and Child Health Bureau and the Census Bureau revised imputation and weighting by race and ethnicity for the 2022 NSCH. The updated weights are applied to the 2022 and 2021-2022 NSCH data but have not been applied to prior estimates on the DRC data query. Revised 2021 datasets are available on the Census Bureau’s Data Release page . Please read the weighting revisions technical document  for more information.

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This project is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) under grant number U59MC27866,National Maternal and Child Health Data Resource Center, $4.5M. This information or content and conclusions are those of the author and should not be construed as the official position of or policy of, nor should any endorsements be inferred by HRSA, HHS or the U.S. Government.

A Child’s Health is the Public’s Health

Preparing for unexpected events is an important part of keeping children safe and healthy all year long. Events like the spread of a serious infection, an explosion, an earthquake, or a weather event, such as a hurricane, may cause health problems for large numbers of people, and especially for children.

Children make up one in four people in the United States and they have special needs during and after emergencies. Children are not just little adults; their bodies are different from adults’ bodies. Although younger children are often more affected than adults during disasters, there are concerns for children of all ages during emergencies because

• Children may not be able to follow directions or make decisions to keep them away from danger during a disaster.
• Children’s bodies use energy quicker than adults’ do, and they need food and water more often. This means that they will absorb poisons or dangerous chemicals faster than adults will.
• Children have thinner skin and breathe faster than adults do, making them more likely to take in harmful substances through the skin or breathe them in.
• Children are smaller than adults, but they have more skin in relation to their overall size, compared to adults. This means they have a higher chance of being harmed by certain chemicals or very hot or cold temperatures.
• Children are more likely to put their hands in their mouths, and spend more time outdoors and on the ground, making them more likely to come into contact with dangers in the environment.
• Children may not be able to explain how they are feeling, which can make it harder to identify a medical problem and treat them quickly.
• Children have more contact with others, and they have less developed immune systems to fight off infections. This means they are more likely to catch an illness that can spread from person to person.
• Some children have special healthcare needs . These can increase a child’s chance of getting sick during an emergency, especially if the child is separated from a parent or caregiver.

Caring for children during emergency procedures calls for planning and action before an emergency happens.

Progress on Including Children’s Needs During Emergencies

Although children have a greater chance of being harmed during an emergency, it takes special attention to children’s needs to make sure they are not passed over when emergency plans are made or carried out. Caring for children during emergency procedures, such as  evacuation ,  decontamination , and sheltering , calls for planning and action before an emergency happens. For example, in an emergency, hospitals might have to care for a large number of children. Without planning ahead of time, hospitals may not have the right equipment and supplies to care for more than the usual number of young patients.

Agencies in local communities and at the state and national levels are working to make sure children are protected during disasters by taking steps, such as

• Making new or stronger connections between public health, children’s healthcare providers, children’s hospitals; schools and the Board of Education;
• Developing instructions for how to keep children healthy during an emergency and how to treat children who are sick or have special health care needs;
• Sharing information and ideas about including children’s needs in emergency plans and about how to carry out these plans during an emergency; and
• Preparing for the next event by reviewing what was learned from previous events and making improvements.

The Centers for Disease Control and Prevention (CDC) created a Children’s Preparedness Unit  (CPU) in 2012 to focus on protecting children during outbreaks and other emergencies. CPU works with partners to include children’s needs in all stages of an emergency. CPU has participated in these CDC emergency responses:

• Unaccompanied Minors (2014)
• Ebola Virus (2014-2015)
• Zika Virus (2015-2017)
• Flint, MI Water Contamination (2016)
• Hurricane Matthew (2016)
• Hurricanes Harvey, Irma, and Maria  (2017)
• Hurricanes Florence and Michael (2018)
• Outbreak of e-cigarette, or vaping, product use-associated lung injury (2019)
• COVID-19 (2020)

Moving Forward

Progress has been made, but there is still more work to do to protect children during emergencies. More research could determine how well emergency plans have protected children so far, how plans can be improved, and what can be done to serve children better during emergency events. For example, research could provide information on the mental health of children in disasters. Children respond to upsetting events differently, depending on their ages and states of development. Taking these differences into account in emergency plans might be one way to do a better job of caring for children.

Preparing to take care of children during a disaster is not always easy but planning now can protect their safety and health in the future. For more information about children in emergencies, please visit CDC’s Caring for Children in a Disaster  site.

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Impact of the use of cannabis as a medicine in pregnancy, on the unborn child: a systematic review and meta-analysis protocol

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Introduction: The use of cannabis for medicinal purposes is on the rise. As more people place their trust in the safety of prescribed alternative plant-based medicine and find it easily accessible, there is a growing concern that pregnant women may be increasingly using cannabis for medicinal purposes to manage their pregnancy symptoms and other health conditions. The aim of this review is to investigate the use of cannabis for medicinal purposes during pregnancy, describe the characteristics of the demographic population, and to measure the impact on the unborn child and up to twelve months postpartum. Methods and analyses: Research on pregnant women who use cannabis for medicinal purposes only and infants up to one year after birth who experienced in utero exposure to cannabis for medicinal purposes will be included in this review. Reviews, randomised controlled trials, case control, cross-sectional and cohort studies, that have been peer reviewed and published between 1996 and April 2024 as a primary research paper that investigates prenatal use of cannabis for medicinal purposes on foetal, perinatal, and neonatal outcomes, will be selected for review. Excluding cover editorials, letters, commentaries, protocols, conference papers and book chapters. Effects of illicit drugs use, alcohol misuse and nicotine exposure on neonate outcome will be controlled by excluding studies reporting on the concomitant use of such substances with cannabis for medicinal purposes during pregnancy. All titles and abstracts will be reviewed independently and in duplicate by at least two researchers. Records will be excluded based on title and abstract screening as well as publication type. Where initial disagreement exists between reviewers regarding the inclusion of a study, team members will review disputed articles status until consensus is gained. Selected studies will then be assessed by at least two independent researchers for risk bias assessment using validated tools. Data will be extracted and analysed following a systematic review and meta-analysis methodology. The statistical analysis will combine three or more outcomes that are reported in a consistent manner. The systematic review and meta-analysis will follow the PRISMA guidelines to facilitate transparent reporting [1].

Competing Interest Statement

The authors have declared no competing interest.

Funding Statement

This study did not receive any funding.

Author Declarations

I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained.

The details of the IRB/oversight body that provided approval or exemption for the research described are given below:

The study will use ONLY openly available human data from studies published in biomedical and scientific journals.

I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals.

I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance).

I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable.

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All data produced in the present work are contained in the manuscript.

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New Rules Will Help Adults and Children Enroll — and Stay Enrolled in — Medicaid and CHIP

Prepared for the commonwealth fund.

Kinda Serafi

Manatt Health

On April 2, 2024 the Centers and Medicare & Medicaid (CMS) published the most significant set of eligibility regulations since the initial rule implementing the Affordable Care Act (ACA). The new rule will help eligible individuals enroll in Medicaid and CHIP coverage and stay enrolled as long as they remain eligible. Many of the provisions address issues that contributed to coverage losses during the unwinding of the continuous enrollment provision that has resulted in at least 13.7 million people losing Medicaid coverage, mostly for procedural reasons.

To read the Commonwealth Blog, click here.

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Your information, recipient's information.

I'm 38 and single, and I recently realized I want a child. I'm terrified I've missed my opportunity.

• I didn't want kids and didn't think I'd want to get married again after my divorce.
• But recently I realized I actually do want to build a life — and a family — with someone. 
• I'm almost 39, and I'm starting to panic about whether my chance to have a child has passed.

I can still picture it. I was 20, sitting on the kitchen countertop with my legs dangling over the cabinets. He was 21, leaning against the stove of the home he hoped we'd share. We'd been dating for nearly two years and were at a standstill.

I was clinging to my dream of moving five hours away to attend the design program at the Art Institute of Seattle. He wanted a simple life with children and home-cooked meals in the little resort town of Coeur d'Alene, Idaho, where we met in sixth grade .

That day in the kitchen, we decided to stay together, and we each gave up something to do that. I would no longer pursue design school and the big-city life I'd always dreamed of, and he'd forgo having children and a wife who prioritized homemaking. I made it clear to him that I did not see motherhood in my future and that he needed to be OK with that. Two years later, we married.

My now ex-husband wanted kids and a stay-at-home wife

My husband thought I'd change, and I thought I could change for him. I told myself that it was silly to go after my dreams and that I should be content in the pretty mountain town where I grew up.

But I grew resentful when he asked where dinner was or complained that his gym clothes hadn't been washed. I did little to hide my disdain for our small-town life. He was a good and hardworking man, but I don't think I made him feel that way.

We were young, foolish, and sweet, thinking our love would allow us to overcome our differences. We were also very wrong.

Related stories

Shortly after I turned 30, we divorced . We were both tired of sacrificing the things that were important to us for each other.

I didn't think I'd want to get married again or have kids

I told my friends and family I'd never get married again. I needed independence, a fulfilling career, and space to chart my own course, and I didn't think marriage fit into that vision. I was content to look toward a future without a husband, children, or the trappings of a "traditional" life.

I was also in no hurry to get into a serious relationship after my divorce. I was terrified of repeating my mistakes. Nevertheless, months later I stumbled into one that lasted 7 ½ years.

He was significantly older and wasn't interested in marriage or children, and we were focused on our careers. We expected little of each other aside from fidelity. We took trips, drank nice wine, and stayed out late. Without the expectations or duties of a shared mortgage or a family, we simply enjoyed our time together. When we were apart, we did our own things. Those were great, easy years.

It was an incredibly healing relationship, and, ironically, I started to become the woman my ex-husband had wanted. I enjoyed cooking, cleaning, and caring for someone when it was my choice and when it wasn't asked of me. I'd been so preoccupied with preserving my independence and caring for myself that I hadn't realized how much I could enjoy caring for someone else and allowing them to care for me.

I changed my mind about wanting to build a family with someone

I started to think I might want more than an easy, aimless relationship. I realized I might actually want to build a life from the ground up with someone who wanted the same thing. And while I knew that might take more work, it also felt like the type of connection worth pursuing.

I felt restless, and I couldn't ignore that what I wanted had changed. Though we were technically together, we were living our own lives. That was exactly what I had wanted and needed after my divorce, but autonomy was no longer my top priority. It felt like the relationship had run its course. He's a wonderful man, and we're still close, but we'd entered our relationship without intention or a shared vision of our future.

We broke up shortly before my 37th birthday. Over the following year and a half I dated around for the first time in my life. I broke hearts, had my own heart broken, and did in my late 30s what many people do in their 20s. I didn't know it then, but I was learning what I wanted and needed in a relationship. Ultimately, I want to build a life with another person, not simply join theirs when it's convenient.

I began to feel an incredible urgency to find the relationship and stability to see me through the second half of my life. To my amazement, I began seriously thinking about marriage and children — I hardly recognized myself.

I also began to feel selfish for spending so much time focusing solely on myself. I went from proudly proclaiming I was too self-centered to be bothered with a family to realizing there was more to life than independence and the pleasures of living for oneself. My very existence started to feel shallow and hollow.

I worry I'll end up alone, but I'm still hopeful

Now, months after that realization and at nearly 39, I feel panicked thinking I'll be a single, childless middle-aged woman. I worry that my youthful looks will fade and that I won't be able to attract the man I want to spend the rest of my life with.

If I sound desperate, it's because I honestly do feel a little desperate. At my age, I know that creating life may not be an option for me. And I worry that men who want a family aren't looking for a woman pushing 40. I get it; I'm no longer the ideal candidate for motherhood , and it's a scary truth. But I still hope to find someone who thinks I'm the ideal partner and create our family together.

I understand the appeal of life without the constraints of marriage or children; for many years I was quite satisfied living that way. I know people can live happy, purpose-driven lives without those things. I just don't believe I'm one of those people anymore. I know now that my purpose lies in having a husband and a family. I'm meant to care for more than myself.

I'm looking for my forever person and hoping he's looking for me, too.

Watch: Watch Tony Robbins bring someone to tears in a one-on-one motivational session

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