Background: Health attitudes and behaviours formed during childhood greatly influence adult health patterns. This paper describes the research and development protocol for a school-based health literacy program. The program, entitled HealthLit4Kids, provides teachers with the resources and supports them to explore the concept of health literacy within their school community, through classroom activities and family and community engagement. Methods: HealthLit4Kids is a sequential mixed methods design involving convenience sampling and pre and post intervention measures from multiple sources. Data sources include individual teacher health literacy knowledge, skills and experience; health literacy responsiveness of the school environment (HeLLO Tas); focus groups (parents and teachers); teacher reflections; workshop data and evaluations; and children’s health literacy artefacts and descriptions. The HealthLit4Kids protocol draws explicitly on the eight Ophelia principles: outcomes focused, equity driven, co-designed, needs-diagnostic, driven by local wisdom, sustainable, responsive, systematically applied. By influencing on two levels: (1) whole school community; and (2) individual classroom, the HealthLit4Kids program ensures a holistic approach to health literacy, raised awareness of its importance and provides a deeper exploration of health literacy in the school environment. The school-wide health literacy assessment and resultant action plan generates the annual health literacy targets for each participating school. Discussion: Health promotion cannot be meaningfully achieved in isolation from health literacy. Whilst health promotion activities are common in the school environment, health literacy is not a familiar concept. HealthLit4Kids recognizes that a one-size fits all approach seldom works to address health literacy. Long-term health outcomes are reliant on embedded, locally owned and co-designed programs which respond to local health and health literacy needs. Keywords: Health literacy, Health promotion, School, Children, Teacher, Community, Equity, Co-design Background “Health literacy is the ability to make sound health Health literacy is the ability of an individual to find, ap- decisions in the context of everyday life; at home, in praise, understand and apply information to promote the community, at the workplace, the health care and maintain good health and wellbeing [1–3]. It is system, the market place and the political arena. composed of three interwoven components; the individ- It is a critical empowerment strategy to increase ual, the community they belong to and the healthcare people’s control over their health, their ability to environments they access [4, 5]. This is encapsulated by seek out information and their ability to take Kickbusch, Wait and Maag; responsibility.”  Some suggest health literacy is much more complex * Correspondence: Rose.Mcshane@utas.edu.au than the individual consumer and thus the terms low School of Medicine, College of Health and Medicine, University of Tasmania, and high health literacy should be avoided [7, 8]. Private Bag 34, Hobart, TAS 7000, Australia Full list of author information is available at the end of the article © The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Nash et al. BMC Public Health (2018) 18:690 Page 2 of 13 However others have demonstrated the existence of a objectives in addition to achieving the broader aims of social gradient for health literacy, reporting that financial HealthLit4Kids. By design, HealthLit4Kids encompasses deprivation remains the strongest predictor of low health knowledge, skills and behaviours that underpin two of literacy, followed by social status, education, age and the general capabilities set out in the Australian Curricu- gender . lum; critical and creative thinking, and personal and so- Health literacy is influenced by both personal factors cial capability, and provides a mechanism to facilitate and the context in which health care encounters take teachers and school children to explore, discuss, design place. Personal characteristics include age, social sup- and share resources capable of improving the health lit- port, ability to appraise health information, educational eracy of Australian school children and their families attainment and relationships with healthcare providers. . The recently introduced Australian Curriculum, The characteristics of the health care environment in- Health and Physical Education (ACHPE) theme area pro- clude the use of plain language, signage and way-finding, vides an appropriate framework to support the sustainabil- and communication skills of health service providers . ity of the HealthLit4Kids program. The pilot of the Health literacy is dynamic as it can change over a life- program (based in Tasmania, Australia) is a unique oppor- time with exposure to new or unfamiliar health settings tunity to begin to populate the ACHPE content and ensure or information. the delivery is underpinned by health literacy design princi- Despite the growing literature on health literacy, there ples to maximise the benefit and outcomes of this curricu- is a lack of evidence regarding effective strategies to in- lum. These curricula resources can be subsequently shared crease health literacy, especially in children. Health atti- and further adapted, strengthening the synergies between tudes and behaviours formed during childhood greatly education and health. HealthLit4Kids acknowledges the in- influence adult health patterns , therefore it is im- fluence of the WHO Health Promoting Schools Framework perative that children are supported in becoming and its elements which include: curriculum, teaching and knowledgeable and critical consumers of health informa- learning, school organisation, ethos and environment and tion and environments. HealthLit4Kids responds to this partnerships and services . need using a school-wide program to engage its children Structured interventions are required to improve and their local community in conversation about health health and equity outcomes in communities . The literacy and health issues. Although HealthLit4Kids is Ophelia principles (Table 1.) can be used to underpin likely to have a positive impact on health outcomes, it is health literacy programs to ensure they are participatory, further justified given the positive correlation reported community-focused, equity driven and sustainable. between health literacy and educational attainment While much is known about the concept of health lit- [5, 11]. Situating health literacy education within the eracy and its relationship to health outcomes, there are school context allows class teachers, who have a full ap- limited studies that focus on children and the school en- preciation of their learners’ worlds, to teach children to vironment . HealthLit4Kids is justified given that no become increasingly involved in managing their own tools currently exist to measure the health literacy pro- health. Additionally, improving the health literacy of file or competencies of children under 10 years old . children has the potential to trigger an intergenerational This program will contribute to gathering empirical evi- response in improving health outcomes by filtering dence to identify the health literacy profile of children through to families and communities an increased and determine age appropriate health literacy expecta- understanding and recall of health messages, knowledge tions of children. The design and implementation of of health determinants and use of preventive health HealthLit4Kids recognises the UN Convention on the strategies and services. When health concepts and be- Rights of the child and responds to the child’s right to haviours are presented in culturally relevant, age appro- participate in research about their lives . priate and socially supported ways, they become It is imperative to encourage children to become en- normalised and children may understand their import- gaged and knowledgeable consumers of health informa- ance at an earlier-than-expected age . tion and the impacts of the environments in which they HealthLit4Kids aims to enhance the health literacy of learn and play. The children’sactive engagement in the a whole school community through a sustainable and lo- production of a HealthLit4Kids artefact (creative piece – cally driven model. Here the whole school community poem, video, garden beds, models, painting, drawing, includes teachers, children, support staff, school parents story, song), followed by reflection on their artefacts sup- and friends association, parents/carers, families, local ports this objective. Art provides children with an age ap- community (including health and wellbeing aligned or- propriate voice to express their views. HealthLit4Kids ganisations and businesses in the local area). Aligning responds to a direct call to address an existent research gap the initiative with the Australian Curriculum recognises whereby children’s voices and perspectives largely remain and supports teachers to achieve their curriculum-based unheard. Broder et al. found that active participation by Nash et al. BMC Public Health (2018) 18:690 Page 3 of 13 Table 1 The Ophelia (Optimising Health Literacy and Access) principles that guide the aims, development and implementation of structured interventions to improve health and equity outcomes in communities  Principles Description 1. Outcomes focused Improved health and reduced health inequalities 2. Equity driven All activities at all stages prioritise disadvantaged groups and those experiencing inequity in access and outcome 3. Co-design approach In all activities at all stages, relevant stakeholders engage collaboratively to design solutions 4. Needs- diagnostic approach Participatory assessment of local needs using local data 5. Driven by local wisdom Intervention development and implementation is grounded in local experience and expertise 6. Sustainable Optimal health literacy practice becomes normal practice and policy 7. Responsiveness Recognise that health literacy needs and the appropriate responses vary across individuals, contexts, countries, cultures and time 8. Systematically applied A multilevel approach in which resources, interventions, research and policy are organised to optimise health literacy children in the conceptual development of Health Literacy rationale, resources, activities, outputs and the short, was only realized in three of the 21 articles included in their intermediate and long term outcomes. recent systematic review . This requires urgent atten- The HealthLit4Kids program has 4 stages: needs as- tion if we are to empower a future generation of children to sessment, discovery, action planning and evaluation. understand and manage their own health and wellbeing. The needs assessment includes the school characteris- Improving health literacy, particularly of children, will tics and needs (assessed using the HeLLO Tas checklist), in turn improve health outcomes by increasing under- and the health literacy knowledge, skills and experience standing and recall of health messages, knowledge of the (KSE) of the teachers. Workshops to discuss these data social determinants of health, and the sorts of public lead to the co-creation of an Action Plan. Individual health actions that protect and improve health (e.g. im- teachers are invited to consider their own context and munisation, water as the drink of choice) and the appro- explore health literacy and design individual interven- priate use of preventative health services. tions (classroom activities) to explore health and While it can be seen as problematic and perhaps an health literacy concepts through planned lessons with oversimplification of health literacy, for the purposes of their class (Fig. 2). this paper, the terms high and low health literacy are The HeLLO Tas checklist and teacher health literacy useful and will be used with the understanding that a KSE surveys are repeated at the conclusion of the pro- more nuanced and complex context exists. gram to detect if there has been any change in health lit- eracy awareness, health literacy competencies and health literacy responsiveness. A HealthLit4Kids Competition Methods encourages message dissemination and conversations Methodological foundations with family and local community. HealthLit4Kids reflects a pragmatist worldview, meaning the research is problem-centred, employs a real world Aims/sequence of events practice orientation and inquiry approach . A prag- As described this program is informed by a pragmatist matist position facilitates exploration of teacher aware- approach and employs mixed methods design to answer ness of health literacy and development of a school wide nine research questions (displayed in Table 2.) action plan to address the health literacy needs of a spe- cific community. This includes greater understanding of Needs assessment the health literacy of individuals and the responsiveness Project commencement of the school environment and community to those indi- A briefing with the Principal provides an opportunity to viduals. It seeks to better understand the health literacy determine the alignment of HealthLit4Kids with the profile of children. schools existing strategic plan, to set dates for work- Consistent with a pragmatist approach, the research ap- shops, key data collection points, the school exhibition plies a sequential mixed methods strategy of enquiry . and the identification of HealthLit4Kids champions It combines principles from mixed methods research, (Children, Teachers, Parents). A focus group provides an participatory action research , implementation science opportunity to engage the parents/carers from the com-  and realist synthesis . Figure 1 uses a program mencement of the program, their contributions are fed logic model  to visually present the program goals, into workshop 1. The consent forms and information Nash et al. BMC Public Health (2018) 18:690 Page 4 of 13 Fig. 1 Program Logic Model sheets are sent home with children, consent is requested Discovery and action planning for use of the children’s surveys responses and the arte- Workshop 2: The second workshop supports the im- facts and artefact descriptions. plementation of the action plan at a school level as Workshop 1: This workshop defines and describes well as the identification and design of individual health literacy and explores its application within the classroom HealthLit4Kids activities (interventions). school and classroom context. It gives an overview of The workshop begins by revisiting the health literacy the HealthLit4Kids aims and program design and out- definition and description of health literate schools lines the HealthLit4Kids competition. Teachers are in- from workshop 1. This is a useful opportunity to car- vited to complete an individual health literacy KSE ryout member checking , whilst also providing survey to determine their baseline health literacy. The staff with an opportunity to add or remove items teachers are also invited as a group to define health liter- from their description. In addition to finalizing the acy and describe a health literacy responsive school. school wide action plan teachers are provided with a Through a sequence of educational activities, this first template to plan their individual classroom interven- workshop facilitates discussion and engagement with tions. This includes an activity description, logistical the concept and works towards a shared definition of information, and asks the teachers to describe how health literacy. A major aspect of workshop 1 is the small success will be measured. The teachers are encour- group work where teachers complete the HeLLOTas tool. aged to align their individual activities to the Austra- The tool is used to facilitate teacher led assessment of the lian Curriculum. The authors re-introduce the idea of health literacy responsiveness of the school environment. a school wide competition and describe how this as- All data collected throughout the workshop informs the pect of the program brings the families, local com- collaborative development of the school wide action plan. munity and surrounding business into the The workshop participants are also invited to complete a conversation. All participants are invited to complete workshop evaluation. a workshop evaluation. Nash et al. BMC Public Health (2018) 18:690 Page 5 of 13 Fig. 2 Program design including pre-post measures Intervention health literacy responsiveness of the school environment. Throughout Terms 3 and 4 (months August–October) Teachers are invited to repeat the health literacy KSE sur- teachers use their individual classroom action plans to vey to allow for comparison with the survey completed focus on the development of HealthLit4Kids artefacts with during workshop 1. In addition, teachers may choose to their class. Dedicated in classroom activities support the complete a written reflection of HealthLit4Kids and their development of artefacts in two categories- class group or classroom intervention (to be included in their own Pro- individual student. The children’s description of their fessional Development Portfolio) and provide this to the work accompanies each artefact. A consent form includ- researchers as data. Each workshop concludes with an ing the artefact description, age of child and the ACHPE evaluation. In addition following workshop 3 two focus theme area(s) is required for entry in the HealthLit4Kids groups, one with teachers and one with parents, will be competition. The teachers assist the children to identify held to capture the overall impressions of the HealthLit4- the appropriate theme area(s). The consent forms and in- Kids program. formation sheets are sent home with children to prompt discussion about the artefact with their parents/carers. All Project follow-up children participate in the Classroom Activities, however A six month and 12 month follow up interview with the entry in the competition relies on parental consent. The Principal and Parents & Friends will be utilised to deter- teachers at the pilot school chose the School Fair as the mine the sustainability and reach of the program. opportunity to showcase the artefacts. Parents/carers, family and friends at the fair are invited to judge the arte- Setting facts for a “People’sChoice Award”. Local business and or- The pilot school is situated in Southern Tasmania. Tas- ganisations identified as Health and Wellbeing aligned are mania’s population has demonstrated low health literacy invited to donate prizes for the artefacts or consider pro- levels and chronic disease risk factors above the national viding activities or volunteers at the School Fair. The arte- average including smoking, obesity, physical inactivity facts and their descriptions are collected and curated and elevated cholesterol levels . There is an impera- using the ACHPE theme areas. tive for improving health literacy at an individual and systems level in Tasmania, as reflected in the Premier’s Evaluation ambitious target to be the healthiest state by 2020 . Workshop 3: The final workshop revisits the HeLLO Tas It is within this context that HealthLit4Kids was devel- checklist to determine if there has been a change in the oped with a specific focus on children and schools. The Nash et al. BMC Public Health (2018) 18:690 Page 6 of 13 Table 2 Research questions mapped to methods Research Question Methods 1. How does a school-wide Health Literacy Project (HealthLit4Kids) � Quant: Tool 1. Self-Assessment Checklist affect the health literacy of the school environment? � Mixed: Workshop evaluation (including Tool 2: Individual Health Literacy Survey) � Qual: Focus Groups (Teachers and Parents) 2. How does HealthLit4Kids affect the awareness and health literacy � Quant: Tool 1. Self-Assessment Checklist of the teachers involved in the project? � Mixed: Workshop evaluation (including Tool 2: Individual Health Literacy Survey) � Mixed: Teacher 200 word reflection. 3. Of the Health and Physical Education areas outlined in the Australian � Mixed: Students’ creative pieces (artefacts) curriculum which are the most commonly raised by students through � Mixed: Competition Entry Form (artefact category/description) their creative pieces (artefacts)? � Mixed: Teacher 200 word reflection. 4. How does HealthLit4Kids impact on the health literacy of the wider � Quant: Tool 1. Self-Assessment Checklist school community (parents, carers, community)? � Qual: Focus Groups (Teachers and Parents) � Mixed: Teacher 200 word reflection. 5. How does feedback from teachers and students who use the � Mixed: Students’ creative pieces (artefacts) Healthlit4Kids resources inform the development of a health literacy � Mixed: Workshop evaluation (including Tool 2: Individual Health measurement tool specific for children? Literacy Survey) � Qual: Focus Groups (Teachers and Parents) � Mixed: Teacher 200 word reflection. 6. What are the lessons learnt from implementation of HealthLit4kids at � Mixed: Workshop evaluation (including Tool 2: Individual Health the trial school? How can this inform a state-wide version in the future? Literacy Survey) � Qual: Focus Groups (Teachers and Parents) � Mixed: Teacher 200 word reflection. 7. In what context and via what mechanisms can the HealthLIt4Kids � Comparative Evaluation (using all data as per Pilot). project be optimised and sustainably embedded? � Principal Interviews – 6 months, 12 months 8. How can technology be used to optimise the reach, future participation � A-Lab Showcase/Digital production of program and artefacts. and sustainability of HealthLit4Kids? � A-Lab visitor evaluation of experiential learning site. 9. How does a school-wide Health Literacy Project (HealthLit4Kids) affect � Student questionnaire survey based on questions in the ASHFS/ children’s school engagement and attitudes and beliefs towards health CDAH survey behaviours? reference school has a diverse socioeconomic profile, contemporary health literacy theories [4, 5]. This pilot with the majority of the population in Socio Economic program will use some recently developed tools to assess Indexesfor Areas(SEIFA)Decile 6(range5–10), the health literacy environment of the school. indicating this is an area of medium to high socio-economic advantage relative to other areas . HeLLOTas Self-Assessment tool In 2017 the school had approximately 340 enrolments, 34 Developed by the Tasmanian Council of Social Services teaching staff and 15 non-teaching staff. The school hosts (TasCOSS), the HeLLOTas Self-Assessment tool is a launch into learning program (birth to 4 years) and for- designed for use in health organisations within the mal education for Kinder to Grade 6 (4-12 years). community sector. Building on the ‘six dimensions of a Written consent is obtained from all participants. health literate organisation’ developed by the New Written information and consent sheet are obtained Zealand Ministry of Health , the HeLLoTas tool has from each participant to ensure consent is informed. been adapted for use in the school context as a Parental consent is provided for collection of data from self-rating tool to measure the health literacy responsive- children. ness of the school environment/community. The HeLLoTas tool includes 36 questions over 6 Domains; Materials Tools to measure the health literacy of individuals and 1. Leadership and management environments have been developed in response to 2. Consumer involvement Nash et al. BMC Public Health (2018) 18:690 Page 7 of 13 3. Workforce The few quantitative questions in the evaluation sur- 4. Meeting the needs of diverse communities vey will also be subjected to statistical analysis using the 5. Access and navigation 3 time points (each workshop) to determine if there has 6. Communication been a statistically significant change in agreement/re- sponse in regards to health literacy awareness and The quantitative data are gathered through prede- acceptance. signed closed questions, with a rating scale from 1 to 5. Each of the six areas of organisational health literacy are Discussion covered. Further, participants are asked to answer two HealthLit4Kids has been designed to respect and re- open-end questions in each of the six areas of interest. spond to the UN Convention on the Rights of the Child This section will provide insight into the qualitative as- (UNCRC). It embodies a salutogenic (strengths based pect of organisational health literacy. approach to health) and through its purposive alignment with the Ophelia principles it co-creates, embeds and re- sponds to the health literacy needs of the participating Health literacy KSE survey local community. Finally, by design it ensures practical- This survey was designed by the Centre for Culture, Eth- ity, usability and sustainability through responding to a nicity and Health to evaluate workshops with health pro- resource gap for classroom teachers aligned to the fessionals participating in health literacy based ACHPE theme areas. Each of these design consider- professional development. The Health Literacy KSE ations are now outlined. Survey , includes 15 questions and a 5 point likert scale where 5 corresponds with high confidence, 1 with UNCRC rights low confidence. Whilst many validated tools for measur- Health literacy is a right of citizenship “Just as there ing health literacy levels exist , this tool better re- is a universal right of access to healthcare, the univer- flects a more contemporary understanding of health sal right of access to health literacy must be recog- literacy competencies; functional health literacy rather nised.” . than the ability to read and understand health informa- The Rights outlined in the UNCRC draw attention tion alone [1, 10, 19]. to children’s rights not only in relation to basic hu- Student Survey: adapted from the Childhood Deter- man needs but also in terms of research about their minants of Adult Health (CDAH) study, the seven ques- lives. HealthLit4Kids responds to a number of articles tions were originally designed in 1989 within the of the UN Convention on the Rights of the Child Australian Schools Health and Fitness Survey which is (UNCRC), specifically 12, 13, 17 and 24 . part of a longitudinal national study and have been vali- Through purposive alignment to the UNCRC Rights dated and used in previous studies that have produced HealthLit4Kids can be confident its program will numerous publications [32, 33]. The survey measures assist children to; engagement, attitudes and beliefs towards health behav- iour at commencement and conclusion of the project. 12. Have the right to give their opinion, and for adults to listen and take it seriously. Statistical analysis Qualitative data 13. Have the right to find out things and share what Analysis of workshop evaluations, focus group re- they think with others, by talking, drawing, writing or sponses, teacher reflections and artefact description will in any other way unless it harms or offends other employ thematic analysis  techniques. people. Quantitative data 17. Have the right to get information that is important Basic statistical analysis will be employed to determine if to their well being, from radio, newspaper, books, responses in the Health Literacy KSE surveys completed computers and other sources. Meanwhile adults will by teachers at the beginning and end of the program is ensure that the information children are getting is statistically significantly different. Given the small num- not harmful, and will help children to find and bers it is anticipated the data will be non-parametric and understand the information they need. thus non-parametric analysis will be employed. The questions and domains in the HeLLO Tas tool will also 24. Have the right to the best health care possible, safe be compared pre and post to determine if there has been water to drink, nutritious food, a clean and safe any change in the responses. The student survey ques- environment, and information to help all children to tions will be analysed using descriptive statistics. stay well . Nash et al. BMC Public Health (2018) 18:690 Page 8 of 13 Salutogenic approach to health it should ensure a health literacy thread is fed through- HealthLit4Kids provides a salutogenic (strengths based out curriculum. For example, the development of a approach to health) , which is now commonly uti- budget in grade 6 mathematics may encourage children lised in Europe, particularly in the Scandinavian coun- to consider the costs of eating healthily and being phys- tries. MacDonald’s description of the benefits of this ically active. approach doubles as a useful description of the Health- There is growing recognition of the importance of im- LitKids program; proving health literacy in order to improve health out- comes. However, current debate is largely confined to “By valuing and encouraging the building upon of the health sector even though this is an issue that re- personal, social, community and possibly global assets quires multi-sectoral collaboration and community en- and resources, students’ focus moves to how they will gagement in order to achieve real and sustained become educated for lifelong health and physical progress. Few studies have engaged across sectors. Al- activity engagement and promote aspirations and though health literacy is receiving much attention in the action for this in their families and communities”  health sector, the education sector is well positioned to partner with health in this increasingly urgent discus- The decision to invite schools and teachers to be the sion. This remains an untapped opportunity locally, na- HealthLit4Kids entry point can be justified given the risk tionally and internationally. that a program targeting parents alone may lead to disen- The close relationship between health literacy, edu- gaged parents inadvertently disadvantaging their children. cational attainment and the health behaviours of indi- This community level approach to health literacy provides viduals highlight that a focus on health literacy is a all children with the opportunity to benefit from health lit- major strategy for improving public health and redu- eracy, health promotion and health programs regardless of cing health inequalities [11, 43]. In addition to the their parents’ position on the subject. This is consistent potential direct benefits to the children (health out- with a universal approach to health literacy which targets comes and educational attainment) [5, 11]schools all people rather than just those assessed as having low and curriculum  provide a useful point of contact health literacy [15, 22]. Further evidence of this inter- with many families in the community who may not national movement is described by the American Heart access health services nor be exposed to health initi- Association which also encourages the implementation of ated health literacy programs . community wide interventions that are socially and cul- Health Literacy is listed as one of the five key proposi- turally appropriate to reduce disparities and inequities in tions that underpin the ACHPE . The Australian cardiovascular health . Curriculum Health and Physical Education Theme areas (which include Health Literacy) are not currently Health literate schools assessed formally on the A-E criteria in the Primary 21st century learning by doing - self awareness, critical School setting. To date students have been awarded a thinking, creativity leads to empowerment Needs Attention/Acceptable/Good/Excellent for their In developing the HealthLit4Kids program, multiple ap- observed ACHPE skills and behaviour. As of 2018 the proaches have been considered including; Health Promot- formal assessment and thus moderation of student as- ing Schools , Australian Research Alliance for sessment items on the A-E criteria will be a requirement Children and Youth (ARACY); The Common Approach for all teachers. Currently there are scarce professional , Head Start Communities (US)  and Ophelia . development, resources or example assessments to sup- There are concerns around the effectiveness of current port classroom teachers with ACHPE moderation re- approaches to school-based Health Education and in- quirements. In fact, a 2015 Victorian study found that creasing recognition that the traditional “one size fits qualifications, preparation, confidence and competence all” health promotion programs imposed on schools are of all teachers for PE implementation remained a con- unlikely to be effective nor sustained beyond project temporary barrier . This Victorian study into the im- funding [41, 42]. plementation of ACHPE curriculum also suggested that In order to realise capacity building in the school com- all teachers in the primary school require professional munity health literacy must be meaningfully embedded development as part of a “whole school” approach . in the school curriculum. As Kickbusch et al. highlight The HealthLit4Kids Program provides a potential solu- “strategies to build health literacy must be viewed as tion to address this existent gap in resources and re- part of life-long learning and health literacy should be sponds to the call for a whole of school approach to integrated into the school curriculum from a young age” ACHPE. . Meaningfully embedding health literacy in curricu- Other innovative aspects of HealthLit4Kids include the lum should not come in the form of an “add on”, rather creative development of health and health literacy Nash et al. BMC Public Health (2018) 18:690 Page 9 of 13 inspired artefacts by schools and their children. In 2012, HealthLIt4Kids Paakkari and Paakari  recognised that health literacy Collective/community level response to health Literacy and involves being able to clearly communicate one’s ideas Ophelia principles and thoughts to others. The creation of the HealthLit4- The HealthLit4Kids program is innovative in that the Kids artefacts therefore provides the children with an research seeks to explore health literacy in the class- opportunity to think more deeply about their health and room and seeks to capture the ripple effect the chil- health related decisions, put their knowledge and skills dren’s classroom activities and the whole school into action and use creativity and critical thinking skills action plan has on the children’sfamiliesand wider to produce their final product. The artefacts which are community. HealthLit4Kids is pioneering given that guided by teacher’s planned learning activities and their collective health literacy [19, 46] has not been carried knowledge of the children’s academic ability provide out in the school and classroom setting in Australia children with an age appropriate medium to express before. health and health literacy through their own eyes. This Given all of this, HealthLit4Kids is now justifiably ex- is justifiable given the literature supports that whilst par- plained through the lens of the 8 Ophelia principles as ental views are often captured, they may not always be shown in Table 3. consistent with their child’s views . Greater In 2017, Broder et al. reported that the extent to self-awareness is supported through the child being re- which families, communities and societies allow chil- quired to describe their artefacts which is an act of re- dren and young people to take an active role and par- flective learning . The empowerment gained by the ticipate in health literacy practices remains a question child through critical thinking and development of for future research . This is consistent with Roth- health literacy lifelong learning skills  are also clear man et al. who previously highlighted the importance advantages of this approach. of focussing on different opportunities for health Table 3 HealthLit4Kids alignment to Ophelia Principles Principle HealthLit4Kids description of alignment 1. Outcomes focused Program Logic model (Fig. 1) describes short term, intermediate and long term outcomes. Program goals; 1. Health Literacy becomes a commonly used and understood term in all Tasmanian schools. “A Health literacy responsive school looks like, feels like, does……” 2. Equip and empower children with HL competencies necessary for their health and wellbeing. 3. Adapt HeLLOTas Tool for use in schools. 4. Tool/Mechanism to measure/document health literacy profile of children < 10 years (co-designed with its target group). 5. Develop and populate OeR with children’s interpretations of health and health literacy. 2. Equity driven Design is to ensure all children in the school setting are involved in discussions. A Universal approach to health literacy whereby health literacy targets all (not just those who are assessed as having low health literacy). All children despite social determinants or parents’ health literacy or health attitudes are given an opportunity to develop their own health literacy knowledge, skills and attitudes. This responds to a basic Human right and the UNCRC rights of the child. 3. Co-designed approach At each stage (facilitated by workshops) all stakeholders/characters are involved in the development of agreed definitions, assessments, action plan and design of individual interventions. 4. Needs- diagnostic approach Self-assessment checklist for school level health literacy responsiveness and design of tasks taking into account context, classroom, curriculum requirements, individuals and resources. 5. Driven by local wisdom Agreed action plan focus and individual classroom activities are by teacher’s knowledge of childrens’ knowledge, skills and attitudes and the appropriate level of health literacy intervention their cohort will manage academically. 6. Sustainable Action plan becomes part of annual cyclical review process and embedded in the school strategy and curriculum. Workshop participation and education on health literacy principles and its relevant to school context empowers teachers to implement new materials and revisit this topic with confidence in the future. 7. Responsive The approach to co-design has portability to any context and enables diverse groups of individuals and schools to apply the same approach and potentially derive completely different goals, action plans and individual classroom activities- in response to the local context. 8. Systematically applied Design is purposefully sequential to capture the built knowledge over time. Each stage of the Ophelia process and its corresponding workshop ensures a systematic approach to a whole of community solution to Health Literacy. Nash et al. BMC Public Health (2018) 18:690 Page 10 of 13 literacy interventions including in the household and In recognition that health literacy is not confined to with families . the health sector, health literacy should be observed HealthLit4Kids is further justified given that no tools within the context that it takes place in and capture the currently exist to measure the health literacy profile or social practices in which it is performed . One such competencies of children under 10 . Healthlit4Kids example may be the classroom supported by teachers, responds to a direct call to fill the existent research gap peers and later challenged or reinforced in the home set- whereby children’s voices and perspectives largely re- ting. Such a comprehensive health literacy construct will main unheard. Being reflective of this, children’s active be challenging to implement and operationalize. This is participation in the conceptual development process was reflected by the necessity of a mixed methods approach only realized in three of the 21 articles included in the to evaluating the HealthLit4Kids program. This ap- recent systematic review conducted by Broder et al. . proach is consistent with advice from Broder et al. who To date the focus has been on maternal or caregivers’ suggest addressing this challenge through a modular de- health literacy competencies, enabling them to secure sign, which is then adjusted as necessary to specific tar- the child’s care needs . This is useful, but may not get groups, contents and contexts . help us to challenge the intractable intergenerational With all of this in mind, HealthLit4Kids seeks to; health literacy barriers. DeWalt and Hink  describe the importance of the parent/child dyad but suggest that (i) strengthen children’s and young people’s and their future research should focus on both the child and par- care takers’ personal knowledge, motivation and ental health literacy to determine the degree of associ- competences to take well-informed health decisions; ation to health outcomes during the “transition” years and (this is where the child begins to separate from the par- (ii) decrease the complexity of society as a whole, and ent and take responsibility for their own health deci- of the health care system in particular to better sions). It is recognised that whilst self-care ability can be guide, facilitate and empower citizens, including variable, children with chronic conditions usually begin children and young people to sustainably manage to self-care from age 11 . Thus identification of this their health . transition point and empowerment prior should be a public health priority. In the proposed rollout the involvement of health and We come full circle then to the need to provide children education faculty students will ensure our future with age appropriate methods for communicating their teachers and health professionals have the confidence understanding of and exploring or presenting their health and competence to take health literacy into the class- concerns. Abram, Klass and Dreyer report on the chal- room and community. This boundary crossing to unite lenges that are inherent to establishing age-related norms health and education using health literacy as the logical or developing age related frameworks for understanding meeting point is certain to produce positive health out- (and improving) children’s conceptualization of their own comes. Thus HealthLit4Kids provides an answer to the bodies, health, and health care . By design, HealthLit4- following statement by Broder et al. Kids is perfectly positioned in the school setting so that teachers can scaffold the learning and respond appropri- “Future efforts must target the redesigning of systems ately to the individual learner’s needs. Guidance and work- to be inclusive and friendly towards children and shopping initially with the teachers provides them with young people, the adjustment of curricula and training the confidence to tackle health literacy in the classroom. of health professionals, teachers and other relevant HealthLit4Kids also responds to De Walt and Hink’s stakeholders in order to better meet the challenge of  request for better understanding of the skills needed the health literacy deficit, and the recognition of by children as they transition to self-management in children and young people as active partners in their order to inform curricula at the primary and secondary health decision making” . school level. As described earlier children, including pri- mary school level or younger have not yet been at the The HealthLit4Kids protocol outlined here contributes focus of health literacy conceptual and intervention re- to the literature and our understanding of health literacy search efforts. Broder et al. provide sage advice; with children and their school community. It is respon- sive to pleas to address health literacy with children in “Given that research has linked health literacy to an evidence based manner . This protocol is a useful health outcomes, and to health (care) costs for the framework for other schools and their communities to adult population, research should follow up on past discuss health literacy. Combined with the pilot findings efforts in order to explore the relevance for young (Completed Nov 2017) the protocol will provide clear people as well as children” . implementation strategies to support portability of the Nash et al. BMC Public Health (2018) 18:690 Page 11 of 13 program nationally and internationally. This protocol UNCRC: UN Convention on the Rights of the Child; UTAS: University of Tasmania; WHO: World Health Organisation also has global applicability and transferability. Acknowledgements We would like to thank the enthusiastic and collaborative principal, teachers, Future research children, families and local community at our pilot school. Also like to Debate endures about the appropriateness of existing Acknowledge the dedicated HealthLit4Kids project team members who have Health Literacy measurement tools. Currently no tools joined us since Nov 2017 to support the next stage of implementation. exist to measure health literacy of children below Funding 10 years of age. This calls for the need to 1) determine if No funding was obtained for the development of the protocol for this study. it is possible to develop a tool for children or 2) deter- However; mine if it is more appropriate to describe a child’s health UTAS Creativity, Culture and Society (CCS) funds ($9,000) literacy profile. supported the evaluation of Phase 1. Pilot project in 2017. In 2018 the project team plan to move to Stage 2 of UTAS College of Arts Law and Education (CALE) Hothouse the project and repeat the protocol design in multiple funds ($19, 000) supported the dissemination of the messages and artefacts using immersive digital technologies schools to determine the context, mechanisms and out- Tasmanian Community Fund ($89,000) will support a Context, comes (CMOs) common across each and identify the Mechanism, Outcomes (CMOs) evaluation at four more Tasmanian factors that guarantee success and the intended out- schools commencing in 2018. comes of the program . Comparisons may also pro- Availability of data and materials vide greater understanding of the relationship between Available from the corresponding author (RN) on request. health literacy, SEIFA decile and educational attainment may inform more targeted solutions in the future. Authors’ contributions RN & SE co-designed the project, are the project CIs and wrote the manuscript. Following this, the HealthLit4Kids team will need to KT was a major contributor in writing the manuscript. RO, KM, BS, LM, SH, DW consider appropriate methods for scalability. This will be contributed to strategic direction of the project and contributed manuscript a balancing act whereby the individualistic response to revisions. All authors read and approved the final manuscript. the local community and empowerment of the project Ethics approval and consent to participate participants must not be lost in the quest for efficiency Ethics approval for application of the HealthLit4Kids Protocol has been obtained usually associated with a larger scale rollout. from the HUMAN RESEARCH ETHICS COMMITTEE (TASMANIA) NETWORK, Social Sciences Human Research Ethics Committee. Conclusion Ethics Approval number: H16289, Title: HealthLit4Kids: A pilot This research protocol will provide a useful technique preventative health project empowering teachers and students to explore, discuss, design and share resources to improve the health for other researchers that plan to explore health literacy literacy of Tasmanian children. and health literacy responsiveness in the school and Ethics Approval number: H17189, Title: A preventative health classroom setting. As described in the protocol, Health- project empowering teachers and students to explore, discuss, design and share resources to improve the health literacy of Tasmanian Lit4Kids recognizes that crossing traditional boundaries children. is necessary to effect change. The protocol describes a solution to health literacy that is designed by a commu- Consent for publication nity in response to the specific health literacy needs of Informed written consent obtained from all participants. Parental consent for collection and inclusion of data (survey, artefacts) obtained from children. its members in their specific context. It will provide new opportunities for characters outside the health sector to Competing interests contribute to awareness raising and supporting the The authors declare that they have no competing interests. health literacy of individuals. HealthLIt4Kids seeks to enhance the health literacy responsiveness of individuals, Publisher’sNote schools, families and communities. This multidimen- Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. sional approach will translate into long term benefits. Most importantly it will provide answers to inform col- Author details lective health literacy solutions. With minor modifica- School of Medicine, College of Health and Medicine, University of Tasmania, Private Bag 34, Hobart, TAS 7000, Australia. School of Education, College of tion this protocol is scalable to multiple schools and Arts, Law and Education (CALE), University of Tasmania, Private Bag 66, transferable globally. Hobart 7001, Tasmania, Australia. Health Systems Improvement Unit, WHO Collaboration Centre for Health Literacy, School of Health and Social Abbreviations Development, Faculty of Health, Deakin University, Geelong, Victoria, ACHPE: Australian Curriculum Health and Physical Education; Australia. School of Medicine, College of Health & Medicine, University of ARACY: Australian Research Alliance for Children and Youth; Tasmania, Hobart, Tasmania, Australia. Peter Underwood Centre for HeLLOTas: Health Literacy Learning Organisation Tasmania; HL: Health Educational Attainment, Academic Division, University of Tasmania, Hobart, literacy; KSE: Knowledge, skills and experience; OeR: Open education Tasmania, Australia. Public Health Services, Department of Health and resources; Ophelia: OPtimise HEalth LIteracy and Access; SEIFA: Socio Human Services, Hobart, Tasmania, Australia. 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