1. Introduction
Health literacy is central to making critical judgements and decisions in health-related settings as well as in our everyday life [
1]. Health literacy can be defined as “the ability to make sound health decisions in the context of everyday life; at home, in the community, at the workplace, the health care system, the market place, and the political arena. It is a critical empowerment strategy to increase people’s control over their health, their ability to seek out information, and their ability to take responsibility” [
2]. Increasing global awareness of health literacy has drawn attention to the concept across populations internationally. The World Health Organization (WHO) has positioned health literacy as a key strategy to address health disparities globally, and numerous efforts have been made to support health literacy development utilizing targeted health programs, initiatives, and interventions [
3,
4,
5]. The fact that these approaches are predominantly aimed at adults [
6] presents challenges to initiation and maintenance of behaviour change, as learning is slower and results in a much lower uptake in adults than interventions with children [
7]. Information and values learned by children at an early age have the potential to shape long-term behaviour and develop positive habits and adult health patterns [
8], and there is now strong evidence demonstrating the ways in which life-long effects of early experiences impact later achievements, mental health, physical health, social adjustments, and longevity of individuals [
9,
10,
11]. It is therefore imperative that children are supported in becoming knowledgeable and critical consumers of health information and environments if wide-scale systemic changes in population health literacy are to occur [
12].
Schools and teachers can create opportunities for students to connect classroom learning activities to their innate needs, provide classroom support for students’ perceived autonomy, competence, and relatedness, and support students to become engaged [
13]—the last of which is a key factor in enhancing learning outcomes. Schlechty [
14] referred to student engagement as any task, activity, or work the student is assigned or encouraged to undertake that is associated with a result or outcome which has clear meaning and relatively immediate value to the student. Although engagement is the desired behaviour, the trait that underpins this is motivation, a pre-requisite for student engagement in learning [
15]. Motivation is of particular importance because it mobilizes a person to act and can be a result of internal or external pressure [
16]. Ryan and Deci’s [
16] Self-Determination Theory (SDT) outlines the psychological needs inherent to motivation-competence, autonomy and relatedness. When satisfied, these needs—the ability to carry out a task effectively (competence); the perception that behaviour is self-determined (autonomy); and perceived connections with peers, teachers, and family members (relatedness) [
17]—interact to enhance and facilitate intrinsic motivation, i.e., the inherent tendency to seek out novelty and challenges to extend and exercise one’ capacities, to explore and learn [
16]. An alternative form of motivation, extrinsic motivation, refers to the performance of an activity in order to attain a separable or tangible outcome, and will depend on the external influences. SDT highlights that both intrinsic and extrinsic motivation can play an important role in student engagement [
16]. The theoretical framework underpinning SDT is grounded within a constructivist approach to learning in that individuals actively construct their own knowledge, which is determined by their individual experiences.
SDT suggests that the interaction between an individual and their social context is the basis for motivation, behaviour, and well-being [
16], and as such, it contributes to understanding how learning environments support health literacy. In recent years, SDT has been utilized by researchers as a theoretical framework to identify and deconstruct the antecedents of student motivations in educational settings, particularly in relation to Health and Physical Education (HPE). Within an HPE setting, controlled motivation can contribute to feelings of boredom and lack of effort. In contrast, volitional engagement complemented by a feeling that participation is by one’s own choice facilitates motivation [
18,
19]. For example, 253 adolescents (aged 12–14) reported that their perceptions of autonomy in HPE significantly predicted need satisfaction and led to learning achievement in personal fitness and conditioning [
20]. Students’ perceived autonomy within learning contexts can foster the fulfillment of their psychological needs, which in turn can influence motivation and long-term behavioural engagement towards a specific learning setting or activity [
16] and has been linked with increased enjoyment of HPE and increased physical activity outside of school [
18,
21]. Against this background, it is reasonable to assume that approaches to the learning of health literacy framed upon SDT would also yield favorable outcomes for students.
Parent–child relationships can also have a significant impact on a child’s achievement and attitude towards school [
22], and schools that effectively work with families and community to support learning see much greater benefits in this area [
23]. Parents and caregivers are in a unique position whereby they observe their child’s behaviour in a natural “home” context, and they can enable learning and facilitate change. The learning trajectory begins well before children enter school and, once attending school, they continue to learn at home and in the community [
24]. Parents play a critical role in providing learning opportunities at home that can reinforce educational messages and themes taught in school [
25,
26]. For example, parents are in an ideal position to influence and reinforce behaviours of their child relevant to nutrition, hygiene, screen time, and physical activity. During the primary school years, parents can participate in opportunities related to play, learning, development and achievement in both the school environment and with tasks children bring home from school. Engaging parents in diverse learning experiences and activities outside school can support them to contribute meaningfully and influence the learning, health, and education of their children.
The Australian Government Department of Education [
27] acknowledges that parental engagement involves parents and caregivers, schools, and communities working together to ensure that every parent can play a positive role in their child’s learning, school community, and social life. Parent engagement can occur at home, in the community, and/or at school, and positive results appear for all [
28]. To facilitate parent engagement in any context, the relationship between the school and parent is paramount, and must involve timely, useful, and clear communication through a range of means and throughout the schooling year [
29], while also integrating effective leadership and community networks [
30]. Teachers have reported that greater engagement with parents of school children is crucial, particularly in promoting health outcomes—of which, the parent has ultimate control (such as buying or cooking particular types of food) [
31].
Despite the proximity of the parent–child relationship and many published papers on the importance of the parent–child dyad [
32,
33,
34,
35], there is a range of identified barriers to parents engaging in the promotion of health with children. Parent concerns about safety have been identified as a central and consistent barrier to physical activity participation of children [
36]. Additional barriers to parent engagement in health promoting behaviours include perceived cost of health food and health activities, lack of time, and competing demands [
37], parents being too busy to engage in healthy behaviours, concern held by providers that they may offend parents, and uncertainty on how to communicate the need to make changes to health choices at home [
38]. Among the identified barriers, communication with parents about health promotion is a key difficulty, which is crucial to address given the importance of effective communication strategies with parents. Morrison, Glick, and Yin [
38] suggest that a “universal precautions approach” should be adopted because all parents will benefit from clear communication. Accordingly, such a universal approach with school-based health programs has the potential to mitigate low levels of health literacy by seeking to align the health literacy demands with the health literacy levels of the families that schools engage with weekly.
While the importance of parent engagement in schools has been established [
39], internationally, only a small proportion of health literacy programs in schools have involved the parent [
40]. According to a recent systematized review of research over the past 10 years, only three of 21 health literacy studies situated in the school context included parent views as part of their program [
41,
42,
43]. This highlights a major gap in the health literacy research field and provides the foundation for the purpose of the current study.
Against this background, the health literacy program, HealthLit4Kids, was developed for primary (elementary) schools in an Australian state. HealthLit4Kids is an education package designed for use in schools to raise awareness of health literacy and prompt discussions about health amongst educators, students, families, and communities. It was specifically designed to respond to the eight Ophelia (Optimising Health Literacy and Access) Principles [
44], and sought to: (i) strengthen children’s and their caretakers’ personal knowledge, motivation and competencies to make well-informed health decisions; and (ii) decrease the complexity of society as a whole, and of the healthcare system in particular to better guide, facilitate and empower citizens, including children to sustainably manage their health. The focus of this study was to evaluate parents’ perception of program impact. The study is nested within a broader HealthLit4Kids research program evaluating student, teacher, and parent perceptions of program impact.
4. Discussion
Parent perceptions about the HealthLit4Kids program focused on student engagement, behaviour change (their own and their child’s), and their own engagement with the program. Insights within each of these themes contribute to learning about mechanisms to influence the health literacy of children and parents within the school setting. How the parent’s perceptions align with the elements of Self Determination Theory (the ability to carry out a task effectively (competence); the perception that behaviour is self-determined (autonomy); and perceived connections with peers, teachers, and family members (relatedness) are also highlighted throughout.
Theme 1. Student engagement—Parents positively reported their children’s engagement and motivation to participate in practical activities and creation of artefacts; and events such as the school fair. These reports were interlaced with comments about student enjoyment, love, and pride. These comments demonstrate authentic engagement in that students were immersed in work that had meaning to them [
14]. The range of activities mentioned indicates that different children are motivated by different things, and therefore the diversity of learning opportunities is important as it responds to the individuality of each child (see
Table 2 for supporting quotes).
HealthLit4Kids is designed to encourage children to create health messages and experience health orientated activities in ways that make sense to them, thus diversity is inherent in this program. This affords the students some autonomy as they can be self-determining through their involvement in the creation and design of the health literacy learning activities. This is evidenced by the parents’ positive perceptions of student engagement whereby their children were motivated to actively engage and experienced enjoyment from these learning activities, particularly those that related to the children’s own interests. This is important, given that autonomy is a key mechanism for motivation and, in turn, sustained behaviour change [
16].
Theme 2. Behaviour change—Parents from all schools talked about positive changes in student behaviour as a result of the HealthLit4Kids program. Parents’ perceptions supported their view that the children should have some responsibility for their own health choices. Changes were most commonly reported related to food and nutrition. However, there were also reports of behaviour and knowledge change in the areas of mental health and well-being, and health benefits of physical activity. In some instances, children were requesting healthier food options at home. This may have been triggered by the classroom activities, excursions to the supermarket, sharing new food experiences with peers, or guided food and nutrition learning inquiries. One child asked his parents for a new bike so he could increase his physical activity. There was also an aspect of parent education involved, where children were reported to be correcting parents’ understanding about health information or informing them of new information in relation to health.
These perceptions of behaviour change, as well as knowledge and skill development, are evidence of the children’s increasing ability to make connections between the learning at school and their everyday lives. Through the lens of SDT, the children are developing their ability to carry out tasks effectively, thus developing their competence [
16]. Supporting the children’s autonomy through facilitating approaches that allow them to create and experience health messages in ways that makes sense to them, helps to bridge the gap between “making choices” and “making sense”. This constructivist approach corresponds closely with the definition of health literacy operationalized within HealthLit4Kids “the ability to make sound decisions in the context of everyday life” [
2]. It is also particularly important to foster autonomy and the development of skills (competence) in relation to health literacy issues that involve lifestyle, such as risk factors for non-communicable diseases. This is consistent with advice from St Ledger and Nutbeam [
48], who highlighted the need to start developing health literacy of children in schools and to teach it in a way that supports an attitude of life-long learning.
Theme 3. Parent engagement—Parent engagement reflected their own values and priorities in relation to health, and therefore there was some diversity in what was perceived as important. The only curriculum area discussed by parents at all schools was food and nutrition. This highlights the importance and benefit of covering health broadly in order to address the priorities of all parents. Similar to the children’s engagement, the diversity is key to the perception of parents that are self-determining, that they have choice and can choose to participate of their own volition in activities that are important to them. In this way, HealthLit4Kids influences the development of health literacy of the parents as well as the children. Parents predominantly talked about HealthLit4Kids through their communication with their children, and communication with teachers and the school. Much of the communication and discussion with children appeared to be centered around the children’s creative artefacts. Parents viewed these discussions as useful for supporting learning and also in reinforcing things such as reduced screen time, that were taught at home.
These kinds of connections between the child, their teacher, and their parents can be viewed through SDT as relatedness which is critical to supporting behaviour change and competence through feedback and social support [
16]. It is important to note that the communication between parents and their children about HealthLit4Kids appeared to vary based on individual students, and factors such as their age and ability to communicate information.
Similarly, there was variation in the parents’ recall of communication by the school about HealthLit4Kids. Therefore, it is an important consideration in the development of school-based health literacy programs to deliberately establish opportunities to promote communication between children and parents, and school and parents to optimize the social support for new learning and new behaviours.
The overlapping relationship between the three themes that emerged from this study is logical, particularly when considered within the frame of SDT. The artefacts and flexibility teachers provided to students in their health literacy inquiries created a sense of autonomy, which in turn could be partly responsible for the positive health behaviour changes observed amongst the children. As expected, when parents see their children becoming highly engaged and interested in their learning, this heightens parent engagement [
27], which enables the child to share and discuss their newfound health literacy competence. This provides critical opportunities for the children to practice their newfound skills and have their meaning and messages reinforced, challenged and communicated by those in their immediate social network—teachers, peers, parents (relatedness) [
15,
16].
As shown in
Table 2, the parents in the program highlighted student engagement, behaviour change, and parent engagement as major outcomes of the program. Unsurprisingly, given the relatedness and social nature of the school environment and concerted efforts in program design to encourage student led health literacy development (competence) developed in a manner that encourages student autonomy, students were highly engaged. HealthLit4Kids places a high priority on student engagement, through health literacy development and artefact creation and sharing. It should be highlighted that this was recognized independently by both the parents and participating teachers at each school. As shown in
Figure 1, the parent perceptions of student engagement highlighted in this study are reinforced by the findings from 84 teachers’ written reflections (WR) during the HealthLit4Kids program [
49]. In addition, the teachers recognized the importance of the whole-of-school approach (relatedness), reported their own personal and professional development (competence), witnessed high levels of student engagement (competence, autonomy) and described a new shared language being used in the classroom and playground (competence, autonomy, relatedness).
When health literacy is viewed as dynamic and changing in response to context—that is, the daily lives of individuals—the importance of constructivist approaches becomes apparent. Supporting the development of health literacy in children requires bridging the gap between helping children to make sense of health messages and then to make healthy choices. SDT is a useful framework to consider the mechanisms by which this occurs. Parent opinions of the HealthLit4Kids program were positive, the children engaged because the activities were described as fun, enjoyable, and exciting. Students were engaged in developing their own health literacy assets—their artefacts became an age-appropriate voice and vehicle to start conversations with their teachers, parents and friends. This study has shown how the students were empowered to start conversations about their health, advocate for health of others, and make positive changes to their own health behaviours.
Parental engagement can be difficult due to time pressures on families. However, the parents in this study reported they would be more likely to engage in programs that interest their children. It should be acknowledged that there will always be a small proportion of parents who will never engage with health topics or show an interest in their child’s learning, however consistent with a “universal precautions approach” [
50], and this reinforces the need to offer health literacy development opportunities to children in schools so that all children have equal opportunities. Useful strategies to engage parents in school-based health literacy programs can include principal communications, school apps, newsletters, interview discussions, invitations to contribute to school strategies/action plans, homework tasks that require direct parent contribution, children interviewing parents, arts in health strategies, student led expos, and parent help in class and on health-oriented excursions. All of the above strategies provide opportunities for program impact to be sustained beyond implementation and thus continued health literacy development of the child. This supports the need for health literacy to be a life-long commitment encouraged by an individual’s immediate social network.
