Health Literacy

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Your research assignment will consist of two parts. These are as follows:
(1) Research and explain all three dimensions (functional/interactive/critical) of the concept “Health Literacy” as it relates to the curriculum area of Health and Physical Education. (approximate word guide range: 800 words).
(2) The Australian Curriculum: Health and Physical Education has been shaped by five interrelated propositions (concept of Health Literacy is one of these propositions) that are informed by a strong and diverse research base for a futures-oriented curriculum. As a result, identify, describe and explore how the concept of Health Literacy can be implemented with a strengths-based approach in the Australian primary school curricular. (approximate word guide range: 1, 500 words)

I MUST USE ONLY THE RESOURCES THAT I ATTACH. MUST BE ON THE AUSTRALIAN CURRICULUM. DO NOT USE ANY OVERSEAS RESOURCES. JUST THE ONES I SUBMIT.
It can be broken up into two sections:
1. Health Literacy defined, and
2. Identify, describe and explore how the concept of Health Literacy can be implemented with a strengths-based approach in the Australian primary school curricular.

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Asia-Pacific Journal of Health, Sport
and Physical Education
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Enacting critical health literacy in
the Australian secondary school
curriculum: the possibilities posed by
e-health
Louise McCuaiga, Kristie Carrolla & Doune Macdonalda
a School of Human Movement Studies, The University of
Queensland, Brisbane, Australia
Published online: 17 Sep 2014.
To cite this article: Louise McCuaig, Kristie Carroll & Doune Macdonald (2014) Enacting
critical health literacy in the Australian secondary school curriculum: the possibilities posed
by e-health, Asia-Pacific Journal of Health, Sport and Physical Education, 5:3, 217-231, DOI:
10.1080/18377122.2014.940809
To link to this article: http://dx.doi.org/10.1080/18377122.2014.940809
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Enacting critical health literacy in the Australian secondary school
curriculum: the possibilities posed by e-health
Louise McCuaig*, Kristie Carroll and Doune Macdonald
School of Human Movement Studies, The University of Queensland, Brisbane, Australia
The teaching of health literacy in school-based health education (SBHE) is of
international interest, yet there is less ready access to how conceptions of health
literacy can be operationalised in school programmes. More specifically, while
articulated in curriculum documents such as the incoming Australian Curriculum:
Health and Physical Education, there are few accounts of planning, implementing
and evaluating units with critical health literacy aims that can inform curriculum
reform. This paper introduces and evaluates a health literacy unit implemented in
three Australian secondary schools. It demonstrates the capacity of schools to
undertake critical health literacy teaching and learning that is valued by the
students as relevant, engaging and contemporary, particularly when the pedagogies
intersect with e-health.
Keywords: critical health literacy; curriculum; e-health
Introduction
Research suggests that adolescents are interested in understanding health information
and learning more about health but often find health messages difficult to understand
(Brown, Teufel, & Birch, 2007). In relation to young people’s capacity to effectively
access, evaluate and utilise health information, school-based health education (SBHE)
programmes offer considerable potential. Schools and their health education programmes
are regularly cited in health promotion literature as a major source of
knowledge about health care and health issues for adolescents (Marcell & Halpern-
Felsher, 2007). From a public health perspective, SBHE provides the early intervention
and prevention that is crucial (Manganello, 2007), with adolescence considered to be
the ideal stage to provide the cognitive and social skills that will empower individuals to
make informed decisions regarding their health throughout their lives.
More recently, health sector bodies such as the National Health and Hospitals
Reform Commission (NHHRC) and health advocates (e.g. The Lancet, 2005) have
focused attention on strengthening consumer engagement within a health system
through the delivery of health literacy within the core curriculum of schools
(NHHRC, 2009). The World Health Organisation (1998, p. 10) defines health
literacy as ‘the cognitive and social skills which determine the motivation and ability
of individuals to gain access to, understand and use information in ways which
promote and maintain good health’. Health literate individuals are therefore able to
make informed health decisions to exert greater control over life events (Shohet &
*Corresponding author. Email: lmc@hms.uq.edu.au
Asia-Pacific Journal of Health, Sport and Physical Education, 2014
Vol. 5, No. 3, 217–231, http://dx.doi.org/10.1080/18377122.2014.940809
© 2014 Australian Council for Health, Physical Education and Recreation
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Renaud, 2006). Health literacy also appears to have the ‘currency’ required to gain
traction within the core curriculum of schools (McCuaig, Coore, & Hay, 2012) given
the primacy that literacy currently holds within contemporary schooling across the
globe (Snyder, 2008) and high stakes assessment regimes.
As such, it was not surprising that health literacy became a cornerstone of
Australia’s new Health and Physical Education (HPE) curriculum (Australian
Curriculum, Assessment and Reporting Authority (ACARA), 2013). As explained
and analysed elsewhere (e.g. Alfrey & Brown, 2013; Macdonald, 2013), there was
strong support for the inclusion of health literacy in the Australian Curriculum for
HPE (AC: HPE). The curriculum-making process, initially instantiated in a Shaping
Paper (ACARA, 2012), required that the concept of health literacy be framed in
educative discourses. Nutbeam’s (2000) model was chosen to inform the approach to
health literacy in the AC: HPE given its resonance with literacy discourses and its
aspirations for SBHE to make a difference to both individuals and communities
(Macdonald, 2013; Ryan, Rossi, Macdonald, & McCuaig, 2012).
Drawing on developments within literacy studies where different types and
practical applications of literacy were being theorised, Nutbeam (2000) built upon
earlier definitions of health literacy to propose a ternary levelled model. The first
level of ‘functional’ health literacy concerns the ability to comprehend health-related
information and function within health system contexts using basic skills in reading
and writing. This level reflects the conventional, narrow characterisation of health
literacy (Nutbeam, 2000; Rubinelli, Schulz, & Nakamoto, 2009). Level two of his
model comprises ‘interactive’ health literacy, which focuses on the personal
communication and social skills which are used to extract and derive information
and to act independently on that knowledge. As such, individuals begin to actively
engage in everyday health-related activities, applying new information to changing
circumstances (McCray, 2005). The final stage of Nutbeam’s (2000, p. 265) model is
‘critical’ health literacy which is orientated towards ‘supporting effective social and
political action, as well as individual action’. Individuals and communities thus
acquire the ability to critically analyse health-related information in order to exert
control over life events (McCray, 2005) and a capacity to act on the social and
economic determinants of health (Nutbeam, 2000, p. 52). According to Nutbeam
(2000, p. 52), as progression between each level occurs so does greater autonomy and
self-empowerment, with progression between levels ‘not only dependent upon
cognitive development, but also exposure to different information/messages’. Here,
Nutbeam provides a strong indication of the educative usefulness of his earlier
model, as the ‘nesting’ of his health literacy levels aligns with other typologies of
cognitive development that inform schooling assessment regimes (Krathwohl, 2002),
an alignment that poses a critical determinant of health literacy’s purchase within
core school curricula (McCuaig, Coore, et al., 2012b). Although as SBHE researchers
we hoped that students’ engagement with the Health Literacy @ Rivercity Schools
(HL@RS) unit would enhance their use of health literacy skills beyond the school
gates, our objective was to design a unit that would deliver, develop and assess
students’ learning. It is this educative intent of SBHE programmes that often differ
from public health-oriented projects that may question the hierarchical nature of
Nutbeam’s model (Chinn, 2011).
Nutbeam’s conception of functional, interactive and critical levels provided a
model that complemented other key propositions and aims in the AC: HPE Shaping
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Paper particularly given the inclusion of its critical dimension. Nonetheless, it was
the inclusion of a critical dimension within the AC: HPE that resulted in questions
concerning its applicability and what was, for some, its ideological appropriateness
(Macdonald, 2014). This was to be anticipated given the vibrant intellectual history
that ‘the critical’ has demonstrated in Australian and international HPE scholarship.
In the early 1990s, the place of the critical project in Physical Education was debated
in a series of Quest journal papers (see, e.g. McKay, Gore & Kirk, 1990). Scholars
advocating for the critical paradigm posed questions, employed methods and
articulated aspirations for the field that reflected mainstream health, sociology and
education research concerns that were looking for schooling, and H/PE, to become
more inclusive, student/inquiry-based and empowering. Since that time, Australian
and international scholarship has argued for a stronger critical dimension in HPE
teacher education (e.g. Garret & Wrench, 2012), curricula (e.g. Evans, Davies, Rich,
& DePian, 2013; Macdonald, 2014) and pedagogies (e.g. Garrett & Wrench, 2011;
Hill & Azzarito, 2012; Macdonald, 2002) with many acknowledging the difficulty of
enacting the vision (Tinning, 2000).
Indeed the translation of the ‘critical vision’ from curriculum document to HPE
classroom has comprised an on-going challenge for the field. Since the early 1990s,
both national and state-based core (Years P–10) and elective (Years 11–12) H/PE
curricula have placed an emphasis on social justice principles, a social view of health
and a sociocultural critique, with students and their teachers encouraged to
interrogate healthy selfhood in relation to the social, cultural, political, legal,
environmental and economic factors shaping their lives (McCuaig & Tinning, 2010).
Yet, Australian HPE scholars have argued that these shifts towards a socially critical
HPE have resulted in considerable resistance amongst many teachers of this learning
area. As Gard and Wright (2014) contend, instead of implementing pedagogical
practices that inspire students to ‘gain a critical self-consciousness and social
awareness and take appropriate action against oppressive forces’ (p. 113), schoolbased
health interventions and curricula are ‘heading in a more instrumental,
individualistic and even punitive directions’ (p. 113). Understanding the factors that
support a more effective translation is thus an important objective, as Evans et al.
(2013, p. 328) in their study of SBHE suggest:
Our data attest that while focussing on (curriculum) policy as emplaced and enacted
should be a necessary element of policy analyses, such processes are likely to evade our
understanding if the multiple ways they are encoded and embodied is left unaddressed …
Rather, they (curriculum policies) are to be viewed as texts having been reassembled,
reordered and ‘performed’ differently in unique organisational settings in respect of
extant imperatives, cultural orientations, attendant clienteles and distribution of
material resources.
We concur with Evans et al. (2013) that the stories, and thereby nuances, of
curriculum implementation, in this case the delivery of health literacy programmes
commensurate with the incoming aims of the AC: HPE, need to be shared if the field
is to understand how (critical) health literacy can be (best) enacted.
Although a burgeoning body of research and literature now surrounds the theory
and practicalities of school-based health literacy curriculum design and implementation,
at the time of this study there was little research into how young people’s health
literacy might be effectively developed through SBHE curricula (see Begoray,
Asia-Pacific Journal of Health, Sport and Physical Education 219
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Wharf-Higgins, & Macdonald, 2009), with even less literature exploring the critical
health literacy domain. As Chinn (2011) has more recently confirmed, ‘health
literacy researchers have made little progress’ (p. 63) in articulating the specific
competencies, including their inter-relationships, means of operationalising and
measuring the critical health literacy domain.
Seeking to address this gap in the research and provide evidence that would both
inform and be informed by the writing of the AC: HPE Shape document (ACARA,
2012) was the motivation for the HL@RS project. Given the agreement about the
importance of adolescent health literacy, and the school as a valuable setting for
enabling health literacy generally and critical health literacy more specifically, the
research project sought to establish:
1. What would constitute a health literacy unit consistent with the incoming
Australian Curriculum: Health and Physical Education (AC: HPE)?
2. What is the response of HPE teachers and their students to health education
that aims to develop critical health literacy?
3. What are the lessons learned for the implementation of the AC: HPE as an
exercise in curriculum reform?
In this paper, we draw on findings from this curriculum project to demonstrate the
inextricability of the critical in the efficacious teaching of health literacy in the
twenty-first century and explore the possibilities posed by the exploding e-health
phenomena which emerged within this research.
Method
The purpose of the HL@RS was to design, implement and evaluate a critically
oriented health literacy unit to establish the ability of schools and their teachers to
deliver such a unit within the reality of contemporary Australian schooling. The
HL@RS project was structured around four phases of research activity that included
preparation, curriculum design, curriculum implementation and evaluation phases.
Activities undertaken in the initial preparation phase focused on the recruitment of
schools and obtaining university and Queensland Department of Education ethics
approvals. A total of three purposively selected schools were approached in a
satellite city in Queensland, Australia, which subsequently resulted in the participation
of 19 HPE teachers and approximately 500 students. Where possible, a balance
and representation of schools and student cohorts was achieved according to the
factors of private/state, single sex/co-educational and socio-economic school status.
Prior to the collection of data, written consent was obtained from school principals,
parents and participating students and teachers.
Work conducted within the curriculum design phase predominantly involved a
review of literature which informed the construction of the health literacy
curriculum. This phase of the research is outlined in more detail in the following
section. After the initial design of the unit, critique and input was explicitly sought
from the projects’ teachers and curriculum leaders, reflecting an endeavour to work
collaboratively with schools (Petrina, 2004). This work was undertaken in a series of
professional development (PD) workshops conducted with those teachers who were
most likely to deliver the HL@RS unit of work. Drawing on the teachers’ input and
220 L. McCuaig et al.
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feedback during the PD workshops, the final curriculum package underwent minor
modifications which focused almost entirely on issues of assessing student performance.
Once amended and disseminated, participating teachers were asked to deliver
the proposed curriculum to their students through the typical operation of their
school’s HPE programme. Throughout the implementation phase, teachers were
required to collect student work so that later analysis could be undertaken.
Due to the strong interest in exploring teachers’ and students’ perspectives, the
project employed qualitative methods to generate a richer understanding of
participants’ thoughts about and responses to the curriculum initiative. As outlined
by Simpson and Freeman (2004, p. 343), ‘the interpretive aspects of qualitative
research attempt to understand the phenomena of health promotion through the
meanings that people assign to them’. In keeping with this intent, during the final
week of curriculum implementation semi-structured teacher interviews (n = 11) and
student focus groups (n = 34 participants) were organised and conducted. Teachers
were asked to select students for the student focus groups who exhibited a range of
ability and engagement across the classes, in addition to the selection of girls and
boys in mixed-sex schools. The curriculum leaders (Heads of Department) of
Inkwater College and Bluemarine State High School agreed to be interviewed
separately to allow for discussion regarding the future direction of the unit, the
leaders’ perception of their teachers’ engagement with the curriculum and their
overall sense of the effectiveness of health literacy as a concept within SBHE. All
recorded data were subsequently transcribed with pseudonyms assigned to all
participants and schools and then analysed using qualitative methods of constant
comparison and thematic analysis.
Designing a critically oriented health literacy unit of work
As noted earlier, the curriculum design process began with a review of pertinent
health promotion and education literature with the literature clustering around four
broad themes which were similarly informing the AC: HPE Shape document
(ACARA, 2012). A thorough overview of these themes and their contribution to
the curriculum unit has been documented elsewhere (McCuaig, Carroll, et al., 2012a).
For the purposes of this paper, however, we want to focus attention on how the three
literature themes of health literacy, student voice and critical inquiry informed the
HL@RS curriculum. As noted earlier, we drew significantly upon the model and
guidance provided by Nutbeam (2000) as the progressive nature of his model
allowed us to scaffold students’ engagement with the knowledge and skills across the
functional, interactive and critical health literacy levels.
In seeking to realise these objectives, we began with the devising of a complex
assessment task (Figure 1). In this way, we not only enabled teachers to gather
evidence of students’ achievement at the functional, interactive and critical levels
that then contributed to assessment decisions but also provided teachers with the key
questions that would motivate students’ engagement with the critical level of
investigation.
Learning activities subsequently emerged in response to these inquiry questions,
facilitating the students’ journey across the health literacy levels to result in the final
presentation of a healthy living website resource (Table 1). Initial activities in the
HL@RS unit focussed on understanding assessment task requirements, research into
Asia-Pacific Journal of Health, Sport and Physical Education 221
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the characteristics of their website’s target audience (Rivercity peers) and the
identification of healthy living resources from a strength-based perspective.
In seeking to ensure a strengths-based orientation, the first learning activity required
Health Literacy @ Rivercity Assessment Task
The local university has identified a need for healthy living information and resources for young people in
the Rivercity area. In response, the university has decided to provide all Rivercity schools with a Healthy
Living @ Rivercity website which will be developed and made publically available to all secondary school
students. The website will also be available for parents, carers and teachers.
However, the university staff believe that it would be more useful to invite Rivercity junior secondary school
students to contribute to this project. Each HPE class will be required to provide a final proposed Healthy
Living @ Rivercity Website. The website will comprise of 5 – 6 healthy living themes and be constructed by
teams of four students within each class.
The website must include the following components:
• Class front page: identifying 5 – 6 healthy living themes
• Theme Home Page – introduce the character/star of your health theme website
• Golden Guidelines and Breaking down health jargon
• Healthy living in action: Interactive challenge activity
• Five Star Resources in our Community
• Reality Check: Tips and strategies from Ipswich young people.
Figure 1. Health Literacy @ Rivercity Assessment Task.
Table 1. Summary of Health Literacy @ Rivercity Schools Unit.
Activity title Key inquiry-based questions to be addressed
1. Introduce assessment task and
healthy living themes
• What information will we need to provide on our
website?
2. Understanding my target
audience
• Who is my target audience and what are their needs
and interests?
3. Designing your team’s
home page
• How can I create a connection with my target
audience?
4. Golden guidelines + breaking
down health jargon
• What healthy living information do my peers need
to know?
5. Healthy living in action –
interactive challenges
• How can I help my peers to respond proactively to
health challenges?
6. Five Star resources • What resources (people, websites, organisations) can
help my target audience to be healthy and happy?
7. Reality check – tips and
strategies
• How can I maximise my target audience’s use and
access to the Five Star resources?
8. Construct team website • How can I maximise my target audience’s use and
access to the Five Star resources?
9. Submit team website
10. Final reflection task • Do I know more about the healthy living needs and
interests of young people?
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students to brainstorm responses to the statement ‘I am healthy and enjoy life
because…’, instead of listing popular health concerns or diseases. Activity Four,
Golden Guidelines + Breaking down health jargon, provided the first explicit health
literacy-oriented learning experience. Here, the objective was to develop the students’
functional health literacy skills according to their chosen resource for healthy living.
In keeping with Nutbeam’s (2000) definition of functional health literacy as
involving ‘the communication of factual information on health risks’ (p. 265), this
activity facilitated students’ recording and presenting of health-related facts and
information as a Golden Guidelines table on their website. Students subsequently
identified the relevant information, terms and concepts that could be further
explained through a glossary employing the language of their peers.
According to Nutbeam’s model, the next level of interactive health literacy
focuses on the ‘development of personal skills in a supportive environments’ (p. 265),
with educative activities endeavouring to improve ‘personal capacity to act
independently on knowledge’ and the ‘motivation and self-confidence to act on
advice received’ (p. 265). Activity Five, Healthy Living in Action – Designing
Interactive challenges, called upon students to first design a healthy living challenge
scenario and then to construct or modify a personal action/strategy framework, such
as a decision-making grid, to support the development of their peers’ personal and
interpersonal skills.
In devising the learning activities of the final critical level, we drew on the body
of literature informing the socio-critical curriculum perspectives of past and current
Queensland HPE syllabuses (Queensland Schools Curriculum Council, 1999).
Although presented in two sequential learning activities entitled, Five Star Resources
and Reality Check – Tips and Strategies, the development of students’ critical literacy
called upon teachers to facilitate their students’ achievement of the following steps:
1. Identify as many personal, school and community resources that support the
development of your healthy living resource within the local community.
2. Evaluate these resources according to three criteria: relevance for young
people; credibility of resource and quality of information/support.
3. Select top performing resources according to this evaluation and construct
Five Star Resources website page.
4. Conduct a second, more in-depth level of evaluation of their Five Star
resources to identify the facilitators, barriers and challenges that may
compromise their peers’ use/access to these resources.
5. Devise ‘teenager friendly’ tips and strategies that their target audience can
use to overcome these barriers and enhance their access to these resources.
The objective of this series was grounded in Nutbeam’s assertion that critical health
literacy education should seek to develop cognitive and skill outcomes which are
‘oriented towards supporting effective social and political action, as well as
individual action’ (p. 265). In both the assessment tasks, where students were
required to develop a website resource that would support their peers’ healthy living,
and these latter learning experiences, students were provided opportunities to
first critically evaluate and then propose youth-informed plans of ‘action to
address social, economic and environmental determinants of health’ (p. 265).
These curriculum experiences reflect Chinn’s (2011) suggestion that critical health
Asia-Pacific Journal of Health, Sport and Physical Education 223
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literacy can be divided into three domains: critical analysis of information (Step 2),
understanding of the social determinants of health (Step 4) and engagement in
collective action (Step 5).
Additionally, Begoray et al.’s (2009, p. 40) findings and recommendations
pertaining to student voice, or lack thereof, in SBHE programmes were particularly
useful for our planning, with the sharing of opinions and engaging in ‘hands on
projects’ with peers, finding expression within the design of the HL@RS assessment
task, and inquiry-based pedagogical approach that was deliberately intended to
motivate the teachers’ use of student-centred pedagogies. Employing an inquirybased
approach similarly responded to Nutbeam’s (2008) request for health
educators to communicate to learners in authentic ways that invite interaction,
participation and critical analysis. Inquiry-based pedagogies are ‘largely informed by
constructivist theories of learning that emphasise the active role of the student in
building or constructing their own understanding and performance’ (Macdonald,
2004, p. 16). Furthermore, inquiry-based pedagogies encourage the learner to not
only acquire information relating to their health but also to critically engage with
and think about their circumstances to promote a deeper understanding of the
complex social issues and forces that influence decisions and action (Lassonde,
2009). Such engagement facilitates students’ capacity to achieve the critical level of
Nutbeam’s (2000) health literacy model.
Finally, it is important to note that the initial motivation to use Information and
Communication Technologies (ICT) within this unit was not a purposeful attempt to
address and develop students’ e-health literacy skills. Instead, the inclusion of a webbased
assessment task and learning activities was simply considered to be reflective
of the increasing popularity of computer-supported inquiry learning within schools
(Weinberger, 2011), and the need for schools to develop students’ ICT knowledge,
skills and confidence (ACARA, 2012).
Findings
Findings from this HL@RS project suggest that teachers found health literacy to be
a useful construct to employ within their SBHE programmes, providing structure
and connection to other core business within the school such as national literacy and
numeracy testing regimes. As the Inkwater College HOD reported, ‘the structure of
functional through to interactive activities worked well … allowing (students) to use
health literacy to develop a theme or idea’. In relation to the development of
students’ functional skills, classroom teachers and their HODs noted the development
of these skills over the course of the unit, with one curriculum leader
commenting:
you can see that the language that they’re using has evolved, even over a short period of
time. So they might have done some research on a particular theme and they might have
come up with something like sleep apnoea…They might not even have heard of it. Then,
by the end, they’re talking about things and medical terminology … So certainly – that’s
been the biggest indicator, just reading their work and how it’s progressed.
Data from both student and teacher interviews also revealed the capacity of the
HL@RS unit to illicit and enhance students’ interactive health literacy skills, with
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participants reporting that this learning experience was the most successful activity
within the unit. Students felt that they were better aware and able to access health
information, particularly on the Internet. One student noted:
I had ‘party safe’ [theme] … and I found it useful that I found out what to do in certain
situations like if the designated driver had been drinking and wasn’t fit to drive. What
do I do? Who can I go to, to get help? I learned a lot about that. I don’t think I would
have focused on that and gotten in and got that information if I hadn’t done this subject
and topic. (Sasha, student, Bluemarine SHS)
Students also recounted their improved confidence to access support services for
themselves:
If I had a problem, I’d probably be less inclined before I started this unit to like go and
talk to people who, if you like, might judge me about stuff. They’re here to help me, not
judge you or whatever. (Sienna, student, Inkwater College)
Not only did students feel better equipped to access health information for
themselves, they also felt better positioned to apply this information to recognise
and help friends or family who have a health concern. For example:
So you know if I thought one of my friends was having problems like depression or
something I could go to the guidance office and ask how can I help them? Or go on the
internet and they usually have that if your friend is in need how do you help them? So
now that I know that I can do that I will. (Jayne, student, Bluemarine SHS)
I: Have you told anybody or have you changed anything yourself?
A: I’ve spoken to three people about it.
F: Have you?
A: Yeah – three of my friends because they get teased a bit about their weight because
they’re big boys as well. So yeah I’ve spoken to them about it.
F: You just told them about them or did you give them some website addresses or what
did you do?
A: I spoke to them about ways of losing the weight like physical education and I also
gave them websites and stuff like that. I’m pretty sure they might have gone onto them.
(Alexander, student, Indigo SHS).
Whilst numerous students attested the unit would not change their health
behaviours, Alexander recounted the way he has used the health information to
take action in his own life. ‘I’ve asked my Dad to get more healthy foods instead of –
because Dad normally gets chips and biscuits and all that for me. I’ve asked him to
get more of the healthy food’ (student, Indigo SHS).
Finally, evidence of critical literacy attainment emerged in relation to young
people’s consumption of health-related information via the Internet. Although the
students involved in this study reported that the Internet was a useful resource, they were
surprised at the volume of health information that was available, and in particular, the
number of websites that are tailored specifically to an adolescent audience:
Well I knew that on the internet there was a lot of stuff, but I think now learning that
there actually are teenage websites that you can look for and specifically search different
things to help with whatever you need help with’. (Izzy, student, Bluemarine SHS)
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Like the BeyondBlue – the youth one … That really helped because it was actually for
people under 25 instead of just the normal Beyond Blue where it was quite adultish ….
But the young, for the younger people, its a lot more helpful. (Jayne, student,
Bluemarine SHS)
The development of critical health literacy skills in relation to ICTs appeared to be
successful with students becoming proficient at ‘analysing resources for reliability
and relevancy to their age group’ (Sam, Inkwater College HOD). Students referred
to Activity Seven: Reality Check – Tips and Strategies when discussing their ability to
find resources:
(L)ike it shows you who might be better to go to and who might be more reliable to talk
to. The five star rating could show who knows more information than the other and
who knows what you are going through. What doctor or therapist or someone could
help you with that. (Eriel, student, Bluemarine SHS)
Teachers noted the importance of this particular activity, as they felt students did not
often go through a process of critical analysis of websites when researching
information. For example:
In the past and particularly with year 11 health … any source would do. Whereas this
one was looking at, okay, let’s find x amount of sources. Hang on. Don’t use it. Let’s
see if it’s any good first. … Because some of the stuff you find, the girls wouldn’t
understand it or its rubbish. So I thought that was really beneficial for the girls. (Sam,
HOD, Inkwater College)
Overall, project findings indicate a modest attainment of critical health literacy was
achieved through the following:
. Students felt they could critically analyse Internet health resources – both for
relevancy to their age group and for the reliability of the information and
. Students felt empowered to help others. They felt they understood the issue
they studied thoroughly and could use the knowledge to help friends and
family.
In this context, the dual dimension of the critical – skills to both differentiate and
advocate – coalesced. Nonetheless, the data did not provide a convincing demonstration
of either the teachers’ development, or students understanding, of the social
determinants of health operating within their local community.
Whilst the critical health literacy skills outcomes may be somewhat modest, the
data point to two features of the HL@RS unit that appeared to promote students’
and teachers’ engagement with the critical level of health literacy. For both teachers
and students alike, engaging in group work was routinely cited as a strength of the
HL@RS unit however, this enthusiasm was often tempered with comments
concerning equitable contribution and the allocation of grades. On the positive
side, teachers from Bluemarine SHS suggested, ‘the unit promoted collaboration
among students and allowed students to draw their own conclusions’. This was
reinforced by the Indigo SHS teacher who reflected, ‘in our few brainstorming
sessions there was just non-stop talking. It was really good’. Students at Bluemarine
226 L. McCuaig et al.
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SHS agreed with the teachers, noting that group work initiated more discussion and
meant students had to understand different points of view, as Tia explains:
Well in my group there were some of us that had more experiences in the areas of what
we were talking about and it helped the rest of our group understand from their point of
view and instead of all the information that we’re being given from a website, it came
from a particular person’s point of view.
However, student commentary indicates that the combination of working in peer
groups while simultaneously engaging with the information provided online was
particularly potent, ‘I liked how we got to work in groups and how we had
technology as well. So it wasn’t as boring as just writing in a book and doing some
written subjects’ (Mary, student, Bluemarine SHS). In response to the question of
‘What did you like about this unit?’, respondents consistently referenced the
inclusion of technology:
I think with books it’s more about like with the facts and everything like what it’s all
about, but if you go online you can just get stories of like what other people have
actually gone through and so you can form better opinions of that I think (Sienna,
student, Inkwater College)
Personally in my class the whole concept, they really loved. That they were developing
this – they really believed that they were having a chance. Giving them computer time
and telling them it’s a website just sold it to them straight up. (Mary, teacher,
Bluemarine SHS)
According to student feedback, working with ICTs also facilitated, as Begoray et al.
(2009) would say, the students’ sense of working independently:
Facilitator: Was that the only aspect about the unit you liked?
Noah: And the web page. Because we had full control over it and the teachers couldn’t
tell us what we could do on it and what we couldn’t do.
Facilitator: What was the difference about this unit – about how you gained that
information, compared to if the teacher had just come and told it to you?
Tia: We found it ourselves. We researched what – on all the information instead of just
it being handed to us and being told about it.
Although students raised concerns regarding time and access to technology, they
nonetheless welcomed the opportunity to explore and develop their knowledge and
skills within the context of a unit that explicitly focused on their local needs,
resources and life experiences. Interestingly, Indigo SHS students stated they were
not particularly concerned about their grades for the unit but were pleased to have
the knowledge to help family and friends and ‘to get it (health message) out there to
a lot of people’ (Jesse, student, Indigo SHS).
Discussion
Findings from the HL@RS project drew attention to the usefulness of learning
experiences involving the construction and critique of ‘real-life’ scenarios, group
decision-making, critical evaluation of e-health resources and website design as
Asia-Pacific Journal of Health, Sport and Physical Education 227
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effective approaches to the development of functional, interactive and critical levels
of health literacy. Positive student engagement with authentic assessment tasks and
learning experiences should come as no surprise, with much educational literature
arguing that, ‘if schools ignore the contexts in which students live and their
experiences, knowledge, capacities and concerns, they run the risk of being
increasingly irrelevant for many young people’ (Wright, 2004, p. 4). Overall,
however, project participants emphasised the twin benefits of collaborative group
work and engagement with e-health, and we suggest that it is within the context of
e-health that the future potential of students’ and teachers’ engagement with the
critical aspects of health literacy may lie.
Technology was a central theme in this SBHE curriculum, with the culmination
of work resulting in an online health resource specifically designed for young
people by their peers. The use of technology was recognised by almost all students
as being an enjoyable part of the unit, while teachers noted it was an important
factor in gaining and maintaining student engagement throughout the unit. These
findings are consistent with a number of studies indicating that computersupported
inquiry learning has the potential to foster productive task-related
interaction and increase student engagement (Jarvela, Veermans, & Leinonen,
2008). Furthermore, as adolescents increasingly use the Internet and Web 2.0
applications at home and school, it is imperative that SBHE embraces the use of
digital tools to provide quality learning opportunities to students. This fosters
the authentic and student-driven health education experience recommended by
Begoray et al. (2009).
At the completion of this unit, students indicated that they felt more confident in
their ability to access relevant health information on the Internet. As noted earlier,
the Internet is a powerful health resource for adolescents, yet the ability to critically
evaluate and apply online health information to their own lives and the lives of
others is a complex skill, one that places significant demands on their health literacy
(Gray, Klein, & Noyce, 2005). A growing body of evidence suggests that
adolescents, whilst proficient in certain digital skills, such as personal communications,
games and downloading music and films, are still inefficient at searching for
information on the Internet and critically evaluating the information they find
(Ladbrook & Probert, 2011). The HL@RS unit aimed to address this broader issue
of digital information literacy by explicitly teaching students how to evaluate
websites according to criteria of relevance, credibility and quality of information,
and it was this dimension of critical health literacy that was most accessible
for teachers.
However, the HL@RS unit demonstrated that e-health not only represents a site
through which young people can be encouraged to develop their critical analysis of
information but also provides a unique medium for community activism. As
Douthat (2014) instructs, young people are seeking new forms of community today
and they have found that place in the online realm. Notwithstanding this potential,
we suspect that the lack of reference to the social determinants of health, which were
implicitly embedded within the latter learning experiences, was indicative of HPE
teachers’ commitment to and understanding of the socio-cultural perspective
(Cliff, 2012).
228 L. McCuaig et al.
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Conclusion
This study demonstrated what could constitute a health literacy unit in Australian
schools consistent with the AC: HPE. The concepts that were employed to construct
an authentic, relevant and robust health literacy unit were well received by schools,
teachers and students. This research reinforced the need for schools to have the
freedom and flexibility to implement comprehensive health literacy units that are
tailored to the specific needs of their students, staff and community. Furthermore,
the findings of this project suggest teachers’ understanding and engagement with
socio-critical approaches to SHBE contemporary pedagogical theory and practice is
no less important than their engagement with disciplinary knowledge and concepts.
In closing, our research suggests that the explicit teaching of Internet search
strategies and critical evaluation of websites is imperative in targeting the health
and digital literacy needs of adolescents (Macdonald, in press), reminding us of the
significance and potential of the inter-relationships of the AC: HPE propositions
focusing on the educative, developing health literacy and inclusion of inquiry-oriented
pedagogies set against a strength-based approach (ACARA, 2012).
Notes on contributors
Dr Louise McCuaig currently coordinates the HPE teacher education programme at the
School of Human Movement Studies, The University of Queensland. Her research and
teaching focus on enhancing young people’s health and well-being through the provision of
quality health education in school settings.
Kristie Carroll is an Associate Lecturer within the HPE teacher education programme at the
School of Human Movement Studies, The University of Queensland. She is an experienced
HPE teacher currently pursuing postgraduate studies exploring relationships between
adolescent health education and digital media.
Professor Doune Macdonald is currently a Research Professor in the School of Human
Movement Studies, The University of Queensland and UQ Co-ordinator for the Collaborative
Research Network for Health. She leads Australian Research Council projects looking at
teachers as ‘health workers’ and international patterns in the outsourcing of HPE.
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Health Literacy

Order Description

Your research assignment will consist of two parts. These are as follows:
(1) Research and explain all three dimensions (functional/interactive/critical) of the concept “Health Literacy” as it relates to the curriculum area of Health and Physical Education. (approximate word guide range: 800 words).
(2) The Australian Curriculum: Health and Physical Education has been shaped by five interrelated propositions (concept of Health Literacy is one of these propositions) that are informed by a strong and diverse research base for a futures-oriented curriculum. As a result, identify, describe and explore how the concept of Health Literacy can be implemented with a strengths-based approach in the Australian primary school curricular. (approximate word guide range: 1, 500 words)

I MUST USE ONLY THE RESOURCES THAT I ATTACH. MUST BE ON THE AUSTRALIAN CURRICULUM. DO NOT USE ANY OVERSEAS RESOURCES. JUST THE ONES I SUBMIT.
It can be broken up into two sections:
1. Health Literacy defined, and
2. Identify, describe and explore how the concept of Health Literacy can be implemented with a strengths-based approach in the Australian primary school curricular.

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Enacting critical health literacy in
the Australian secondary school
curriculum: the possibilities posed by
e-health
Louise McCuaiga, Kristie Carrolla & Doune Macdonalda
a School of Human Movement Studies, The University of
Queensland, Brisbane, Australia
Published online: 17 Sep 2014.
To cite this article: Louise McCuaig, Kristie Carroll & Doune Macdonald (2014) Enacting
critical health literacy in the Australian secondary school curriculum: the possibilities posed
by e-health, Asia-Pacific Journal of Health, Sport and Physical Education, 5:3, 217-231, DOI:
10.1080/18377122.2014.940809
To link to this article: http://dx.doi.org/10.1080/18377122.2014.940809
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Enacting critical health literacy in the Australian secondary school
curriculum: the possibilities posed by e-health
Louise McCuaig*, Kristie Carroll and Doune Macdonald
School of Human Movement Studies, The University of Queensland, Brisbane, Australia
The teaching of health literacy in school-based health education (SBHE) is of
international interest, yet there is less ready access to how conceptions of health
literacy can be operationalised in school programmes. More specifically, while
articulated in curriculum documents such as the incoming Australian Curriculum:
Health and Physical Education, there are few accounts of planning, implementing
and evaluating units with critical health literacy aims that can inform curriculum
reform. This paper introduces and evaluates a health literacy unit implemented in
three Australian secondary schools. It demonstrates the capacity of schools to
undertake critical health literacy teaching and learning that is valued by the
students as relevant, engaging and contemporary, particularly when the pedagogies
intersect with e-health.
Keywords: critical health literacy; curriculum; e-health
Introduction
Research suggests that adolescents are interested in understanding health information
and learning more about health but often find health messages difficult to understand
(Brown, Teufel, & Birch, 2007). In relation to young people’s capacity to effectively
access, evaluate and utilise health information, school-based health education (SBHE)
programmes offer considerable potential. Schools and their health education programmes
are regularly cited in health promotion literature as a major source of
knowledge about health care and health issues for adolescents (Marcell & Halpern-
Felsher, 2007). From a public health perspective, SBHE provides the early intervention
and prevention that is crucial (Manganello, 2007), with adolescence considered to be
the ideal stage to provide the cognitive and social skills that will empower individuals to
make informed decisions regarding their health throughout their lives.
More recently, health sector bodies such as the National Health and Hospitals
Reform Commission (NHHRC) and health advocates (e.g. The Lancet, 2005) have
focused attention on strengthening consumer engagement within a health system
through the delivery of health literacy within the core curriculum of schools
(NHHRC, 2009). The World Health Organisation (1998, p. 10) defines health
literacy as ‘the cognitive and social skills which determine the motivation and ability
of individuals to gain access to, understand and use information in ways which
promote and maintain good health’. Health literate individuals are therefore able to
make informed health decisions to exert greater control over life events (Shohet &
*Corresponding author. Email: lmc@hms.uq.edu.au
Asia-Pacific Journal of Health, Sport and Physical Education, 2014
Vol. 5, No. 3, 217–231, http://dx.doi.org/10.1080/18377122.2014.940809
© 2014 Australian Council for Health, Physical Education and Recreation
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Renaud, 2006). Health literacy also appears to have the ‘currency’ required to gain
traction within the core curriculum of schools (McCuaig, Coore, & Hay, 2012) given
the primacy that literacy currently holds within contemporary schooling across the
globe (Snyder, 2008) and high stakes assessment regimes.
As such, it was not surprising that health literacy became a cornerstone of
Australia’s new Health and Physical Education (HPE) curriculum (Australian
Curriculum, Assessment and Reporting Authority (ACARA), 2013). As explained
and analysed elsewhere (e.g. Alfrey & Brown, 2013; Macdonald, 2013), there was
strong support for the inclusion of health literacy in the Australian Curriculum for
HPE (AC: HPE). The curriculum-making process, initially instantiated in a Shaping
Paper (ACARA, 2012), required that the concept of health literacy be framed in
educative discourses. Nutbeam’s (2000) model was chosen to inform the approach to
health literacy in the AC: HPE given its resonance with literacy discourses and its
aspirations for SBHE to make a difference to both individuals and communities
(Macdonald, 2013; Ryan, Rossi, Macdonald, & McCuaig, 2012).
Drawing on developments within literacy studies where different types and
practical applications of literacy were being theorised, Nutbeam (2000) built upon
earlier definitions of health literacy to propose a ternary levelled model. The first
level of ‘functional’ health literacy concerns the ability to comprehend health-related
information and function within health system contexts using basic skills in reading
and writing. This level reflects the conventional, narrow characterisation of health
literacy (Nutbeam, 2000; Rubinelli, Schulz, & Nakamoto, 2009). Level two of his
model comprises ‘interactive’ health literacy, which focuses on the personal
communication and social skills which are used to extract and derive information
and to act independently on that knowledge. As such, individuals begin to actively
engage in everyday health-related activities, applying new information to changing
circumstances (McCray, 2005). The final stage of Nutbeam’s (2000, p. 265) model is
‘critical’ health literacy which is orientated towards ‘supporting effective social and
political action, as well as individual action’. Individuals and communities thus
acquire the ability to critically analyse health-related information in order to exert
control over life events (McCray, 2005) and a capacity to act on the social and
economic determinants of health (Nutbeam, 2000, p. 52). According to Nutbeam
(2000, p. 52), as progression between each level occurs so does greater autonomy and
self-empowerment, with progression between levels ‘not only dependent upon
cognitive development, but also exposure to different information/messages’. Here,
Nutbeam provides a strong indication of the educative usefulness of his earlier
model, as the ‘nesting’ of his health literacy levels aligns with other typologies of
cognitive development that inform schooling assessment regimes (Krathwohl, 2002),
an alignment that poses a critical determinant of health literacy’s purchase within
core school curricula (McCuaig, Coore, et al., 2012b). Although as SBHE researchers
we hoped that students’ engagement with the Health Literacy @ Rivercity Schools
(HL@RS) unit would enhance their use of health literacy skills beyond the school
gates, our objective was to design a unit that would deliver, develop and assess
students’ learning. It is this educative intent of SBHE programmes that often differ
from public health-oriented projects that may question the hierarchical nature of
Nutbeam’s model (Chinn, 2011).
Nutbeam’s conception of functional, interactive and critical levels provided a
model that complemented other key propositions and aims in the AC: HPE Shaping
218 L. McCuaig et al.
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Paper particularly given the inclusion of its critical dimension. Nonetheless, it was
the inclusion of a critical dimension within the AC: HPE that resulted in questions
concerning its applicability and what was, for some, its ideological appropriateness
(Macdonald, 2014). This was to be anticipated given the vibrant intellectual history
that ‘the critical’ has demonstrated in Australian and international HPE scholarship.
In the early 1990s, the place of the critical project in Physical Education was debated
in a series of Quest journal papers (see, e.g. McKay, Gore & Kirk, 1990). Scholars
advocating for the critical paradigm posed questions, employed methods and
articulated aspirations for the field that reflected mainstream health, sociology and
education research concerns that were looking for schooling, and H/PE, to become
more inclusive, student/inquiry-based and empowering. Since that time, Australian
and international scholarship has argued for a stronger critical dimension in HPE
teacher education (e.g. Garret & Wrench, 2012), curricula (e.g. Evans, Davies, Rich,
& DePian, 2013; Macdonald, 2014) and pedagogies (e.g. Garrett & Wrench, 2011;
Hill & Azzarito, 2012; Macdonald, 2002) with many acknowledging the difficulty of
enacting the vision (Tinning, 2000).
Indeed the translation of the ‘critical vision’ from curriculum document to HPE
classroom has comprised an on-going challenge for the field. Since the early 1990s,
both national and state-based core (Years P–10) and elective (Years 11–12) H/PE
curricula have placed an emphasis on social justice principles, a social view of health
and a sociocultural critique, with students and their teachers encouraged to
interrogate healthy selfhood in relation to the social, cultural, political, legal,
environmental and economic factors shaping their lives (McCuaig & Tinning, 2010).
Yet, Australian HPE scholars have argued that these shifts towards a socially critical
HPE have resulted in considerable resistance amongst many teachers of this learning
area. As Gard and Wright (2014) contend, instead of implementing pedagogical
practices that inspire students to ‘gain a critical self-consciousness and social
awareness and take appropriate action against oppressive forces’ (p. 113), schoolbased
health interventions and curricula are ‘heading in a more instrumental,
individualistic and even punitive directions’ (p. 113). Understanding the factors that
support a more effective translation is thus an important objective, as Evans et al.
(2013, p. 328) in their study of SBHE suggest:
Our data attest that while focussing on (curriculum) policy as emplaced and enacted
should be a necessary element of policy analyses, such processes are likely to evade our
understanding if the multiple ways they are encoded and embodied is left unaddressed …
Rather, they (curriculum policies) are to be viewed as texts having been reassembled,
reordered and ‘performed’ differently in unique organisational settings in respect of
extant imperatives, cultural orientations, attendant clienteles and distribution of
material resources.
We concur with Evans et al. (2013) that the stories, and thereby nuances, of
curriculum implementation, in this case the delivery of health literacy programmes
commensurate with the incoming aims of the AC: HPE, need to be shared if the field
is to understand how (critical) health literacy can be (best) enacted.
Although a burgeoning body of research and literature now surrounds the theory
and practicalities of school-based health literacy curriculum design and implementation,
at the time of this study there was little research into how young people’s health
literacy might be effectively developed through SBHE curricula (see Begoray,
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Wharf-Higgins, & Macdonald, 2009), with even less literature exploring the critical
health literacy domain. As Chinn (2011) has more recently confirmed, ‘health
literacy researchers have made little progress’ (p. 63) in articulating the specific
competencies, including their inter-relationships, means of operationalising and
measuring the critical health literacy domain.
Seeking to address this gap in the research and provide evidence that would both
inform and be informed by the writing of the AC: HPE Shape document (ACARA,
2012) was the motivation for the HL@RS project. Given the agreement about the
importance of adolescent health literacy, and the school as a valuable setting for
enabling health literacy generally and critical health literacy more specifically, the
research project sought to establish:
1. What would constitute a health literacy unit consistent with the incoming
Australian Curriculum: Health and Physical Education (AC: HPE)?
2. What is the response of HPE teachers and their students to health education
that aims to develop critical health literacy?
3. What are the lessons learned for the implementation of the AC: HPE as an
exercise in curriculum reform?
In this paper, we draw on findings from this curriculum project to demonstrate the
inextricability of the critical in the efficacious teaching of health literacy in the
twenty-first century and explore the possibilities posed by the exploding e-health
phenomena which emerged within this research.
Method
The purpose of the HL@RS was to design, implement and evaluate a critically
oriented health literacy unit to establish the ability of schools and their teachers to
deliver such a unit within the reality of contemporary Australian schooling. The
HL@RS project was structured around four phases of research activity that included
preparation, curriculum design, curriculum implementation and evaluation phases.
Activities undertaken in the initial preparation phase focused on the recruitment of
schools and obtaining university and Queensland Department of Education ethics
approvals. A total of three purposively selected schools were approached in a
satellite city in Queensland, Australia, which subsequently resulted in the participation
of 19 HPE teachers and approximately 500 students. Where possible, a balance
and representation of schools and student cohorts was achieved according to the
factors of private/state, single sex/co-educational and socio-economic school status.
Prior to the collection of data, written consent was obtained from school principals,
parents and participating students and teachers.
Work conducted within the curriculum design phase predominantly involved a
review of literature which informed the construction of the health literacy
curriculum. This phase of the research is outlined in more detail in the following
section. After the initial design of the unit, critique and input was explicitly sought
from the projects’ teachers and curriculum leaders, reflecting an endeavour to work
collaboratively with schools (Petrina, 2004). This work was undertaken in a series of
professional development (PD) workshops conducted with those teachers who were
most likely to deliver the HL@RS unit of work. Drawing on the teachers’ input and
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feedback during the PD workshops, the final curriculum package underwent minor
modifications which focused almost entirely on issues of assessing student performance.
Once amended and disseminated, participating teachers were asked to deliver
the proposed curriculum to their students through the typical operation of their
school’s HPE programme. Throughout the implementation phase, teachers were
required to collect student work so that later analysis could be undertaken.
Due to the strong interest in exploring teachers’ and students’ perspectives, the
project employed qualitative methods to generate a richer understanding of
participants’ thoughts about and responses to the curriculum initiative. As outlined
by Simpson and Freeman (2004, p. 343), ‘the interpretive aspects of qualitative
research attempt to understand the phenomena of health promotion through the
meanings that people assign to them’. In keeping with this intent, during the final
week of curriculum implementation semi-structured teacher interviews (n = 11) and
student focus groups (n = 34 participants) were organised and conducted. Teachers
were asked to select students for the student focus groups who exhibited a range of
ability and engagement across the classes, in addition to the selection of girls and
boys in mixed-sex schools. The curriculum leaders (Heads of Department) of
Inkwater College and Bluemarine State High School agreed to be interviewed
separately to allow for discussion regarding the future direction of the unit, the
leaders’ perception of their teachers’ engagement with the curriculum and their
overall sense of the effectiveness of health literacy as a concept within SBHE. All
recorded data were subsequently transcribed with pseudonyms assigned to all
participants and schools and then analysed using qualitative methods of constant
comparison and thematic analysis.
Designing a critically oriented health literacy unit of work
As noted earlier, the curriculum design process began with a review of pertinent
health promotion and education literature with the literature clustering around four
broad themes which were similarly informing the AC: HPE Shape document
(ACARA, 2012). A thorough overview of these themes and their contribution to
the curriculum unit has been documented elsewhere (McCuaig, Carroll, et al., 2012a).
For the purposes of this paper, however, we want to focus attention on how the three
literature themes of health literacy, student voice and critical inquiry informed the
HL@RS curriculum. As noted earlier, we drew significantly upon the model and
guidance provided by Nutbeam (2000) as the progressive nature of his model
allowed us to scaffold students’ engagement with the knowledge and skills across the
functional, interactive and critical health literacy levels.
In seeking to realise these objectives, we began with the devising of a complex
assessment task (Figure 1). In this way, we not only enabled teachers to gather
evidence of students’ achievement at the functional, interactive and critical levels
that then contributed to assessment decisions but also provided teachers with the key
questions that would motivate students’ engagement with the critical level of
investigation.
Learning activities subsequently emerged in response to these inquiry questions,
facilitating the students’ journey across the health literacy levels to result in the final
presentation of a healthy living website resource (Table 1). Initial activities in the
HL@RS unit focussed on understanding assessment task requirements, research into
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the characteristics of their website’s target audience (Rivercity peers) and the
identification of healthy living resources from a strength-based perspective.
In seeking to ensure a strengths-based orientation, the first learning activity required
Health Literacy @ Rivercity Assessment Task
The local university has identified a need for healthy living information and resources for young people in
the Rivercity area. In response, the university has decided to provide all Rivercity schools with a Healthy
Living @ Rivercity website which will be developed and made publically available to all secondary school
students. The website will also be available for parents, carers and teachers.
However, the university staff believe that it would be more useful to invite Rivercity junior secondary school
students to contribute to this project. Each HPE class will be required to provide a final proposed Healthy
Living @ Rivercity Website. The website will comprise of 5 – 6 healthy living themes and be constructed by
teams of four students within each class.
The website must include the following components:
• Class front page: identifying 5 – 6 healthy living themes
• Theme Home Page – introduce the character/star of your health theme website
• Golden Guidelines and Breaking down health jargon
• Healthy living in action: Interactive challenge activity
• Five Star Resources in our Community
• Reality Check: Tips and strategies from Ipswich young people.
Figure 1. Health Literacy @ Rivercity Assessment Task.
Table 1. Summary of Health Literacy @ Rivercity Schools Unit.
Activity title Key inquiry-based questions to be addressed
1. Introduce assessment task and
healthy living themes
• What information will we need to provide on our
website?
2. Understanding my target
audience
• Who is my target audience and what are their needs
and interests?
3. Designing your team’s
home page
• How can I create a connection with my target
audience?
4. Golden guidelines + breaking
down health jargon
• What healthy living information do my peers need
to know?
5. Healthy living in action –
interactive challenges
• How can I help my peers to respond proactively to
health challenges?
6. Five Star resources • What resources (people, websites, organisations) can
help my target audience to be healthy and happy?
7. Reality check – tips and
strategies
• How can I maximise my target audience’s use and
access to the Five Star resources?
8. Construct team website • How can I maximise my target audience’s use and
access to the Five Star resources?
9. Submit team website
10. Final reflection task • Do I know more about the healthy living needs and
interests of young people?
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students to brainstorm responses to the statement ‘I am healthy and enjoy life
because…’, instead of listing popular health concerns or diseases. Activity Four,
Golden Guidelines + Breaking down health jargon, provided the first explicit health
literacy-oriented learning experience. Here, the objective was to develop the students’
functional health literacy skills according to their chosen resource for healthy living.
In keeping with Nutbeam’s (2000) definition of functional health literacy as
involving ‘the communication of factual information on health risks’ (p. 265), this
activity facilitated students’ recording and presenting of health-related facts and
information as a Golden Guidelines table on their website. Students subsequently
identified the relevant information, terms and concepts that could be further
explained through a glossary employing the language of their peers.
According to Nutbeam’s model, the next level of interactive health literacy
focuses on the ‘development of personal skills in a supportive environments’ (p. 265),
with educative activities endeavouring to improve ‘personal capacity to act
independently on knowledge’ and the ‘motivation and self-confidence to act on
advice received’ (p. 265). Activity Five, Healthy Living in Action – Designing
Interactive challenges, called upon students to first design a healthy living challenge
scenario and then to construct or modify a personal action/strategy framework, such
as a decision-making grid, to support the development of their peers’ personal and
interpersonal skills.
In devising the learning activities of the final critical level, we drew on the body
of literature informing the socio-critical curriculum perspectives of past and current
Queensland HPE syllabuses (Queensland Schools Curriculum Council, 1999).
Although presented in two sequential learning activities entitled, Five Star Resources
and Reality Check – Tips and Strategies, the development of students’ critical literacy
called upon teachers to facilitate their students’ achievement of the following steps:
1. Identify as many personal, school and community resources that support the
development of your healthy living resource within the local community.
2. Evaluate these resources according to three criteria: relevance for young
people; credibility of resource and quality of information/support.
3. Select top performing resources according to this evaluation and construct
Five Star Resources website page.
4. Conduct a second, more in-depth level of evaluation of their Five Star
resources to identify the facilitators, barriers and challenges that may
compromise their peers’ use/access to these resources.
5. Devise ‘teenager friendly’ tips and strategies that their target audience can
use to overcome these barriers and enhance their access to these resources.
The objective of this series was grounded in Nutbeam’s assertion that critical health
literacy education should seek to develop cognitive and skill outcomes which are
‘oriented towards supporting effective social and political action, as well as
individual action’ (p. 265). In both the assessment tasks, where students were
required to develop a website resource that would support their peers’ healthy living,
and these latter learning experiences, students were provided opportunities to
first critically evaluate and then propose youth-informed plans of ‘action to
address social, economic and environmental determinants of health’ (p. 265).
These curriculum experiences reflect Chinn’s (2011) suggestion that critical health
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literacy can be divided into three domains: critical analysis of information (Step 2),
understanding of the social determinants of health (Step 4) and engagement in
collective action (Step 5).
Additionally, Begoray et al.’s (2009, p. 40) findings and recommendations
pertaining to student voice, or lack thereof, in SBHE programmes were particularly
useful for our planning, with the sharing of opinions and engaging in ‘hands on
projects’ with peers, finding expression within the design of the HL@RS assessment
task, and inquiry-based pedagogical approach that was deliberately intended to
motivate the teachers’ use of student-centred pedagogies. Employing an inquirybased
approach similarly responded to Nutbeam’s (2008) request for health
educators to communicate to learners in authentic ways that invite interaction,
participation and critical analysis. Inquiry-based pedagogies are ‘largely informed by
constructivist theories of learning that emphasise the active role of the student in
building or constructing their own understanding and performance’ (Macdonald,
2004, p. 16). Furthermore, inquiry-based pedagogies encourage the learner to not
only acquire information relating to their health but also to critically engage with
and think about their circumstances to promote a deeper understanding of the
complex social issues and forces that influence decisions and action (Lassonde,
2009). Such engagement facilitates students’ capacity to achieve the critical level of
Nutbeam’s (2000) health literacy model.
Finally, it is important to note that the initial motivation to use Information and
Communication Technologies (ICT) within this unit was not a purposeful attempt to
address and develop students’ e-health literacy skills. Instead, the inclusion of a webbased
assessment task and learning activities was simply considered to be reflective
of the increasing popularity of computer-supported inquiry learning within schools
(Weinberger, 2011), and the need for schools to develop students’ ICT knowledge,
skills and confidence (ACARA, 2012).
Findings
Findings from this HL@RS project suggest that teachers found health literacy to be
a useful construct to employ within their SBHE programmes, providing structure
and connection to other core business within the school such as national literacy and
numeracy testing regimes. As the Inkwater College HOD reported, ‘the structure of
functional through to interactive activities worked well … allowing (students) to use
health literacy to develop a theme or idea’. In relation to the development of
students’ functional skills, classroom teachers and their HODs noted the development
of these skills over the course of the unit, with one curriculum leader
commenting:
you can see that the language that they’re using has evolved, even over a short period of
time. So they might have done some research on a particular theme and they might have
come up with something like sleep apnoea…They might not even have heard of it. Then,
by the end, they’re talking about things and medical terminology … So certainly – that’s
been the biggest indicator, just reading their work and how it’s progressed.
Data from both student and teacher interviews also revealed the capacity of the
HL@RS unit to illicit and enhance students’ interactive health literacy skills, with
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participants reporting that this learning experience was the most successful activity
within the unit. Students felt that they were better aware and able to access health
information, particularly on the Internet. One student noted:
I had ‘party safe’ [theme] … and I found it useful that I found out what to do in certain
situations like if the designated driver had been drinking and wasn’t fit to drive. What
do I do? Who can I go to, to get help? I learned a lot about that. I don’t think I would
have focused on that and gotten in and got that information if I hadn’t done this subject
and topic. (Sasha, student, Bluemarine SHS)
Students also recounted their improved confidence to access support services for
themselves:
If I had a problem, I’d probably be less inclined before I started this unit to like go and
talk to people who, if you like, might judge me about stuff. They’re here to help me, not
judge you or whatever. (Sienna, student, Inkwater College)
Not only did students feel better equipped to access health information for
themselves, they also felt better positioned to apply this information to recognise
and help friends or family who have a health concern. For example:
So you know if I thought one of my friends was having problems like depression or
something I could go to the guidance office and ask how can I help them? Or go on the
internet and they usually have that if your friend is in need how do you help them? So
now that I know that I can do that I will. (Jayne, student, Bluemarine SHS)
I: Have you told anybody or have you changed anything yourself?
A: I’ve spoken to three people about it.
F: Have you?
A: Yeah – three of my friends because they get teased a bit about their weight because
they’re big boys as well. So yeah I’ve spoken to them about it.
F: You just told them about them or did you give them some website addresses or what
did you do?
A: I spoke to them about ways of losing the weight like physical education and I also
gave them websites and stuff like that. I’m pretty sure they might have gone onto them.
(Alexander, student, Indigo SHS).
Whilst numerous students attested the unit would not change their health
behaviours, Alexander recounted the way he has used the health information to
take action in his own life. ‘I’ve asked my Dad to get more healthy foods instead of –
because Dad normally gets chips and biscuits and all that for me. I’ve asked him to
get more of the healthy food’ (student, Indigo SHS).
Finally, evidence of critical literacy attainment emerged in relation to young
people’s consumption of health-related information via the Internet. Although the
students involved in this study reported that the Internet was a useful resource, they were
surprised at the volume of health information that was available, and in particular, the
number of websites that are tailored specifically to an adolescent audience:
Well I knew that on the internet there was a lot of stuff, but I think now learning that
there actually are teenage websites that you can look for and specifically search different
things to help with whatever you need help with’. (Izzy, student, Bluemarine SHS)
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Like the BeyondBlue – the youth one … That really helped because it was actually for
people under 25 instead of just the normal Beyond Blue where it was quite adultish ….
But the young, for the younger people, its a lot more helpful. (Jayne, student,
Bluemarine SHS)
The development of critical health literacy skills in relation to ICTs appeared to be
successful with students becoming proficient at ‘analysing resources for reliability
and relevancy to their age group’ (Sam, Inkwater College HOD). Students referred
to Activity Seven: Reality Check – Tips and Strategies when discussing their ability to
find resources:
(L)ike it shows you who might be better to go to and who might be more reliable to talk
to. The five star rating could show who knows more information than the other and
who knows what you are going through. What doctor or therapist or someone could
help you with that. (Eriel, student, Bluemarine SHS)
Teachers noted the importance of this particular activity, as they felt students did not
often go through a process of critical analysis of websites when researching
information. For example:
In the past and particularly with year 11 health … any source would do. Whereas this
one was looking at, okay, let’s find x amount of sources. Hang on. Don’t use it. Let’s
see if it’s any good first. … Because some of the stuff you find, the girls wouldn’t
understand it or its rubbish. So I thought that was really beneficial for the girls. (Sam,
HOD, Inkwater College)
Overall, project findings indicate a modest attainment of critical health literacy was
achieved through the following:
. Students felt they could critically analyse Internet health resources – both for
relevancy to their age group and for the reliability of the information and
. Students felt empowered to help others. They felt they understood the issue
they studied thoroughly and could use the knowledge to help friends and
family.
In this context, the dual dimension of the critical – skills to both differentiate and
advocate – coalesced. Nonetheless, the data did not provide a convincing demonstration
of either the teachers’ development, or students understanding, of the social
determinants of health operating within their local community.
Whilst the critical health literacy skills outcomes may be somewhat modest, the
data point to two features of the HL@RS unit that appeared to promote students’
and teachers’ engagement with the critical level of health literacy. For both teachers
and students alike, engaging in group work was routinely cited as a strength of the
HL@RS unit however, this enthusiasm was often tempered with comments
concerning equitable contribution and the allocation of grades. On the positive
side, teachers from Bluemarine SHS suggested, ‘the unit promoted collaboration
among students and allowed students to draw their own conclusions’. This was
reinforced by the Indigo SHS teacher who reflected, ‘in our few brainstorming
sessions there was just non-stop talking. It was really good’. Students at Bluemarine
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SHS agreed with the teachers, noting that group work initiated more discussion and
meant students had to understand different points of view, as Tia explains:
Well in my group there were some of us that had more experiences in the areas of what
we were talking about and it helped the rest of our group understand from their point of
view and instead of all the information that we’re being given from a website, it came
from a particular person’s point of view.
However, student commentary indicates that the combination of working in peer
groups while simultaneously engaging with the information provided online was
particularly potent, ‘I liked how we got to work in groups and how we had
technology as well. So it wasn’t as boring as just writing in a book and doing some
written subjects’ (Mary, student, Bluemarine SHS). In response to the question of
‘What did you like about this unit?’, respondents consistently referenced the
inclusion of technology:
I think with books it’s more about like with the facts and everything like what it’s all
about, but if you go online you can just get stories of like what other people have
actually gone through and so you can form better opinions of that I think (Sienna,
student, Inkwater College)
Personally in my class the whole concept, they really loved. That they were developing
this – they really believed that they were having a chance. Giving them computer time
and telling them it’s a website just sold it to them straight up. (Mary, teacher,
Bluemarine SHS)
According to student feedback, working with ICTs also facilitated, as Begoray et al.
(2009) would say, the students’ sense of working independently:
Facilitator: Was that the only aspect about the unit you liked?
Noah: And the web page. Because we had full control over it and the teachers couldn’t
tell us what we could do on it and what we couldn’t do.
Facilitator: What was the difference about this unit – about how you gained that
information, compared to if the teacher had just come and told it to you?
Tia: We found it ourselves. We researched what – on all the information instead of just
it being handed to us and being told about it.
Although students raised concerns regarding time and access to technology, they
nonetheless welcomed the opportunity to explore and develop their knowledge and
skills within the context of a unit that explicitly focused on their local needs,
resources and life experiences. Interestingly, Indigo SHS students stated they were
not particularly concerned about their grades for the unit but were pleased to have
the knowledge to help family and friends and ‘to get it (health message) out there to
a lot of people’ (Jesse, student, Indigo SHS).
Discussion
Findings from the HL@RS project drew attention to the usefulness of learning
experiences involving the construction and critique of ‘real-life’ scenarios, group
decision-making, critical evaluation of e-health resources and website design as
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effective approaches to the development of functional, interactive and critical levels
of health literacy. Positive student engagement with authentic assessment tasks and
learning experiences should come as no surprise, with much educational literature
arguing that, ‘if schools ignore the contexts in which students live and their
experiences, knowledge, capacities and concerns, they run the risk of being
increasingly irrelevant for many young people’ (Wright, 2004, p. 4). Overall,
however, project participants emphasised the twin benefits of collaborative group
work and engagement with e-health, and we suggest that it is within the context of
e-health that the future potential of students’ and teachers’ engagement with the
critical aspects of health literacy may lie.
Technology was a central theme in this SBHE curriculum, with the culmination
of work resulting in an online health resource specifically designed for young
people by their peers. The use of technology was recognised by almost all students
as being an enjoyable part of the unit, while teachers noted it was an important
factor in gaining and maintaining student engagement throughout the unit. These
findings are consistent with a number of studies indicating that computersupported
inquiry learning has the potential to foster productive task-related
interaction and increase student engagement (Jarvela, Veermans, & Leinonen,
2008). Furthermore, as adolescents increasingly use the Internet and Web 2.0
applications at home and school, it is imperative that SBHE embraces the use of
digital tools to provide quality learning opportunities to students. This fosters
the authentic and student-driven health education experience recommended by
Begoray et al. (2009).
At the completion of this unit, students indicated that they felt more confident in
their ability to access relevant health information on the Internet. As noted earlier,
the Internet is a powerful health resource for adolescents, yet the ability to critically
evaluate and apply online health information to their own lives and the lives of
others is a complex skill, one that places significant demands on their health literacy
(Gray, Klein, & Noyce, 2005). A growing body of evidence suggests that
adolescents, whilst proficient in certain digital skills, such as personal communications,
games and downloading music and films, are still inefficient at searching for
information on the Internet and critically evaluating the information they find
(Ladbrook & Probert, 2011). The HL@RS unit aimed to address this broader issue
of digital information literacy by explicitly teaching students how to evaluate
websites according to criteria of relevance, credibility and quality of information,
and it was this dimension of critical health literacy that was most accessible
for teachers.
However, the HL@RS unit demonstrated that e-health not only represents a site
through which young people can be encouraged to develop their critical analysis of
information but also provides a unique medium for community activism. As
Douthat (2014) instructs, young people are seeking new forms of community today
and they have found that place in the online realm. Notwithstanding this potential,
we suspect that the lack of reference to the social determinants of health, which were
implicitly embedded within the latter learning experiences, was indicative of HPE
teachers’ commitment to and understanding of the socio-cultural perspective
(Cliff, 2012).
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Conclusion
This study demonstrated what could constitute a health literacy unit in Australian
schools consistent with the AC: HPE. The concepts that were employed to construct
an authentic, relevant and robust health literacy unit were well received by schools,
teachers and students. This research reinforced the need for schools to have the
freedom and flexibility to implement comprehensive health literacy units that are
tailored to the specific needs of their students, staff and community. Furthermore,
the findings of this project suggest teachers’ understanding and engagement with
socio-critical approaches to SHBE contemporary pedagogical theory and practice is
no less important than their engagement with disciplinary knowledge and concepts.
In closing, our research suggests that the explicit teaching of Internet search
strategies and critical evaluation of websites is imperative in targeting the health
and digital literacy needs of adolescents (Macdonald, in press), reminding us of the
significance and potential of the inter-relationships of the AC: HPE propositions
focusing on the educative, developing health literacy and inclusion of inquiry-oriented
pedagogies set against a strength-based approach (ACARA, 2012).
Notes on contributors
Dr Louise McCuaig currently coordinates the HPE teacher education programme at the
School of Human Movement Studies, The University of Queensland. Her research and
teaching focus on enhancing young people’s health and well-being through the provision of
quality health education in school settings.
Kristie Carroll is an Associate Lecturer within the HPE teacher education programme at the
School of Human Movement Studies, The University of Queensland. She is an experienced
HPE teacher currently pursuing postgraduate studies exploring relationships between
adolescent health education and digital media.
Professor Doune Macdonald is currently a Research Professor in the School of Human
Movement Studies, The University of Queensland and UQ Co-ordinator for the Collaborative
Research Network for Health. She leads Australian Research Council projects looking at
teachers as ‘health workers’ and international patterns in the outsourcing of HPE.
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