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1

Theorising a framework for contemporary health literacies

in schools

Mary Ryan1, Anthony Rossi2, Doune Macdonald2, Louise McCuaig2, lisahunter3

1Queensland University of Technology, Australia; 2The University of Queensland, Australia; 3University of Waikato, New Zealand.

Introduction

This paper first reviews the current state of health and health education in Australia,

and outlines popular uses and applications of the term ‘health literacy’. Then, drawing

on Antonovsky’s (1996) salutogenic model of health and mainstream literacy theory,

a new definition of health literacies is proposed. We continue by presenting a robust

framework for guiding the development of a health curriculum based on wellness and

critical health literacies that accounts for the complexity of health and well being in

contemporary society. Furthermore, the framework incorporates capacities for making

meaning of integrated multimodal texts, which is a crucial skill for being (health)

literate in the 21st century and which goes beyond the limited conventions of how

health literacy is both accepted and generally understood (Fetro, 2010; Ozdemir,

Alper, Uncu, & Bigel, 2010).

Given the centrality of literacy education in contemporary schooling, ‘health literacy’

offers the potential to close the perceived gap between community expectations of

health education and schools’ capacities to develop curriculum that focuses on healthy

living. To date, there has been no research as to what a literacies based health

curriculum could look like. By placing education at the centre of the emerging health

literacy discourse, we argue that the research that informs literacy more generally can

be recruited to broaden the current narrow discourse of health literacy that seldom

2

ventures beyond the language of medicine. We suggest that this approach provides an

innovative yet familiar framework for much-needed curriculum reform in school-

based health education (SBHE).

Background

There is a compelling case for health reform in Australia (National Health and

Hospitals Reform Commission, 2009; National Preventative Health Taskforce, 2009)

because the health of a nation is so inextricably tied to its economy, national security

even national identity. The NHHRC under the third goal of its report (Creating an

agile and self-improving health system) recommended that one way to strengthen

consumer engagement within a health system is to ensure health literacy comprise a

core element of the National Curriculum for primary and secondary schooling.

Nutbeam and Kickbush (2000) also recognise the essential role that health literacy in

schooling could play in enabling people to make healthy choices leading to

productive and fulfilling lives. However, there is no universal agreement over the role

of schools in educating for health. Health promotion advocates believe schools fall

short of their alleged responsibilities, citing ongoing issues of: competing agendas;

low priority and low status; few trained health education teachers; lack of resources;

ad hoc support from health services and significant gaps between the policy and

practice of health promotion within Australian schools (Marks, 2010; Ridge, et al.,

2002). Consequently whilst schools are mandated to teach health education, there is

considerable disjuncture between broad expectations and schools’ capacities to

deliver programs that promote healthy living.

Almost one fifth of Australia’s population comprises children aged 0-14 years. Their

health and wellbeing are critical as they are considered to be the key to Australia’s

3

future (Australian Institute of Health and Welfare, 2009). The latest national report on

their health indicates that significant concerns still exist regarding disability, diabetes

and dental decay, as well as there being too many children who are sedentary,

overweight, eating unhealthily, homeless or at risk of homelessness, and who are

victims of assault (Australian Institute of Health and Welfare, 2009). Further, in 2009,

the top ten issues of concern to young Australians (n=48,000), aged predominantly 11

– 19 years, were in ranked order: drugs, suicide, body image, family conflict,

bullying/emotional abuse, alcohol, physical/sexual abuse, personal safety, coping with

stress, and depression (Mission Australia, 2010).

Schools, health and education

International health and education sector organisations readily support the notion that

“healthier students are better learners” (Basch, 2010, p. 4). Health and Physical

Education (HPE) commentators have captured the health related significance of

school settings noting, the “school is one of the key institutional influences on

children and youth...and a key site for education about healthy lifestyles” (Tinning,

1996, p. 8). Advocates within the health sector argue that the “interaction between

schools and young people, and the overall experience of attending school, provides

unique opportunities for health promotion which can be sustained and reinforced over

time” (National Health and Medical Research Council (NHMRC), 1996, p.1). Health

and education advocates suggest that schools exhibit a number of characteristics

which are critical to the successful implementation of health promotion initiatives

including: the close and regular student–teacher contact; coverage of formative years,

unique opportunities to provide a sustained and reinforced program; and, the capacity

to capture all children irrespective of socioeconomic status, ethnicity, or location

(Basch, 2010; Marks, 2010).

4

 

Health education in schools, however, has been fraught with political agendas and

territorial debates. From the early nineties, efforts by educators to name and define a

HPE related Key Learning Area (KLA) have stimulated considerable debate and

contestation, with some commentators even claiming a crisis of identity for PE (Kirk,

1996; Thorpe, 2003). PE and sport advocates have depicted a desperate state of

affairs, variously arguing that Australian children: had poor fitness and motor skill

levels; experienced poorly designed school PE and sport; lacked role models or

trained teachers; and, faced inequitable opportunities (SSCERA, 1992). Meanwhile,

health and education experts treated sport advocacy with suspicion, drawing attention

to reductions in youth participation, highly competitive adult attitudes, inequitable

opportunities and rising participation costs (QG, 1992). Despite this, the KLA was

eventually entitled Health and Physical Education, flagging the formal union of

health education, physical education and personal development outcomes to be

pursued under the auspices of this KLA (Macdonald & Kirk, 1999). Nationally, the

HPE KLA reflected Australia’s commitment to WHO initiatives and health promotion

theories. Consequently, the rationale of the Queensland HPE KLA establishes a

sociocultural approach to health as one of four key messages of the syllabus, with

physical activity engagement, social justice principles and learner-centred approaches

constituting the other three (QSCC, 1999). According to syllabus support materials a

sociocultural approach to HPE emphasises a multi-dimensional nature of health, the

promotion of health through individual and collective action and the influence of

social, cultural and physical environments on health, physical activity and personal

development (QSCC, 1999).

5

Within the rubric of health promoting schools, the curriculum continues to be

regarded as the essential site to achieve maximal influence on the health behaviours of

young people (Fetro, 2010; Rowling, et al., 1998). Interest in a health agenda for

Australian school curricula has ensured the inclusion of health as a component of

Australia’s goals of schooling (MCEETYA 1989, 1999). In the latest iteration of

these goals, confident and creative individuals are those who “have the knowledge,

skills, understanding and values to establish and maintain healthy, satisfying lives”

(MCEETYA 2005, p.9) and “a sense of self-worth, self-awareness and personal

identity that enables them to manage their emotional, mental, spiritual and physical

wellbeing” (MCEETYA 2005, p. 9). Such potential is reflected in the World Health

Organisation’s Health Promoting Schools (HPS) approach, an internationally

recognized strategy for the design and delivery of positive and comprehensive school

health promotion programs. These have included a range of macro and micro health

intervention strategies focusing on community partnerships and school policy such as

physical activity and dietary strategies promoted in Queensland, Australia through the

Eat Well Be Active: Healthy Kids for Life action plan (Queensland Health, 2005).

In spite of significant investments of time and effort into school based health

programs (McCuaig, 2011; Wright & Harwood, 2009) many believe that such

programs “have never been fully embraced” (Basch, 2010, p.7). Although education

authorities recognise the opportunities of intersecting health and education agendas,

“this rhetoric is not matched by a carefully articulated policy and plan which is

adequately funded, on a sustainable basis, in human and financial terms” (Stewart,

Parker, & Gillespie, 2000, p. 253). Nationally and internationally, research would

suggest that “high quality, strategically planned, and effectively coordinated school

6

health programs and policies have not been widely implemented” (Basch, 2010, p. 7).

Central to the tensions between education and health agendas is the perception by

schools and teachers that health promoters and their organisations attempt to dictate

school policy and practice, with schools viewing health and education sector goals as

having competing agendas and languages (Macdonald, Abbott, Hay, McCuaig, &

Monsen, 2010; Macdonald, et al., 2009). As Ridge et al (2002) argue, the “language

that emanates from the health sector is not central to the running of schools, or a part

of teachers’ thinking” (p. 28). Paradoxically then, SBHE curricula, considered to be

the essential site of impact, have failed to achieve the accountability that would

ensure its sustained presence within the core business of Australian classrooms.

Consequently, Australian SBHE is littered with well intentioned and thoroughly

researched programs that have failed to gain sustained purchase within the everyday

curriculum of Australian classrooms (McCuaig, 2008). Literature pertaining to SBHE

programs has consistently identified the classroom teacher as the most significant

component of effective school health education (Ridge, et al., 2002). Consequently,

the limited support and training to ensure the uptake of SBHE principles and

pedagogical approaches by teachers has been of considerable concern (Ridge, et al.,

2002; Rowling, et al., 1998). In the absence of teacher confidence and competence,

schools have tended to rely on health promotion professionals, external agencies

and/or one-off issue related presentations. It is against this background, that we argue

the strength of a health literacy approach to SBHE.

Health literacy in practice

Health literacy is complicated by multiple definitions contingent upon the context in

which health literacy demands are made (e.g., health care, media, fitness facilities)

and the skills that people bring to that situation (Bush, et al., 2010; Rudd, Moeykens,

7

& Colton, 1999). Many studies purporting to discuss ‘health literacy’ focus on

information, knowledge and action within health care settings; what might be better

termed ‘medical literacy’ (Peerson & Saunders, 2009). Health literacy then, as it is

generally reported in the literature, relates to an individual's ability to read, understand

and use healthcare information to make decisions and follow instructions for

treatment. The 2006 Adult Literacy and Life Skills survey revealed that nine million

Australians or 60 percent of the population between the ages of 15 and 74 years do

not have the basic knowledge and skills to understand and use information about their

own health (Australian Bureau of Statistics, 2006). Further afield, it has been

suggested that some 90 million Americans have difficulty reading texts with moderate

levels of complexity and yet most health related texts use highly sophisticated and

complex forms of language.

Although the term ‘health literacy’ has been in use for at least 30 years, Nutbeam

(2008) has more recently drawn attention to the continuing lack of systematic

attention to a broader approach to health literacy. Indeed, contemporary international

literature on health literacy provides a limited evidence base for current models of

health literacy (Rootman & Gordon-El-Bihbety, 2008) and highlights the need for

further research (Keleher & Hagger, 2007). Researchers indicate a need to increase

our understanding of the role of various factors and relationships relevant to the

‘decisional balance’ about health issues for individuals and population groups, and the

impacts on everyday life (Peerson & Saunders, 2009). Others claim that there is a

paucity of research concerning the ‘complex interaction between general literacy,

health literacy, information technologies and the existing health care infrastructure’

(McCray, 2005, p. 158). Consequently, more comprehensive analytic frameworks are

8

needed to better capture the meaning of ‘health literacy’ as opposed to ‘medical

literacy’ (Peerson & Saunders, 2009), in order to make it user-friendly for

professionals in, and consumers of, medical and allied health services, including

school based health educators. Finally, such work needs to address individuals and

population groups of different ages and life stages (Fetro, 2010; Nutbeam, 2008).

In arguing for a more holistic and critical view of health literacy we suggest that

health literacy should address the capacity of individuals to understand and act on

multiple health messages not only in health-related settings, but also in the social

communities and environments in which they live. This approach highlights the social

conditions within which individuals live their lives, thus it shifts the locus of control

from individuals alone, to more complex conditions of influence from groups,

governments, institutions and global media, and the resources they provide and/or

withhold. Thus we prefer the term ‘health literacies’ in a move away from an

individual capacity to control one’s health, to a focus on the way in which an

individual comprehends and manages their health across multiple contexts, with

multiple messages relayed in multiple forms from multiple stakeholders. Further,

critical literacies focus upon the broader socio-historical influences on the production

of texts, whereby text interpretation and production invite multiple meanings,

perspectives and points of view at different times in different places by different

groups and individuals. This perspective, underpinned as it is by critical theory (see

Landow, 2006), also advocates active (virtual and real) civic participation for social

change.

9

Contemporary social messages are relayed in both local and global contexts via

different and often interconnected text forms including linguistic or written, visual,

audio, gestural, and spatial modes. These modes are often combined within texts, so

the ability to make meaning from integrated modalities within texts is a crucial feature

of being literate in contemporary society (Cope & Kalantzis, 2000). Being health

literate is no exception as health information, knowledge and understandings are

drawn from a wide range of modalities (Rossi & Ryan, 2006; Ryan & Rossi, 2008).

For example, the use of written information and slogans, visual images and tabulated

nutrition data on packaged food needs to be understood in terms of the new meanings

that are created by the relationships between, and possible contradictory messages

across, these modes. Unsworth and Chan (2009) suggest that integrative interpretation

of multimodal texts is one of the most challenging tasks of understanding texts in

today’s world. In other words, it is not only important to understand the visual

components or written components or audio components of a text; one must

understand how the integration of these modes affects the meaning and impact of the

text and the ways in which it can be used, for example, to enhance or harm one’s own

health or the health of others.

This holistic and critical approach to health literacies is guided by complementary

theories of salutogenic health and wellbeing advocated by Anton Antonovsky (1996),

and socio-cognitive and transformative literacy theories and pedagogies (for example

Freebody & Luke, 1990; Luke, Comber & Grant, 2003; Kalantzis & Cope, 2005). A

salutogenic approach to health eschews a deficit model of health and non-illness, and

recognizes both individual and social influences on being healthy. This approach

complements socio-cognitive literacy theory and pedagogy that sees students’

10

backgrounds, prior knowledges and literacy abilities in productive rather than deficit

terms, and utilizes both cognitive (individual) strategies and social influences to

enhance literacy development (Kalantzis & Cope, 2005). The complementarity of

these approaches enables a powerful conceptualisation of health literacies as an

active, participatory curriculum agenda that meets the needs of young Australians in

diverse contexts, operating within different social, political and cultural conditions.

A Health Curriculum Framed by Wellness and Literacies

In the dominant pathogenic model of health literacy as outlined previously, a person’s

health is generally considered in deficit terms and is referenced against states of

illness with the objective of medical and health services to return the person to a state

of non-illness. Such a ‘downstream’ focus on health lies outside the optimal

conception of health advocated by the World Health Organisation (Antonovsky,

1996). Antonovsky conceptualised health as a multidimensional continuum with what

he called ‘health-ease’ at one end and ‘dis-ease’ at the other. This means that health is

defined by wellness and people fit on to the continuum in various places. A

salutogenic model of health mobilised through more comprehensive health literacies

curricula aims to move young people closer to the ‘health-ease’ end of the continuum.

Hence Antonovsky’s approach to health is not simply a conception of what health is,

rather it focuses attention on an individual’s access to, and use of, resources in the

creation, preservation and development of healthy living within their social

environments.

Antonovsky (1996) took this philosophy of health further by arguing that the degree

to which an individual coped with the “inherent stressors of human existence” (p.15)

was an indicator as to where someone might be on the health-ease/dis-ease

11

continuum. He indicated that these general resources of resistance give an individual

their ‘sense of coherence’. The strength of a person’s ‘sense of coherence’ (SOC),

shaped by consistency of experiences, underload-overload balance, and participation

in socially accepted decision-making, is what places them in the health-ease/dis-ease

continuum. The SOC is a generalised orientation towards the world, on a continuum,

which perceives one’s place in the world as meaningful, comprehensible and

manageable. Meaningfulness is denoted by a motivation and a wish to cope with the

inevitable stressors of life; comprehensibility is realised by a belief that one

understands the challenge of life; and manageability is evident in a belief that

resources are available to help cope with the challenge. The particular combination of

cognitive, behavioural, social and motivational factors, which can vary for

individuals, contexts and cultures, is what makes it a powerful, comprehensive and

systematic theoretical guide for practice (Antonovsky, 1996).

Following Antonovsky, we contend that health literacies must incorporate people’s

own literate practices, prior knowledge and circumstances, so that health decisions are

manageable and meaningful for them in their specific social environment. This view

sees health literacies as the knowledge and wide range of skills that people start to

develop in their early years and continue over their lifetimes to seek out, comprehend,

evaluate, and use health information and concepts to make informed choices, reduce

health risks, and increase quality of life (Zarcadoolas, Pleasant, & Greer, 2005). This

focus on active participation in one’s health (see also Kickbusch, Wait, & Maag,

2005) is closely aligned with Kalantzis and Cope’s (2005) pedagogy of multiliteracies

with its commitment to active forms of learning by individuals within particular social

and cultural contexts. Multiliteracies pedagogy sees learning across various modes as

12

a combination of: experiencing both known and new ideas, practices and

understandings; conceptualising new concepts and theorising about outcomes, risks

and effects; analysing knowledge in different forms and relating it critically to

broader issues and contexts; and applying new understandings in both conventional

and innovative ways. Nutbeam (1999) also suggests a concept of health literacy needs

to include critical elements. He sees critical health literacy as the ability to critically

analyse information, increase awareness and participate in action to address barriers

to good health. This concept has strong parallels with multiliteracies and Freebody

and Luke’s (1990) Four Resources Model of literacy, central to educational reforms in

Australia. Freebody and Luke note that effective literacy draws on a repertoire of

practices that allow learners, as they engage in reading and writing activities, to break

the code of texts, participate in the meanings of text, use texts functionally, and

critically analyse and transform texts (Ryan & Rossi, 2008). These approaches to

literacy teaching and learning are underpinned by the central idea that literacy is a

cultural practice with significant implications for how schools contribute to social

access and equity, cultural assimilation and discrimination and economic power

(Luke, Comber, & Grant, 2003). Texts in all their forms are key moments where

social identity and power relations are negotiated and established, and they do so

through a variety of textual and semiotic features (Fairclough, 1989). Thus it is

important to understand the lexical, grammatical and semiotic features of texts that

are both consumed and produced to identify the meanings and subject positions that

bestow or reduce power in everyday life.

A framework for guiding health (literacies) curriculum development

The framework we propose (see Figure 1) uses Antonovsky’s continuum of health

for quality of life, and recognises that individuals and groups need to be active

13

participants in their own health (under their particular social/cultural/economic

conditions) by making decisions that are best for their lifestyle and situation at

different times (Fetro, 2010). The value of this framework is that it offers a systematic

blueprint for collaborative curriculum development across national, state and school-

based stakeholders.

In providing a framework for collaborative curriculum development, rather than a

prescribed curriculum package, we take the position that knowledge is emergent

rather than static and transmitted (Davis & Sumara, 2000), and that it is generated

through an array of experiential possibilities. Thus, in practice it recognises that

teachers and students and the idiosyncracies of their context, relationships,

background knowledge, interests etc are pivotal to student learning outcomes (Hayes,

Mills, Christie, & Lingard, 2006). Accordingly, curriculum innovation research (often

seen in health-related content areas), that takes a quasi-experimental approach relying

on teaching fidelity to a curriculum package may produce disappointing outcomes in

terms of student learning and behaviour changes (see for example, beyondblue

initiatives, Sawyer et al., 2006). Therefore the curriculum making process we

advocate helps to overcome criticisms of curriculum innovation, for example in

Australia over the past two decades, whereby design has resided with bureaucrats

(Marsh, 1987) and ‘done’ as little more than “batch processing and transmission”

(Green, 2003, p. 129).

Within the framework (Figure 1), the multiliteracies knowledge processes (Kalantzis

& Cope, 2005) indicate ways in which we actively come to know our health through

experiencing, conceptualising, analysing and applying our knowledge. School

14

curriculum can utilise scenarios and real-life examples that enable students to engage

with, and create health knowledge in active ways. From our salutogenic and critical

perspective, being health literate requires the provision of inter-connected resources at

local and global sites of health pedagogy, to enable individuals and groups to engage

meaningfully in health contexts and with multimodal health-related texts. The New

London Group (2000) posits multiple modes from which we make meaning and

understand our world. The framework foregrounds the importance of literacy

resources to make meaning of combinations of visual, written, audio, gestural and

spatial texts, given that the ability to process information from integrated modes of

delivery is a key element of being (health) literate in contemporary society (Unsworth

& Chan, 2009). Luke and Freebody’s (1999) Four Resources Model of literacy has

been utilised in the framework to indicate key foci for health literate behaviours.

Explicit attention to codes and conventions of health-related texts and contexts (code

breaking) is essential, yet on its own is not sufficient. Understanding such texts and

contexts in relation to one’s own background, experiences and current situation

(meaning making), and having the skills and knowledge to use these understandings

in practical ways (pragmatic use) is crucial for health literate citizens. Of course, the

three resources of code breaking, making meaning, and pragmatic use, do not occur in

a vacuum. Health literate citizens must also be aware of the impact of their choices

and understandings on others, whether they have the best information for their

situation and what other alternatives they may have (critical analysis). Indeed,

sometimes health choices are group decisions or require a sustained collective effort

to enact change (Antonovsky, 1992). These resources need to be developed

interdependently so that individuals and groups have repertoires of skills and

knowledge to draw upon as active participants in their own health.

15

Insert about here: Figure 1 Framework for Health Literacies Curriculum

Development

The framework outlined here recognizes core principles of literacy development used

in school literacy programs, namely the complex repertoires of practice required to

engage with different texts and contexts. Thus, it can provide a smooth extension into

the health education curriculum for classroom teachers who are already familiar with

key mainstream literacy approaches. Intellectual rigour in the curriculum necessitates

deep and substantive knowledge of discipline areas. Freebody, Maton and Martin

(2008) argue that the ways of working within disciplines will vary according to key

topics, social and cultural functions, and the ways in which knowledge is generated.

These values and philosophies about how knowledge is generated, its purposes and

cultural functions, also determine the kinds of texts that are consumed and produced.

Moje (2008) sees these disciplinary knowledges and skills as integral to becoming

active and informed participants in society. Moje (2008) argues that students should

learn how to enact particular identities in different disciplines. She suggests that

teachers need to provide opportunities for students to develop metadiscursive skills,

whereby they not only engage in the different discourse communities of the different

disciplines, but they also know how and why they are engaging and what those

engagements mean for them and others in terms of social positioning and power

relations. In attending to the disciplinary literacies of health as degrees of wellness,

using familiar literacy frameworks, the model accounts for active, salutogenic ways of

knowing and understanding that can be implemented by classroom teachers in an

ongoing, context specific manner.

16

Conclusion

Utilising Antonovsky’s (1996) philosophy of healthy living to underpin the

framework outlined in this paper enables a comprehensive and more sophisticated

view of health literacies in contemporary society. Schools and teachers in particular,

can use the framework we have developed to plan robust SBHE, which attends to

rigorous content knowledge, socially just views of health development, and also to

salutogenic decision-making skills that enhance young people’s ‘sense of coherence’.

Our approach is consistent with national curriculum design initiatives (Australian

Curriculum Assessment and Reporting Authority, 2010) in that it prioritises the

importance of context in curriculum-making. We envisage the next step in our

research program is to work with schools to trial the model, ascertain its impact on

students’ health literacies, and consequently refine the framework. Further,

foregrounding educational discourse, and particularly current theorising from the field

of literacy, provides a framework and resources for health educators beyond the

school context to understand and promote positive, ongoing, healthy decision-making.

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Figure 1 Framework for Health Literacies Curriculum Development