Adolescents’ health literacy perspectives and implications

Abstract

Background

Adolescence is an essential stage of life during which individuals develop knowledge, attitudes, and behaviors that can have significant impacts on their present and future health. Therefore, health literacy issue among adolescents is a pressing matter. Understanding adolescents’ perspectives of health literacy is crucial for making informed interventions. However, the topic remains unexplored in developing countries like Ethiopia. This study seeks to explore adolescents’ perspectives of health literacy within their socio-environmental context in Ethiopia and draw out the implications.

Methods

This study employed qualitative research approach, utilizing in-depth interviews and focus group discussions as methods of data collection. Data collection took place from March to October 2023, involving 86 participants (41 male and 45 female) selected through purposive sampling (maximum variation sampling) to capture a wide range of perspectives on the issue. The data analysis followed a thematic analysis approach, using Atlas.ti (version 7.5.18) software.

Results

From the adolescents’ perspectives, health literacy or being health literate is regarded as comprising various competencies and qualities essential for health, including health awareness and knowledge, abilities to deal with health information, practicing healthy behaviors, upholding healthy norms and values of the community, and being a responsible citizen. The adolescents regard health literacy or being health literate as highly beneficial in healthcare, disease prevention, health maintenance and enhancement, and in taking responsibility not only for ones’ own health but also for the health of others, thereby benefiting those around them and their community and society. However, this study found notable gaps in health literacy among the adolescents, influenced by various factors ranging from individual to community and societal levels.

Conclusion

The study explored health literacy from adolescents’ perspectives in Ethiopia, and contributed to understanding of the issue. It identified notable gaps in adolescent health literacy and provided insights into the enabling and hindering factors. This study laid the ground for developing a health literacy tool sensitive to the Ethiopian sociocultural context and for broader studies to enhance understanding and to develop effective interventions to improve and promote health literacy among adolescents and within the broad society.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-025-22341-y.

Background

Adolescence is a phase of life during which profound physical, emotional, cognitive, and social changes occur, and health-related behaviors and skills that set the foundation for lifelong health develop [1–4]. Behaviors and lifestyles related to smoking, alcohol consumption, drug use, diet, and exercise, which influence chronic conditions in later life, are often established during this period of life [2, 4–6]. The consequences of behaviors developed during this phase of life may also impact the health of one’s future children [3–5]. And health knowledge, attitudes, and behaviors that emerge and develop during young age are often harder to change later in adulthood [3, 4, 7]. Thus, it is a critical stage of life during which behaviors that compromise the present and future health of individuals and populations are firmly established [1, 5, 8].

Developing healthy behaviors and promoting good health among adolescents requires them to acquire abilities and capacities such as accessing and using health information, and making informed health decisions, which represent health literacy (HL) competencies [9, 10]. HL is an evolving concept with various definitions [10–12]. Widely, it is regarded as comprising a broad range of knowledge and competencies that empower one to seek, engage with, and use health information to make judgments and take decisions in everyday life to maintain or improve quality of life during one’s life course [10]. According to Nutbeam [11], there are two conceptual approaches or perspectives to HL: HL in medical contexts and HL in public health and health promotion contexts. In the former, HL is concerned with individuals’ abilities to read and/or understand medical information whether it is in written form or conveyed in personal encounters, for instance with doctors. In the later, it refers to a broader range of competencies that enable one to exert greater control over his/her health and the range of personal, social, and environmental determinants of health, for healthy living [11]. Thus, HL generally represents the health knowledge and competencies needed to navigate the complex demands of health in this contemporary world [10, 13].

Due to the aforesaid facts, HL knowledge and competencies among adolescents are a pressing matter for themselves as well as for their families, communities, and nation at large [14]. Thus, emphasizing adolescents as a target group of HL research, especially from a public health perspective, is paramount to provide appropriate guidance and implement effective interventions that improve and foster HL in adolescents, thereby promoting their health and wellbeing [8, 9, 14].

HL literature has been rapidly growing; however, until recently, HL studies had mainly been conducted in clinical settings with less attention to public health perspectives[12, 15, 16] and were criticized as a top-down approach [17]. Nowadays, there is an increasing emphasis on understanding consumers’ or lay persons’ perspectives of HL [18]. This is because individuals engage with health information and services differently due to various reasons [14, 19, 20], and understanding their perspectives and their situations is essential to make effective interventions and deliver tailored services. Also, although it has been growing currently, HL among adolescents is relatively under-researched [9, 21, 22], especially in developing countries like Africa [23]. There are many gaps in adolescents' HL research, including their perspectives on HL. However, it is crucial to understand how adolescents perceive HL, including what it means for them and their abilities and practices in accessing, engaging with, and utilizing health information and services, to address and improve HL in adolescents [14].

In Ethiopia, HL studies are rare, and HL studies on adolescents is almost lacking [23, 24]. Therefore, to address this gap, this study seeks to explore adolescents’ perspectives of HL within their socio-environmental context in Ethiopia, thereby contributing to clarification of the issue and providing the basis for the development of HL tool specific to local context and for innovative interventions to improve and promote HL among adolescents.

Methodology

Study setting, population, approach, and methods

The study was conducted in high school settings located in Jimma city administration. Jimma city is the largest urban area in southwestern Oromia, Ethiopia. At the time of the study, Jimma city had 16 high schools. Eight of them were public schools, and the remaining eight were private schools. This study was conducted on adolescents in eight high schools (four public schools and four private schools). These schools were selected based on their student population. From the total public high schools, four high schools with larger student populations were sleeted. Similarly, from the total private high schools, four with larger student populations were selected. At the time of the study, the total number of students in the selected eight high schools was 9799 (male 4439 and female 5360). In the four public high schools, there were 8428 students (male 3858 and female 4570), and in the four private high schools, there were 1371 students (male 581 and female 790). This study employed a qualitative research approach, guided by constructivist grounded theory [25]. In-depth interviews and focus group discussions (FGDs) were used as data collection methods.

Sampling technique and sample size

Qualitative research typically requires information representative of the range of experiences, perspectives, and behaviors relevant to the research objectives or questions [26]. Thus, in this study, purposive sampling (maximum variation sampling) was used to select participants, ensuring participant diversity, specifically in terms of gender, age, school type (private/public), origin (rural/urban), economic characteristics, and religion, to capture a broad range of views and experiences representative of the target population. Accordingly, a total of 86 adolescents (male 41, female 45) were selected and participated in this study: 47 in in-depth interviews (male 22, female 25), and 39 in six FGDs, each ranging from 6 to 7 participants (male 19, female 20), with boys and girls in separate groups.

Data collection

Interview and FGD guides were used to collect data, from March to October 2023. The data collection guides were developed based on the understandings of the concept of HL gained from critical engagement with HL literature and the research objectives (see Supplementary Information). The questions were tested on five school adolescents to ensure their clarity, quality, and appropriateness. Based on the test results, some changes were made to improve coherence. The interviews and discussions were conducted at a mutually agreed-upon time and location within the school compounds, to ensure the participants’ and researcher’s comfort, confidentiality, and safety, and to facilitate the gathering of in-depth perspectives [27]. The conversations were conducted in Afaan Oromo and Amharic languages based on the preferences of the participants. While data collection guides were used to collect the information, the participants’ responses determined the course of the conversation during the data collection [28]. Questions were clarified or probed whenever necessary to make the issue clear or to explore the participants’ views and experiences regarding the issue under consideration. The researcher also made the conversations return to the track, whenever they went in the wrong directions, by expressing again or rephrasing the issue of conversation. Voice recorder was used to record conversations, in addition to taking notes, based on participant willingness, in almost all interviews and FGDs. In-depth interviews were conducted until data saturation was achieved, meaning that information became redundant [29, 30]. Data saturation was reached during the 45th interview, but interviews continued through the 47th. FGDs were then also conducted to triangulate the data, to strengthen the credibility of the research, as well as to obtain a collective view of the topic. The conversations took between 24 min 30 s and one hour and a quarter. Fieldnotes were also taken during the study, providing some hints for data analysis.

Data analysis

In this study, data analysis progressed hand-in-hand with the data collection and the writing process [25, 31], and followed the following steps: First, after careful listening, researchers fluent in Afaan Oromo, Amharic, and English transcribed/translated the conversations. Then, the translated data were sorted and arranged into their different types. Next, after repeatedly reading and looking for the explicit and implicit meanings and patterns, the sentences and/or paragraphs were segmented into categories and coded. Then, by combining them, the codes were reduced to the following concepts: definition, components/characteristics, abilities/competencies, benefits, status, practices, enablers, and barriers. Finally, based on these concepts, the following themes were developed: adolescents’ definitions and conceptualizations of HL, including the components or characteristics of HL or being health literate, benefits of HL or being health literate, HL status and practices, and enablers and barriers of HL among adolescents. Atlas.ti (version 7.5.18) software assisted the analysis process.

Trustworthiness

In this study, the following strategies [31–33] were employed to achieve the credibility, transferability, dependability, and conformability of the results: Purposive maximum variation sampling was used to capture the variations in and depth of the issue. Different methods of data collection were used, ensuring that all the required information was properly gathered. Adequate time was taken to build trust and develop good relationships with participants before the start of the in-depth interviews and FGDs. The interviewees’ responses were paraphrased and reflected back to them to avoid misinterpretations. Translations, coding, and categorization of the data were done carefully, and rechecked, and memos of important activities were carefully written and used to make sure that everything is accurately done. Detailed and thorough descriptions of the themes or findings were given, providing a good picture of the issue. As well, the researcher was open to the data throughout the study processes.

Results

Socio-demographic characteristics of the participants

A total of 86 school adolescents participated in this study, including 41 males (47.7%) and 45 females (52.3%). The participants’ ages ranged from 14 to 19 years, and the mean age was 17.13 ± 1.29 years. Details of the socio-demographic factors of the participants are provided in Table 1. These factors are presented to indicate that the participants were from diversified socio-demographic backgrounds.

Table 1.

Socio-demographic characteristics of the participants

Variable	Category	Frequency (Percentage)	Variable	Category	Frequency (Percentage)
Sex	Male	41 (47.7%)	Father’s education	Unable to read and write	9 (10.5%)
	Female	45 (52.3%)		Primary school	30 (34.9%)
	Total	86 (100%)		Secondary school	19(22.1%)
Age in years	14–15	10 (11.6%)		Diploma	9 (10.5%)
	16–17	42(48.8%)		Degree/above	19 (22.1%)
	18–19	34(39.5%)	Mother’s education	Unable to read and write	18 (20.9%)
				Primary school	35 (40.7%)
Class or grade level	9th −10th	44(51.2%)		Secondary school	16 (18.6%)
				Diploma	5 (5.8%)
				Degree/above	12 (14.0%)
	11th – 12th	42(48.8%)	Father’s occupation	Employed/health-related	5 (5.8%)
				Employed/not health-related	18 (20.9%)
School type	Public	55 (64.0%)		NGO worker	4 (4.7%)
				Merchant	22 (25.6%)
	Private	31 (36.0%)		Framer	31 (36.1%)
				Religious leader	4 (4.7%)
Religion	Islam	41 (47.7%)		Retired	2 (2.3%)
			Mother’s occupation	Employed/health-related	6 (7.0%)
	Orthodox	18 (20.9%)		Employed/not health-related	10 (11.6%)
	Protestant	27 (31.4%)		NGO worker	2 (2.3%)
Origin (primary school background)	Urban	44 (51.2%)		Merchant	19 (22.1%)
	Rural	42 (48.8%)		Framer	23 (26.7%)
				Housewife	26 (30.2%)

The findings of this study are categorized into four themes and presented as follows, along with important direct quotes from the participants

Definitions and conceptualizations of health literacy and being health literate

This section examines the definitions/conceptualizations of HL or being health literate, including the elements of HL or characteristics of being health literate from the adolescents’ perspectives.

The participants defined/conceptualized HL and characterized being health literate in different ways, in some cases, narrowly and in many cases, broadly. Some participants viewed HL as health awareness/knowledge, while many stated it as not only having health knowledge but also practising the knowledge and being a role model for others. They associated being health literate with having awareness and knowledge of reproductive health, mental health, hygiene and sanitation, communicable and non-communicable diseases, and nutrition, as well as engaging in healthy behaviors. They do not perceive as a health literate someone who has health knowledge but does not translate it into action. For instance, one participant stated, “HL refers to having health awareness/knowledge but having knowledge alone is meaningless; it needs applying that knowledge in one’s life.” (Female, 17 years old). Another participant added, “HL is about having knowledge about health, about factors that affects/harms health, and about how to protect one’s health, and practically living that knowledge and being exemplary for others; otherwise, he/she is health illiterate.” (Male, 19 years old).

In some cases, the participants expressed awareness/knowledge of where to get health information and services and the ability to acquire valid health information from different sources, understand that information, and use it practically, as aspects of HL. For instance, one participant expressed, stressing also the importance of having health awareness, as follows, “HL is concerned with the ability to access valid health information, understand that information heartily, and practically applying it; and this depends on having awareness about risks to health and the need to care of one’s health.” (Male, 19 years old). Here, the participants stressed reading ability (health-related materials or topics, medication instructions, and also religious books, such as Bible), hearing ability, listening wholeheartedly (to messages and advice, including that of elders and religious teachings), and knowing and understanding health terms, and exercising what is heard/learnt as essential elements of HL or being health literate.

In other cases, they related HL to the ability to understand one’s health condition, access and use health services as instructed, and take care of one’s health. For example, a 14-year-old girl stated, “…HL is concerned with the ability to read or understand medication instructions and use health services properly … I think someone who understands her condition, seek services timely, and manages her health properly is a health literate.” In a number of cases, the participants associated HL with having interest and motivation or commitment to access and use health information and services. For example, a 17-year-old boy said, “…It is concerned with having interest to learn about health, using social media for getting health information, and respecting and learning from each other”. Another 17-year-old girl added, “…It is concerned with not ignoring what is heard or giving value to the information obtained…I may have awareness/knowledge about health issues, but I lack commitment to do.”

In some cases, the participants associated HL with being aware of and ability to critically observe and evaluate others’ behaviors or actions and the consequences, learn from them, and take care of oneself. One adolescent stated this as follows, “…HL is concerned with the ability to learn from the faults or wrong behaviors of others and the consequences and taking care of oneself and this is wisdom.” (Male, 17 years old). Another adolescent added, “Being health literate is being careful…it needs to be careful not to be deceived and trapped into problems, and not doing things only since one did it, without thinking whether it is good or bad.” (Female, 18 years old). HL was also related to knowing oneself, using one’s time properly, and being optimistic and purposeful. For instance one participant expressed, “…Health literate is someone who knows himself and differentiates what is beneficial and harmful for his life, thinks for his futurity, and takes care of his life.” (Male, 16 years old). Another adolescent stated, “…Being health literate is related to being optimistic and having a goal, not being careless and aimless, having the ability to pass temptations, and striving to attain one’s goal.” (Female, 17 years old). Girls stressed these issues more than boys, and a 16-year-old female adolescent added:

HL is concerned with knowing what you do have, being responsible for your life, having a plan, knowing what you have to do and have to be in the near and far future, using your time properly, selecting friends based on wisdom not carelessly, being free from addiction, and restricting yourself from unnecessary or untimely things.

The participants, especially females, in a number of cases, related HL to confidence in communication (with parents, friends, health professionals and others) and decision-making. For example, a 17-year-old girl expressed, “…Being health literate firstly needs being self-confident, ability to openly tell our problems or the problem we faced to our friends, families, and community members and seek solutions for it.” An 18-year-old girl added, “HL includes having purpose or life goal, having strong stance and being brave, and ability to break and pass through whatever challenges we may face on our ways.” There were also those who associated HL with having patience and self-control ability. For instance, one adolescent stated, “HL includes self-control ability, healthy thinking such as how to lead oneself and control oneself. Someone who has no good thought and who doesn’t control himself will also raise a child who doesn’t have self-control ability.”(Male, 19 years old). Here, the participants, especially, females stressed the importance of patience, not to be too emotional and angry with each other and especially with their parents, as their parents may fail to meet their material needs and understand their situations, or because of work burden related issues. For instance, a 17-year-old girl stated:

Being health literate includes being patient. Sometimes, one may be in conflict with parents, especially the mother because of failure to accomplish household tasks on time. In such situations, it is important to practice patience, obey them and avoid leaving home to somewhere that may expose one to different problems.

There were also participants who associated HL with having good and peaceful relationships, respecting others, and thinking and doing something good for others including sharing health knowledge with them. For example, one adolescent expressed, “Being health literate include having good relationship with friends, family, and the local community. Someone who is health literate respects others, do not harm others; and s/he is known by thinking and doing good things for others.” (Male, 17 years old). And a 17-year-old girl added, “…It includes advising/sharing one’s knowledge with others; if I am a health literate, I do not allow my friend fall into bad things; I advise her and make her return from bad things… I should not let her be lost.”

In some cases, the participants related HL to self-discipline, ethical behavior, and awareness of and playing one’s role properly. They do not regard someone as health literate unless that person cares for others and performs his/her roles properly. For instance, a 19-year-old female stated, “HL includes having self-discipline and refraining from doing bad things that harm others. As I think, being health literate involves proper behaviors, ethics, playing one’s role properly, and taking care for oneself and for others.” Another participant added, “Someone who is health literate protects his/her own health and takes care for others; do not do what harms the health of others…do not cast out garbage into the environs where it can harm the health of others.” (Male, 17 years old). Finally, there were participants who associated HL with being aware of and obeying or living/acting according to one’s own community’s (including religious) norms and values. The following is a representative quote:

Being health literate includes doing what is good and what has acceptance in the community; having behaviors that are in agreement with community’s norms and values; respecting others; not being deviant, and not doing something that community regards as bad and that affect one’s own health and relationships with people in one’s environment. (Female, 19 years old)

In this study, in some cases, the participants identified having education/reading skill as important issue in being health literate; however, in many cases, they indicated that HL is not restricted to the educated ones (having formal/modern education). Because as they expressed, there are those who are educated (including health professionals and teachers) but do not exhibit healthy behaviors, and there are those who do not have formal education but have healthy behaviors. For instance, a female adolescent stated, “…Someone who knows what to do and what not to do is health literate. He/she may not be updated by or may not have modern education.” (16 years old). A male adolescent also said, “…Even though he is not educated, my father knows it well, he gives me clear advice so that I know what helps/benefits me and what may harm me.” (17 years old). And a 17-year-old female adolescent added, “I think, HL is not only concerned with being educated… there are a number of educated individuals whom we think that they know more about health than we do, yet we observe them smoking and doing other things.”

In general, from the adolescents’ perspectives, HL or being health literate is regarded as comprising various competencies and qualities essential for health, including health awareness and knowledge, abilities to deal with health information, practicing healthy behaviors, upholding healthy norms and values of the community, being a responsible citizen, and other related qualities.

Benefits of health literacy and being health literate

This section explores the adolescents’ perspectives on the benefits of HL or being health literate. The participants stated that HL or being health literate is beneficial for one in numerous ways as outlined below.

Health responsibility and readiness: Some adolescents stated that HL empowers one to take responsibility for and to take care of his/her health, to be aware of what benefits and what harms, to know what to do and what not to do, and to make informed health decisions in everyday life and prepare for the future. One adolescent stated this as follows, “…Having awareness about our health and being health literate is very important, as someone who is health literate knows what to do and what not to do.” (Female, 16 years old). Another adolescent added, “…It enables me to make better health decisions, to be prepared to manage problems that may occur in life, and to take care of myself.” (Female, 18 years old).

Healthcare or treatment: A number of adolescents expressed that HL makes one understand his/her condition (disease symptoms), know how (what to do) to manage/treat an illness or a health problem and what should not do, give value for his/her health and timely seek treatments, and do what is recommended to recover, and be careful of his/her health. For instance, a 17-year-old girl stated, “…The health awareness and knowledge we got from our health club has helped me a lot, as we learned what we have to do about our health and if we become ill.” And a 17-year-old male adolescent added, “…I have benefited from health information I accessed from Internet; it helped me to recover from my gastric problems; now, I know what I have to consume and what I should not consume.”

Disease prevention or protection: The participants stated that being health literate enables one to protect him/herself from sexually transmitted diseases (STDs), keep personal and environmental sanitation, avoid risky behaviors such as smoking and excessive consumption of sweet foods, refrain from unnecessary relationships, resist peer pressure, cope up with challenges and stress arising from family or other circumstances, and stay away from violence. Here, the adolescents stressed the importance of mental HL, reproductive HL, and personal and environmental hygiene related HL, and knowledge of non-communicable diseases related issues. Regarding mental health issues, one adolescent stated, “…I was in stress and different problems…I watch motivational speakers (from YouTube), and it benefited me a lot, it enabled me change my attitude and bad behaviors… now, I stopped using substances.” (Male, 17 years old). Another adolescent expressed the benefits of personal/environmental hygiene related HL issue as follows, “Someone who is health literate keeps his/her hygiene… knowing the importance of personal and environmental hygiene/sanitation, and how its lack endangers one’s health, is very important…it is better to keep one’s personal and environment hygiene than getting diseased and suffering.” (Female, 19 years old). In relation with reproductive HL related issues, an 18-year-old girl stated, “If a girl does not have understanding at this stage, she will be deceived easily; … to take care of herself, she needs HL.”, and a 16-year-old female added:

The health awareness/knowledge I got from school, church, and family has helped me a lot… the advice I got helped me not to fall into problems, not to have relationship with those who have bad behaviors, to distance myself from something affecting my health, and to take care of myself.

Health maintenance and enhancement: In some cases, the participants, especially females mentioned that HL empowers one to adopt healthy behaviors and lifestyles. This includes following proper nutrition practices, participating in regular physical activities, and working towards improving his/her overall health. For instance, one participant expressed, “Someone who is health literate follows the principles of health; it can be known from his/her behavior; s/he is known with healthier lifestyle and ethics, and s/he cares for her/his health.” (Female, 19 years old). Another participant stated, “…Health information is very important. I personally found the information I accessed form the Internet to be very interesting; it was related with hair and helped me to maintain and enhance my hair.” (Female, 17 years old). And a 17-year-old male said, “…A health literate person does physical exercises intentionally; s/he does something good for his/her health, and something good waits for him/her in the future. For individuals who are addicted, it is the reverse and also difficult to come out of that addiction.”

Confident and healthy life: Some participants expressed that being health literate makes one feel confident and safe, have positive attitude, live purposeful or goal oriented life, and have healthier and happier life. For example, one adolescent said, “…A health literate person is known by his/her condition; such individuals are happier and tend to do good things; there are some individuals whom I even envy for being like them; they are physically healthy and good in academic performance.” (Male, 17 years old). Another adolescent expressed, “…Someone who is health literate possesses understanding and is careful…s/he is not someone who is unable to control herself/himself; makes strong decisions and is assertive; s/he has a plan/goal, and lives accordingly.” (Female, 18 years old).

In a number of cases, the participants stated that being health literate is also beneficial for others, including family members and friends. They stated that someone who is health literate takes care of one’s lifestyle and be a good role model for others, shares his/her health knowledge with others, has good/peaceful relationship with others, and thinks and does something good for others. One adolescent expressed this as follows, “If there is someone health literate, s/he is physically, mentally, and attitudinally healthy, and helps others to come out of a problem; s/he makes you know what benefits you, and helps you refrain from what harms you.” (Female, 19 years old). Another adolescent added, “…Someone who is health literate has health knowledge/awareness and maintain his/her own health and also takes care of others; taking care of oneself also means taking care of others.” (Female, 16 years old). The participants also stated out that being health literate is essential for one’s community and the wider society’s wellbeing. They stated that a health literate person has self-discipline, respects community’s norms and values, is aware of the consequences of his/her action on others, participates in keeping environmental sanitation, and is a responsible citizen. For example one adolescent said, “…Someone who is health literate works with discipline/ethics….they work for their country as their country also serves them.” (Female, 16 years old). Another adolescent stated, “…You protect yourself; also give advice to your friends, and help your parents, which in turn benefits your community and country.” (Male, 19 years old).

Thus, in general, from the adolescents’ perspectives, HL or being health literate is beneficial not only for oneself but also for others around him/her and for the wider society in several aspects, including healthcare, disease prevention, and health promotion.

Health literacy status and practices among the participants

This section examines the adolescents’ self-perceived HL status and HL practices, focusing on their health information accessing, understanding, evaluating, and using abilities and practices.

The participants’ self-perceived HL status and practices varied, reflecting significant differences in their health awareness/knowledge and in their ability to access, understand, evaluate and use health information. As can be noted form the subsequent sections, although their expressions indicate poor HL, some participants did not recognize the limitations in their HL and perceived themselves as having good HL status. While in many cases, the participants expressed that they have poor HL and need it to be improved. For instance, one participant said, “…Now, I am not health literate; I have to learn and become health literate in the future.” (Female, 16 years old). Another participant added, “…I have very little knowledge about health…I need more information which is related to mental health issues; I need to know very well about the health of adolescents and the factors which may affect our health.” (Female, 17 years old).

Seeking and accessing health information

Regarding seeking and accessing health information, although they reported knowing where to access it, in many cases, the participants stated that they did not deliberately search for it. Mostly, they get it accidentally form various sources, including parents, school, television/radio, social media, friends, neighbors, and faith-based programs. For instance, one participant stated, “To speak frankly, I didn’t deliberately search for health information, but I learn it at school, hear it from television, and from my neighbors when they talk about the causes of health problems they faced.” (Male, 17 years old). A 15-year-old girl added, stressing that she seriously considers the health information that she accidentally came across, as follows:

I often come across health information accidentally and accept it into my heart; I read it accidentally while browsing the Internet or hear it from someone or from a church program. It makes me realize that I am with some problems [behavior related]. You might think that you are good, but there could be certain wrong things happening in your life that you are unaware of.

But in contrast to the above quote, there were also adolescents who did not take seriously the health information that they came across accidentally. For example, a 17-year-old male said, “I did not deliberately try to get health information from anywhere; often we take something we hear also for granted; we hear some issues as advice from media; but we do not take it seriously.”

In a number of cases, the participants mentioned that they did not engage in accessing health information deliberately, feeling that it was not seriously needed for them, as they were healthy. One participant stated this as follows, “Since I have no health problem, I did not search much for health information and services, but sometimes when I see something from Tick Tock, I search and check whether that information is correct or not.” (Female, 18 years old). There were also participants who felt that they have the required health information for a while or for their age level; thus, no need to search for more. And some participants expressed that they started seeking out health information only as a result of experiencing health problems themselves or someone close to them experienced health problem. For instance, one adolescent stated, “It was only one day, when I was in bad condition as my result declined, that I tried to get health information as it is needed for me; I consulted my father to come out of that problem…” (Female, 15 years old). Another adolescent also said, “… I can get it if I become ill; also if I am feeling bad, I can search for motivational speakers from YouTube and listen and get relief.” (Male, 17 years old). And a 17-year-old girl added, “… I was searching mental health-related information as I was in trouble; I was with urine tube infection; my academic performance also declined…after getting advice from my friend, a university student, now I am better.” (Female, 17 years old).

There were also some participants who stated that they often engaged in deliberately seeking for health information from various sources and learning about health. For instance, one stated, “I often try to learn more about health; I read books, ask seniors, listen and ask my teachers. I also follow media, and I also ask and talk with a health professional, who is close to me, about health issues.” (Male, 17 years old). Another adolescent added, “I am interested in learning about health; I attend and learn from school club, I also use and learn from social media; I read different books/materials, including psychological related ones.” (Female, 16 years old). More female adolescents stated deliberately engaging in searching for health information than male adolescents did.

In general, whether it is deliberately or accidentally, the participants reported getting health information from various sources, including parents, school lessons (text books), school clubs, television/radio, friends, faith-based programs, the Internet, health workers, neighbors, relatives, and psychiatrists. There is a variation among the adolescents in accessing different sources of health information. Adolescents from private schools reported getting health information from various sources including school clubs, psychiatrists, and health professionals more than those from the public schools. Most of the participants reported getting health information from someone or through watching television and/or YouTube rather than through reading. In most cases, reading is also limited to information from social media and text books.

Comprehending/understanding health information

There were variations in the participants’ comprehension and understanding of the health information they acquired from various sources. For instance, one participant expressed, “I can understand the health information I get from different sources, although sometimes there are issues or words that are not easy to understand…however, for many individuals [adolescents] it may not be easy.” (Male, 17 years old). And another adolescent stated, “There are many things which I could not understand; I sometimes accept them with guess…But there was a time when we got reproductive health-related training; during that training, I asked questions on issues which were not clear.” (Female, 19 years old). Also, concerning the health information they obtained specifically from health professionals, while some participants expressed clearly understanding it and asking questions whenever clarification was needed, others did not, for various reasons. For instance, one adolescent said, “I contact health professionals…I understand what they tell me, because they give me advice on overt health issues, not complex ones.” (Female, 17 years old), and another participant stated, “I recently contacted a doctor for my gastric case…I interact with him as a friend, and he speaks to me in way that I can easily understand. If there is something unclear, I ask him for clarification.” (Male, 17 years old). But another adolescent complained, “I normally like asking questions if something is unclear; but they don’t talk with you in detail; they only tell you how you use the medications; thus, I don’t ask many questions although there is something unclear.” (Male, 19 years old). Another participant added, “…the problem of understanding is there; information written by health professionals is often not clear/understandable; you can’t understand it.” (Male, 18 years old). Adolescents who reported having access to and contact health with professionals at private health facilities stated that they had friendly and clear discussion with them and understood the issues; however, those who used public health facilities reported several challenges, including the ones mentioned above. And participants who reported trying to obtain health information for various reasons, and those who found the health information they acquired to be beneficial, raised more issues regarding the importance of understanding health information.

Evaluating health information

Regarding the evaluation and identification of valid information, there were participants who mentioned that they rarely questioned the health information they acquired. In many cases, they reported having little doubt about the accuracy of the information they obtained from sources such as television, Google, and religious organizations, in addition to health professionals. In a number of cases, there were also participants who reported finding it challenging to identify valid and helpful health information, especially when it came to the Internet. For instance, one participant stated, “…I obtain health information from television, Internet, and others…I did not question the validity of the health information I got…and I did not tried verifying it.” (Male, 17 years old). Another adolescent said, “Something interesting in these days is that you get health information from different sources, but it is not easy to identify helpful information from different sources especially from Internet.” (Female, 18 years old). And another participant added, “…I hear contradicting information including about political [country] issues… health information also gets distorted when transmitted from one individual to the others. It is difficult to identify valid information not only for me but also for everyone.” (Male, 17 years old).

Some participants, who reported engaging in accessing health information for different purposes, stated that they tried to verify the validity of the information they obtained through various means, such as consulting someone who is experienced, knowledgeable, or educated, and cross-checking. For example, one adolescent said, “…I consult someone close to me who is educated or who have more knowledge or experience than me, as I often could not get a health professional.” (Male, 19 years old). Another participant stated, “…I ask teachers because I often get them here and also as everyone who reached a high level of achievement, including doctors, was educated by teachers; if we ask him, a teacher can help us identify the valid information.” (Male, 15 years old). And 16-year-old female said, “Identifying helpful information is not easy, especially from Internet… I ask my parents because they might have experienced the issue in their lives; I also ask health professionals, as they are educated and know about it.” But another adolescent stated, “…I ask and confirm from health professionals, as they are concerned with the issue and work on it; but family may say something incorrect, and others also may mix it up with wrong things.” (Male, 18 years old).

In many cases, the participants felt that they lacked health information evaluation skills, and it was a difficult task for them, especially to identify helpful websites and information form the Internet. They expressed a desire to contact health professionals for this issue, but they stated not having easy access to them, and also if they may reach a health profession, they may not get sufficient and comfortable time with him/her.

Using health information

When it comes to using the health information they obtained, the participants had different levels of commitment and profiles. A number of them expressed using it personally, including in taking care of their health, making informed health decisions, avoiding risky behaviors, correcting and improving their behaviors, seeking and using health services properly, and focusing on their education and life goals. For instance, one participant said, “…in my everyday life, I give priority for my health, and I don’t do anything that may harm my health, as much as I know and as much as I can, as health is life.” (Male, 18 years old). Another participant expressed, “…I was experiencing gastric problem that aggravated by my aggressive behavior towards minor things. Based on the advice of health professionals, I have decided to improve my behavior to maintain my health and be careful with what I consume.” (Male, 17 years old). And a 16-year-old girl stated, “…I move forward with a decision not to do what harms my health. I know what I have to do and what I shouldn’t do; I confront things with strong stance and decisions in my everyday life.” Some participants also mentioned using the health information they obtained to help their parents manage their health problems. For instance, a 16-year-old female said, “…I appreciate diabetic related information that I get from Internet for the sake of my father; diabetes is a serious disease. I am very concerned about this issue to help him protect himself from what causes him sick.” And some stated sharing it for their friends and encouraging them to avoid risky behaviors; for example, one participant stated, “…besides using it for myself, I also advise my friend when I observe that what she does and her behavior are not good.” (Female, 17 years old).

However, in many instances, the participants expressed often disregarding the health information they came across because of different reasons as described below and in the subsequent subsections. A number of the participants stated avoiding it because of not noticing it wholeheartedly, not believing in the benefit of what they heard or undermining the issues as not helpful, or because of ignorance or lack of commitment and carelessness. For instance, a 15-year-old boy sated, “…even adolescents who participate in different risky behaviors may have information about the issue, but they don’t understand it; if they do have understanding, they don’t do it. They should have to be aware well about the issue.” And a 17-year-old girl said, “…adolescents who participate in risky activities are also often not because of lack of knowledge; it is because of ignorance and not thinking over it or about its bad consequences, taking it as a minor issue.” Another participant stated, “…I use the information I obtained, but sometimes I don’t apply it; I become careless about it…Sometimes I do what my uncle [who is a health professional] advise me not to do although I know that it harms me.” (Female, 17 years old). And an 18-year-old female added, “…sometimes there is ignorance/carelessness; a man has both strong sides and weak sides, often the weak sides overcomes; you often postpone things that you have to do now, saying I will do it latter or tomorrow.”

There were also those who mentioned disregarding it in favor of current/temporary pleasure, rather than considering the future health consequences, or for trying or experimenting with things. For example, one adolescent stated, “…may be except few individuals, majority of the adolescents participating in risk behaviors have knowledge about the problem…there are those who do it for temporary pleasure.” (Female, 16 years old). And a 17-year-old boy said, “… nowadays, if you say, ‘don’t do that, it doesn’t help you and do that, it benefits you’, they [adolescents] do not hear you; they say ‘what is that, that does not help me, let me see/test it’.” And other participants reported that there were various external factors that hindered them from applying the health information they had acquired. For instance, one participant said, “…I may not apply it, sometimes I am attracted to peers and spend time with them, but I try to improve this.” (Male, 19 years old). And an 18-year-old girl expressed, “… concerning relationship, I think that I can protect myself from relationships that I believe could harm me,…but there are conditions which make you unable to apply it; also I could not avoid stress e.g., due to education/exam.”

Generally, there is variation among the adolescents regarding using the health information they acquired. Primarily, females and those who reported deliberately seeking and accessing health information expressed that they had been using it for various purposes, including the ones mentioned above.

Enabling and hindering factors to HL and becoming health literate

This section presents the enabling and hindering factors for becoming health literate or engaging in HL practices from the adolescents’ perspectives. The participants identified a range of enabling and hindering factors related to family, school, religion, media, and life circumstances.

Family (communication, awareness, peace, and economic resources related issues)

As enablers or barriers to their HL, the participants identified several factors related to their families’ situations. These factors include whether parents engage in open discussions with them, maintain a peaceful relationship, are aware of health issues, and have economic resources. For instance, a 16-year-old girl stated, “…There was no time when I worried or regretted about my health-related behavior, because starting from lower level, I have a friendly relationship with my parents; they advise me openly, and I have been living accordingly.” But a 19-year-old girl complained, “…I could not apply what health professionals advise me, such as avoiding worrying and terrifying, because of the situations in my family; my parents (father) treat me wrongly, and they also quarrel with each other.” And a 14-year-old girl said, “…I mayn’t apply my health knowledge….when I tell my parents that I am sick, they say, ‘you exaggerate it; do you take this as a serious problem!?’ ; they wouldn’t take you to health facility until it becomes serious.” Another participant added, “…..I could not get it; I delay it expecting that I may get relief from that illness; getting services depends on my parents’ economic ability and awareness. It is them who make me get it.” (Male, 17 years old). And an 18-year-old male said, “…Being health literate needs having different facilities fulfilled, such as mobile phone and Internet; those who have them can get much information; but for those who don’t, it is difficult.” Another participant confirmed this saying, “… I do have a smart phone, and I use Internet to search for any information I need, and I benefited from it; I get recovered from gastric problem following the advices I got from it.” (Male, 17 years old). And he added, “… I can get services whenever I want. Since my father is an NGO employee, we have health insurance.” Additionally, some participants expressed that they learned important healthy behaviors from their parents, which are related to exercise, diet, being optimistic and thinking good. However, a number of the participants complained that their parents even do not understand them or their needs, and as mentioned above, there was a lack of open-discussions or smooth relationships, which hindered their HL practices.

Schooling and school related issues

The participants also identified several school related factors as enablers or barriers to adolescents’ HL. These include having access to education itself, access to health education, school discipline, teachers’ manners as role models, and access to or availability of personal/private advising services (in addition to classroom education).

The participants stated that schooling helped them learn and gain health awareness and knowledge, and consequently they stated being careful about their health. For example, a 16-year-old girl stated, “…At school, we learned about sanitation/ hygiene, physical exercise, about the different types of food with different vitamins, about STDs and reproductive health.” And 17-year-old boy added, “The information I got regarding STDs form reproductive health and HIV/AIDS related club, at grade six (at school), helped me a lot; now when I come across with individuals with risky behaviors, I take care of myself.” The participants, generally, considered school as a crucial social setting playing a great role in enabling adolescents to be health literate, as they spend there most of their time. However, they complained that the conditions of some schools were not good, especially when it comes to providing the required services and supervising students and what is going on in school compounds, and as a result, schools were becoming places where adolescents develop risky behaviors rather than being health literate. Regarding this issue, one participant said, “…Primarily, this is the responsibility of the school; there should be open discussion; teachers should not be pessimistic about the students and leave them with wrong behaviors, they have to supervise them and advise them.” (Male, 17 years old). And another participant added, “In some schools, students are left to be as they want… some teachers are also acting like other ordinary individuals…feeling discomfort… they have to be good role models and give advice.” (Female, 18 years old).

A number of participants stated that more than class lessons or education, school club is helping them in making them to take care of their health. Participants from private schools expressed participating in and benefiting from school clubs more than the adolescents from public schools. Participants, primarily, those from the public schools complained about a lack of respect for school discipline, as well as about a lack of private advice service in school, and stressed its importance more than that of classroom education.

Media (Television, Radio, and Internet) related issues

A number of the participants also identified media, including television, radio, and Internet as impacting their HL. Many stated learning and getting benefited from health-related programs transmitted through television or radio. For instance, one participant expressed, “Health information can be obtained from television, radio, and health professionals. I hear health information from television… I heard about fistula from television and learned about its causes; I also learned about cervical cancer from television.” (Female, 18 years old). Another participant added, “I follow television health programs…the health information I obtained about tooth from television helped me. It helped me get recovered from the problem doing what was recommended although I didn’t go to health facility.” (Female, 16 years old). However, there were also participants who complained that they couldn’t get as much health information from television or radio as they wanted. For example, one participant stated, “Television transmits about health; but we aren’t getting sufficient health information from television. It isn’t giving us adequate information to enable us internalize the issue… it focuses more on other issues such as political matters rather than health issues.” (Male, 19 years old). In a number of cases, the participants who have access to Internet also expressed learning important health issues from Internet. For instance, one participant stated, “I get information on different health issues from Internet, and get benefited…I search Internet for more clarifications….there is something that you can learn from Internet.” (Female, 17 years old). However, in many cases, the participants stated mostly using only social media and getting health information only accidentally, and also they stated that they did not know how/where to access valid health information from the Internet. Additionally, some participants complained wasting too much time on social media, even reducing from their sleep time, and expressed concern over its strong negative influence on adolescents’ behavior.

The participants’ expressions also indicate that health professionals had been impacting their HL as enabling factor, but mostly through television/radio and school. In several cases, the participants from urban background stated learning important health issues from health professionals through television rather than by physically contacting them. And in some cases, participants from rural background stated that health extension workers were visiting them on some special days such as on HIV/AIDS days and others, and making them aware on health issues, primarily hygiene and STDs related issues.

Religious-based teachings and related issues

The participants also identified religious organizations and religious figures related factors as enablers or hindrances to HL in adolescents. These factors include religious teaching itself, special adolescents focused programs/teachings, and the religious figures’ manners as role models. For instance, one adolescent expressed, “…Religion teaches us not to participate in risky behaviors… as much as I can, I am trying to live as my religion teaches.” (Female, 17 years old). And 17-year-old boy said, “…There is an education program for those aged 16 years and above at church. From this program, we learned a lot about reproductive health and addictions, and get benefited.” However, there were also participants who expressed complaints, highlighting the following points. One participant said, “….Religious places often talk only about religious issues; they do not talk openly on adolescent issues; if they had helped[advised] adolescents on such like issues, these problems would not have occurred.”(Female, 18 years old). Another participant added “…Nowadays, religious persons themselves are also not good role models for adolescents; they are not restricting someone, who did something immoral, from giving services in church…education and advice need to be given.” (Male, 17 years old).

In general, a number of participants expressed getting benefited from religious-based teachings. They stated that religious teachings had made them to be careful about their health and lives, and made them think and do well also for others. Some, particularly those from the Protestant religion, expressed that the presence of and participation in church-based especial programs for adolescents made them take care of their health. However, a number of participants complained the absence of health education from religious-based teachings and open-discussions on the adolescent issues, as well as the failure of religious personnel to focus on core values and to be good role models for adolescents.

Life circumstances related issues

The participants identified various life circumstances related factors as enablers or barriers to their HL, including putting their health knowledge into action. These factors involve the community environment (including peer influence), life conditions, and experiences. The participants identified these factors as challenging or hindering more than as enabling conditions.

One participant described the challenge related to the community environment as follows, “…Now, children [adolescents] smoke cigarette and walk on street holding khat openly not secretly; there are situations that make you use such like things; there is peer influence. It is difficult to stop it, unless you leave the environment.” (Male, 18 years old). And a 16-year-old girl, adding social media-related challenge, stated the issue as follows, “…There are so many challenges, including relationships or peer influence, social media, in schools and in outside school environs that can easily take us away in a bad direction if we can’t resist it.” Others emphasized factors related to life conditions, such as stress in life, a lack of options, and related issues, as challenges to their HL practices. For example, one adolescent said, “…we may be in stress/worrying because of different things; we maybe in a problem related to family, relationship, or with teachers….one may use substances because of the conditions, to refresh his mind or to get relief, but knowing its problems.” (Male, 17 years old). And an 18-year-old boy stated, “…sometimes if you have no other alternative, what can you do other than doing what your friends do to get entertained. Since we couldn’t get what we want, we do what others do.” Another participant added,“…to speak frankly, despite being aware of its health risks, the condition makes you do it; e.g., children in the street sniff glue to get rid of cold, knowing its harms or effects on themselves.” (Female, 18 years old).

The participants further expressed the challenges, highlighting the problem of hopelessness caused by issues related to life conditions and experiences. For instance, a 17-year-old boy, who has no parents, said, “…Sometimes, you may not apply your knowledge as you may feel hopeless. For instance, since I live with my grandmother, sometimes I feel hopeless, and say, up to when I bother her.” And another participant stated, “…I had had a friend, who used to start and then stop relationships with different males…now she acts like someone hopeless; she always do bad things. Her parents also have become pessimistic about her and stopped following/advising her.” (Female, 17 years old). Focusing on the problem of addiction, another participant stated the issue as follows, “…Although they know that it harms, they could not avoid it because of addiction.” (Female, 19 years old). There were also participants who raised work burden related conditions as challenges to their HL practice. For instance, a 17-year-old girl stated, “…Sometimes, you can’t; work burden is a barrier; there are home activities, and also there is education and readings, and others.” Finally, in some cases, the participants identified personal experiences with their own health problems and chronic health issues of their parents/relatives, as factors that positively impacted their health awareness and HL, influencing them to seek out and access health information.

Discussion and implications

This study explored HL from adolescents’ perspectives, including its definitions and conceptualizations, components, benefits, practices, and the enablers and barriers to HL as perceived by adolescents. The participants had various perceptions of HL and being health literate and defined or characterized it in different ways, reflecting different understandings of HL issues among adolescents. And their expressions indicate that HL and being health literate comprise various competencies and qualities. This includes health awareness and knowledge, personal responsibility for one’s health, and knowledge of where and how to access health information and services. It also involves the ability and motivation to access health information from multiple sources (including hearing, wholeheartedly listening, and reading abilities), as well as the ability to understand health information and terms, identify reliable health information, and communicate confidently to express needs, conditions, and thoughts. In addition, it includes critical thinking, self-awareness, patience, self-control, and future vision. Moreover, it involves the capacity to make informed decisions and apply health information/knowledge, such as taking care of one’s own health, practicing healthy behaviors, seeking health service timely and using it properly, being exemplary for others, and being a responsible citizen. In general, they regard HL as a multidimensional issue, encompassing various aspects and elements.

These expressions reflect what is in the HL literature, encompassing young people and adults. For instance, Kindig, Panzer [34] stated that HL includes having skills such as the ability to read, write, speak, and listen effectively, and other related abilities. Zarcadoolas, Pleasant [35] regarded HL as encompassing fundamental literacy (reading, writing, and speaking abilities), science literacy (knowledge/understanding of scientific terms), civic literacy (awareness of public issues and active involvement), and cultural literacy (recognizing and using collective beliefs). Jordan, Buchbinder [18] described patient HL as encompassing competencies such as knowing when to seek health information, knowing where to seek health information, verbal communication, assertiveness, literacy, retaining and processing information, and the application of skills. And in a systematic reviews of definitions and models of HL in childhood and youth, Bröder, Okan [9] identified different dimensions and components of HL, such as cognitive attributes (including knowledge, functional skills, information processing skills, and others), affective and conative attributes (including self-awareness, self-efficacy, motivation, and others), and operational/behavioral attributes (including communication, health information application, and others). The concepts in these studies align with those in the current study (described above), though not exactly with the same connotation in some cases.

Adolescents’ perspectives on HL, in the current study, indicate that HL competencies and qualities are not limited to those who are literate or have got formal/modern education, and being educated alone also may not be sufficient to be considered health literate. Literature also confirm that while functional skills are essential to be health literate [34, 36], being educated may not always imply being health literate [16, 37].

Adolescents in the current study regard HL or being health literate as highly beneficial in healthcare, disease prevention, health maintenance and enhancement, and in taking responsibility not only for ones’ own health but also for the health of others, thereby benefiting those around them and their community and society. Literature also state that HL empowers individuals to appreciate their own health/wellbeing as well as that of their families and community, and to take responsibility and address the factors that influence health [10]. As well, the adolescents descriptions of the characteristics and benefits of being health literate or HL in the current study reflect Nutbeam [36] consideration of HL from both clinical and public health/health promotion perspectives, and Sørensen, Van den Broucke [10] description of HL as encompassing a set of competencies required for everyone to make sound decisions regarding healthcare, disease prevention, and health promotion.

The current study found notable gaps in HL among the adolescents. Many of the adolescents primarily get health information accidentally from sources such as school, parents, friends, television, social media, and faith-based organizations programs, and those who sought reliable information from sources like health professionals often found it difficult to access. And for many of them, there were significant gaps in understanding, evaluation, and application of health information. Similarly, a review of HL studies among young people in Africa noted insufficient HL among the respondents in almost all of the included studies [23]. As well, a synthesis of available evidences on sexual and reproductive HL among young people in Sub-Saharan Africa reported the same condition. It found inadequate sexual and reproductive knowledge, high reliance on peers, media, and school for health information, low utilization of health professionals as information sources, and failure to apply health knowledge in practice among the young people in many of the included studies [38].

The adolescents HL practices and their perceptions of enablers and barriers to HL, explored in the current study, indicate that HL among adolescents is influenced by various factors. These factors comprise personal related issues (such as commitment and perception), family related issues (communication, peace, health awareness, and economic resources), school and education related issues, media (television, radio, and Internet) related issues, religious organizations and bodies related issues, and life circumstances (community environment, life conditions, and experiences) related issues. Manganello [39], Sørensen, Van den Broucke [10], and Bröder, Okan [14] also explain that it is the combination of these and other related factors that influences one’s HL, as either enabling or hindering conditions.

The findings of this study have essential implications for interventions and future research, as detailed below.

• ❖ The adolescents’ perceptions of HL and being health literate and their HL practices, as explored in the current study, have important short-term and long-term implications (both positive and negative) for the adolescents themselves and for society at large. It asserts that adolescents need HL both for their current and future health benefits and for that of their communities and nations, and failing to address adolescent HL issues would constitute an increased risk for the individual and the wider society [40–42]. This highlights the importance of prioritizing HL promotion among adolescents.

• ❖ The current study noted critical gaps in the adolescents’ HL, particularly with regard to engaging with health information and practising health knowledge. In many cases, the adolescents themselves felt that they had poor HL and expressed a need for HL knowledge and skills to effectively manage their health and ways of lives. There were also those who even did not recognize the gaps in their HL and felt they were health literate, with sufficient health information and knowledge needed for their age level. Yet, in contrast, they stated not engaging in seeking out and accessing health information and also struggling to translate their knowledge into practice. Thus, this study calls for group-specific, tailored interventions to improve and foster HL in adolescents.

• ❖ In many cases, adolescents in the current study stated relying mostly on the health information they got from parents, school, television/radio, and faith-based organizations. Hence, the adolescents’ health awareness and HL depends on the health awareness of these bodies or the contents of health information transmitted through these channels. Thus, working on and using these bodies in interventions, is vital to improve HL in adolescents.

• ❖ In addition, in many cases, the adolescents complained about the lack of open-discussions with parents and limited access to facilities, health professionals, and friendly services, leading them to rely on potentially untrustworthy sources. This may make adolescents vulnerable to misinformation, poor decisions, and unhealthy practices [38]. Thus, working to improve community awareness, open discussions within families, and access to friendly services is greatly needed.

• ❖ As well, in many cases, adolescents who reported having access to the Internet and using it for health information, stated difficulties in identifying reliable sources or sites, and some reported relying on Google as a reliable health information source. Therefore, this study calls for interventions and training to teach adolescents how and where to access reliable online health information. This is crucial to improve HL in adolescents as nowadays access to Internet, a source of abundant health information, is increasingly growing.

• ❖ This study identified various factors that facilitate or curtail HL in adolescents. Understanding and recognizing these factors is essential to support or promote the enabling factors and to effectively address the barriers, as otherwise interventions may not be successful. Addressing and promoting HL in adolescents is not a responsibility of a single body, as HL is influenced by multiple factors [14]. It needs providing healthy alternatives to address adolescent needs for temporary pleasures or refreshments, creating healthy community environment, promoting healthy or peaceful families, providing adequate and tailored health educations and facilities, and being a good role model for adolescents. Thus, it needs the involvement of all stakeholders, including families, schools/teachers, religious organizations and bodies, health organizations and workers, researchers, media, and policy makers.

• ❖ This study explored various concepts/components of HL from adolescents’ perspectives and identified factors impacting HL in adolescents. Further studies are needed to enrich or validate the findings of this study and to investigate how and the extent to which the identified factors affect HL in adolescents. Furthermore, the design, identification, and implementation of effective HL interventions are needed to improve HL in adolescents.

Strengths and limitations

This study examined adolescents’ perspectives on HL and addressed a significant knowledge gap. The study employed maximum variation sampling to select 86 adolescents aged 14 to 19 years, as study participants. Utilizing triangulated research methods and face-to-face interviews and discussions in a natural setting, this study generated rich data and provided in-depth understanding of the issue. It has shed light on adolescents’ HL, including factors enabling or hindering HL practices, and has offered key implications for addressing HL in adolescents. It has also provided a foundation for the development of an adolescent HL tool that is relevant to the sociocultural context of Ethiopia. However, this study was not limitation free. As it was conducted in school settings, it did not include adolescents who were out of school. Consequently, generalizing the findings to the entire adolescent population is limited, although most adolescents are typically in school. Furthermore, in a qualitative study, drawing causal conclusions is difficult. Nevertheless, the strengths of the study can help offset these limitations.

Conclusion

The study explored HL from adolescents’ perspectives in Ethiopia, a developing country, and contributed to understanding of the issue. It identified notable gaps in adolescent HL and provided insights into the enabling and hindering factors. This study laid the ground for developing a HL tool sensitive to the Ethiopian sociocultural context and for broader studies to enhance understanding and to develop effective interventions to improve and promote HL among adolescents and within the broad society.

Authors’ contributions

AAA conceptualized the study idea and design, prepared the proposal, supervised data collection, analyzed and interpreted the data, and prepared the manuscript. ZB contributed to the conceptualization of the study idea and design, supervised the preparation of the study proposal, and contributed to the analysis and interpretation of the data and the manuscript. AG contributed to the conceptualization of the study idea, supervised the preparation of the study proposal, and contributed to the analysis and interpretation of the data and the manuscript. All the authors have read and approved the submitted version of the manuscript for publication.

Funding

Apart from support provided by Jimma University, this research received no external funding.

Data availability

All data generated or analysed during this study are included in this published article (and its supplementary information).

Declarations

Ethics approval and consent to participate

This study was approved by the Institutional Review Board of Jimma University (Ref. No. JUIH/IRB/321/23), and it adhered to the central ethical concerns in research with human subjects. Eligible adolescents who were fully informed about the study and voluntarily gave informed consent/assent participated in this study. In the case of minors, under 18 years of age, informed consent was first obtained from their parents (with whom they live), and then assent was obtained from these adolescents. The participants were informed that they could withdraw from the study at any time before or during the data collections, and they were assured that their identities and the information they provided will be kept anonymous and confidential.

Consent for publication

It is not applicable.

Competing interests

The authors declare no competing interests.