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. Author manuscript; available in PMC: 2021 Jul 1.
Published in final edited form as: Am J Health Behav. 2020 Jul 1;44(4):392–408. doi: 10.5993/AJHB.44.4.3

Adolescents’ Health Literacy and Decision-making: A Qualitative Study

Sasha A Fleary 1, Patrece Joseph 2
PMCID: PMC8191815  NIHMSID: NIHMS1701422  PMID: 32553022

Abstract

Objective:

Adolescents assume increased responsibility for their health, particularly regarding health decision-making for lifestyle behaviors. Prior research suggests a relationship between health literacy (HL) and health behaviors in adolescents. Yet, the specific role of HL in adolescents’ health decision-making is unclear. This study qualitatively explored adolescents’ use of HL in their health decision-making.

Methods:

Six focus groups with adolescents (N = 37, Mage = 16.49, 86% girls) were conducted. Adolescents’ responses to questions about their HL use were coded using thematic analysis.

Results:

Adolescents identified passive and active HL engagement and several individual (eg, future orientation, risk perception) and environmental (eg, access to resources/information, media) factors that influenced their use of HL in health decision-making. Feedback from others, subjective health, and ability to navigate multiple sources of information also determined adolescents’ confidence in their HL skills.

Conclusions:

Our results support expanding the types of HL studied/measured in adolescents and provide insight on how HL can be leveraged to improve adolescents’ health decision-making. Though there was no guiding theory for this study, results support using the Information-Motivation-Behavior Skills model to assess the HL/health decision-making relationship in adolescence.

Keywords: health literacy, adolescents, health decision-making, Information-Motivation-Behavioral Skills Model, preventive health

Approximately 80 million adults in the United States (US) have limited health literacy (HL)1 and there are no national data on the status of HL in US adolescents. HL was first defined in 2000 by Ratzan and Parker2 as the ability to obtain, process, and understand health information. Nutbeam3 differentiated HL into 3 progressively advanced sets of skills: functional (health-related reading, writing, and numeracy skills); interactive/communicative (cognitive and social skills for understanding and participating in health communication); and critical (skills needed to act on health information for personal and social benefit). Manganello4 identified a fourth type of HL: media HL. Levin-Zamir, Lemish, and Gofin5 delineated media HL into the ability to identify health-related media information, recognize its influence on behavior, critically analyze information, and respond through taking action on personal health behaviors or social action. Furthermore, in a systematic review of 17 definitions and 12 conceptual models of HL, Sorenson et al6 concluded that HL includes 4 types of competencies (access, understand, appraise, and apply) that generate knowledge and skills that are necessary to navigate 3 parts of the health continuum (healthcare, disease prevention, and health promotion). Sorenson et al’s6 model spans medical and public health views of HL. Given the complexity of Sorenson et al’s6 definition, in this study, we will utilize the HL definitions proposed by Ratzan and Parker,2 Nutbeam,3 Manganello,4 and Levin-Zamir et al5 for interpreting and contextualizing the results.

HL represents one of many skills encompassed in cultural health capital. Cultural health capital is the culture-based resources that people draw on to engage in actions that favor their health.7,8 It is a combination of health-related skills, behaviors, and attitudes that can be used to promote a healthy lifestyle.7,9 Shim8(p 3) argues that it “develops in and through the repeated enactment of health-related practices.” Cultural health capital is socialized intergenerationally and through interactions with institutions.8,10 Acquisition of cultural health capital relies on opportunity to develop the skills and is thus limited by one’s social determinants of health (SDH).8 SDH is associated with disparities in health behaviors11 and health outcomes (eg, obesity12,13). Furthermore, there is an overlap in the demographic characteristics of populations at risk for health disparities and low health literacy.14–17 HL is considered both a SDH and mediator of SDH.18,19 Logan et al19 argue that improving HL is necessary for achieving health equity. Given this strong connection between HL, health disparities, and SDH, it is imperative that individuals and agencies committed to addressing health disparities and improving health equity have an understanding of how HL impacts health behaviors and health decision-making across the lifespan.

In adults, low functional HL is related to poor preventive health behaviors, increased use of emergency services, low involvement in health decision-making, and lower satisfaction with disease status and healthcare.20–24 Though most HL research focuses on adults, there is some evidence of the importance of HL in adolescents’ health decision-making and behavior. In one systematic review, 2 of 17 studies identified a positive relationship between adolescents’ HL and preventive health behaviors and 8 studies found a negative relationship between HL and substance use.25 None of the studies considered adolescents’ developmental characteristics or used a comprehensive theoretical framework to explain the multiple contexts, pathways, or mechanisms by which HL impacts adolescents’ health decision-making and health behaviors.25

Salient developmental characteristics in adolescence include poor impulse control and increased sensation-seeking.26,27 Decision-making in adolescence is complicated by the asynchronous development of reward systems and self-regulatory abilities. Due to their lack of experience and underdeveloped self-regulatory capabilities, adolescents tend to rely on environmental cues for decision-making in affective situations.28,29 Despite this, adolescents are expected to assume increased responsibility for their health.30 This is especially true for youth with chronic conditions. Sansom-Daly et al31 highlight the importance of HL skills for youth with chronic conditions who may need to assume responsibility for their health earlier than their peers and whose mortality depend on good decision-making. In addition to taking more responsibility for lifestyle behaviors (eg, sleep, eating, physical activity), adolescents in the US, in particular, are also gaining rights to interact with healthcare providers without parental consent or notification32 via minor consent laws. Though this is empowering for adolescents, their ability to benefit from and follow through on health decision-making arising from these encounters is likely impacted by their HL. Studies highlight the role of external influences (eg, peers, parents, social environment)33 and individual characteristics (eg, risk perception,34,35 motivation,36,37 mental health status,38,39 and health knowledge40,41) on adolescents’ behaviors. However, beyond the few studies supporting the relationship between HL and health behaviors,25,31 little is known about adolescents’ utilization of HL in their health decision-making.

Current Study

HL includes the skills needed for health knowledge uptake and application of health knowledge in health decision-making and health behavior action. Given the importance of the relationships involving HL, health knowledge uptake, health decision-making, and health behaviors in the adult literature,23,42–45 the lack of research on HL in adolescents is a major gap in the adolescent health decision-making literature. Furthermore, racial, ethnic, and income disparities in adolescents’ health behaviors are well-documented,46–49 and are related to subsequent increases in adult chronic disease risk50–52 and health disparities.53 Given that HL might mediate the relationship between these SDH/demographic characteristics and health outcomes and is a modifiable SDH,19 it is important to explore how HL can be used to improve adolescents’ health decision-making and reduce health disparities. Hence, the goal of this study was to add to the adolescent HL and health decision-making literature by qualitatively exploring adolescents’ use of HL in their health-decision making. Specifically, this study explored (1) how adolescents perceive they use HL in their health decision-making, and (2) how they appraise their HL skills. Addressing these points can provide insight on how HL can be leveraged to improve adolescents’ health decision-making.

METHODS

Study Design

This study qualitatively explored how adolescents use their HL skills to engage in health-related decision-making and their appraisal of their HL skills. To do this, we conducted 6 focus groups with adolescents (N = 37) in school settings. One group included all boys, 4 were comprised entirely of girls, and one group included both girls and boys. Our data collection occurred from May 2015 to December 2017.

Procedures

To recruit a convenience sample for the study, we posted flyers around 2 local high schools, distributed them in adolescents’ health classes, and had teachers make announcements about the study in their classes. All participants assented and provided signed parental consent. Several students (mostly boys) showed up for focus groups without consent forms and were not allowed to participate in the study. We used focus groups rather than one-on-one interviews to generate in-depth point-counterpoint discussion on a topic that was likely novel to some adolescents. Prior to the focus groups, participants completed a demographic questionnaire (with paper and pencil) and were administered the Newest Vital Signs (NVS). A research assistant took each participant in a private area to conduct the 3–5-minute NVS interview. The number of research assistants administering the NVS varied by focus group; however, there was typically a 3:1 ratio of participants to research assistants. Focus groups were held at the respective schools after school dismissal. Multiple focus groups were held simultaneously. Where possible, participants were stratified by sex, and then randomly assigned to focus groups. Mixed-gender focus groups were conducted in cases where there were not enough boys to form a separate group. Focus groups lasted 45–60 minutes and were conducted by trained and experienced moderators who had no relationship with the participants. Participants received refreshments and a $10 gift card for participation. Focus group recordings were transcribed verbatim and checked for accuracy by 3 members of the research team.

Measures and Qualitative Assessments

Demographics.

On the demographic questionnaire participants indicated their age (ranged from 14–20 years), sex (male or female), free/reduced lunch status, and race/ethnicity (American Indian/Alaskan Native, Asian, black/African-American, Hispanic/Latino, Native Hawaiian/other Pacific Islander, white, other). Table 1 summarizes the demographic information.

Table 1.

Demographic Characteristics of Focus Group Participants

N (%)
Sample size 37
Sex
 Boys 5 (13.5)
 Girls 32 (86.5)
Race/ethnicity
 Black or African American 13 (35.1)
 Hispanic or Latino 13 (35.1)
 White 3 (8.1)
 Asian 4 (10.8)
 Multiraciala 4 (10.8)
Free/reduced lunch
 Yes 34 (91.9)
 No 3 (8.1)
Newest Vital Signs Scoreb
 0–1 high likelihood of limited health literacy 0 (0)
 2–3 possibility of limited health literacy 15 (41.7)
 4–6 adequate health literacy 21 (58.3)
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Note.

a:

Participants were able to select more than one option for race/ethnicity.

b:

One participant did not complete the Newest Vital Signs due to research assistant error.

HL.

Adolescents were administered the NVS,54 a 6-item objective measure of functional HL, via a structured interview. Adolescents were given the nutritional facts label for a pint of ice cream and responded to 6 reading- and numeracy-based questions about the information on the label. Correct responses were summed and categorized into high likelihood of limited HL (0–1 correct), possibility of limited HL (2–3 correct), and adequate HL (≥ 4 correct). The first 2 categories identify individuals who would require or may require more assistance during patient-provider communication, with the high likelihood of the limited HL group requiring the most assistance.

Semi-structured focus group questions.

Our focus group protocols used semi-structured questions to generate discussions among adolescents. Table 2 contains some sample questions. Moderators asked follow-up and clarification questions. The moderators consisted of research assistants trained and experienced in conducting focus groups. The questions were designed to elicit information about how HL is related to adolescents’ health decision-making and adolescents’ perceptions on their HL skillset. These questions were intentionally broad and were not designed to elicit specific types of HL or engage a predetermined theory. Given there were no behavioral change theories associated with adolescent HL at the time of our study design, the focus group questions elicited information that would be useful when considering intervention development to change behavior (eg, barriers, protective factors, motivation). Generating broad interview questions has the benefit of allowing an existing theory to emerge or a new theory to form. The questions were pilot-tested with undergraduate research assistants for clarity and face validity. For this paper, researchers analyzed focus group questions regarding adolescents’ perceptions of how they use HL, confidence in their skills, and factors associated with use of HL. Adolescents were asked to define HL as part of the focus group; however, the Ratzan and Parker2 definition was provided prior to them being asked the questions analyzed for this paper.

Table 2.

Sample Focus Group Questions

Focal area Questions asked
Perceptions of health literacy use How do you know that you are using health literacy?
Factors associated with use of health literacy What makes it difficult to use health literacy?
What makes it easy for you to use health literacy?
Confidence in skills Give some examples when you feel unsure of your health literacy skills?
Give some examples when you feel sure of your health literacy skills?
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Note.

Follow-up and clarifying questions are not included as they varied by focus group.

Data Analysis

Focus group transcripts were analyzed in Microsoft Word using thematic analysis.55,56 Two coders generated codes through an open-coding process, in which the coders read each transcript and identified potential codes across focus group questions. The codes generated during the open coding process were calculated for reliability as the number of agreed upon codes divided by the total number of codes generated (Kappa = 0.81). Next, the codes were reviewed by the 2 coders and collated into themes. Consistent with the thematic analysis process,33 themes and codes for each focus group were entered into a table with the focus group number and the transcript page number and reviewed against the original transcripts to ensure that the themes comprehensively and accurately represented the data (ie, the theme matched the context of the quote and code). The codes and themes in this table were then used to create a thematic map in which the 2 coders identified, named, and defined overarching themes and subthemes. Table 3 provides the thematic map.

Table 3.

Major Themes and Subthemes Elicited from the Focus Groups about Health Literacy (HL)

Focal Area Major Themes Subthemes
Types of HL Active Informed deliberate engagement
Passive Subconscious engagement
Subjective feelings post non-deliberate engagement
Barriers/protective factors associated with HL acquisition and utilization Adolescent characteristics Future orientation
Self-control
Personal motivation
Low risk perception/susceptibility
Environmental factors Provider communication
Access to resources/information
Parent characteristics
Media
Religion
Inadequate health knowledge Knowledge of health terminology
Not being taught HL skills at all
Being taught HL skills too late
Misinformation
Uncertainty/self-doubt in current knowledge
Confidence in HL skills/usage Sure of Skills Informed health-decision making
Good patient provider communication
Behavior and knowledge align
Share information with others
Unsure of skills (but reflects opposite) Questioning media content
Consult multiple sources of information
Communicate lack of understanding with providers
Unsure Failing to disclose info to providers/ intimidation
Not able to answer friends’ health questions
Ignore own knowledge/fail to question reliable source
Medical non-adherence
Insufficient research on medication
Unfamiliar terminology
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RESULTS

Our participants were on average 16.49-years-old (SD = 1.35) and mostly girls (86.5%). Adolescents were predominantly Black/African-American (~35%) and Hispanic/Latino (~35%), ~92% received free/reduced lunch, and ~58% scored within the adequate functional HL range (Table 1).

Focus Group Themes

The open coding process yielded several themes within our 3 major areas of focus: (1) types of HL engagement; (2) barriers and protective factors associated with HL acquisition and utilization; and (3) confidence in HL skills. Themes and subthemes are described below and outlined in Table 3.

Types of HL Engagement

Adolescents identified both active (purposeful engagement) and passive (automatic engagement) use of HL skills. For active use, they provided examples of informed and deliberate decision-making that reflected use of multiple types of HL skills. For functional HL, they discussed making a conscious effort to read labels; for interactive HL, they gave examples of actively interacting with providers for health information. For media HL, they provided examples of seeking out online resources for answers to some of their questions. Representative quotes included:

When you’re reading labels…when you stop and think before you do

(purposefully reading labels, functional HL)

Sometimes you’ll have something you might want to ask the doctor, but like when you’re in the moment, you forget to ask, and…I usually get the answers to some of my questions when I look online

(using online sources, interactive and media HL)

When I first started my birth control…that’s when I ask a lot of questions because I take other medications for mental health issues, so I couldn’t take the pills because it would mess up my hormones with my pills, so I have to ask questions about my birth control

(asking questions, interactive HL)

For passive use, adolescents reported that HL use may happen subconsciously and they may be able to tell by their subjective feelings after they used the skills. Representative quotes included:

I never really know, it [using HL] just sort of happens

(subconscious engagement)

I guess that you feel like…you’re getting some kind of benefit from it…because what you did the other day just improved how you are right now

(subjective feelings post non-deliberate engagement)

Barriers and Protective Factors Associated with HL Acquisition and Use

Adolescents described both protective factors and barriers to how and if they used HL in their health decision-making. These factors included adolescent characteristics, environmental factors, and inadequate health knowledge.

Adolescent characteristics.

This was defined as adolescents’ personal attributes that encouraged or discouraged their use of HL skills in their health decision-making. Major themes were future orientation, self-control, personal motivation, and low risk perception/susceptibility.

The extent to which adolescents thought about their future health and how their current health behaviors would impact their long-term health influenced their current thoughts about their health and health decision-making. Representative quotes included:

When you’re looking at like a better life and what you can do to change the way that you’re living now

(long-term consequences of behavior change)

So is this homework worth like losing sleep over…especially if you’re awake past a certain, certain span of time…do I really think that this is more of a priority than my own health tomorrow morning?

(use HL skills to prioritize behavior given future consequences)

Regarding personal motivation, adolescents’ low motivation and personal health conditions negatively and positively impacted their use of HL in health decision-making, respectively. Representative quotes included:

Sometimes I am just too lazy to do it [use HL]

(low personal motivation)

I’d say I use it [HL] pretty often because…I have a chronic illness that requires me to visit the doctors like about more than 4 times a month, so I keep that in mind to keep my body in check quite often

(high personal motivation)

Adolescents used HL skills and previous knowledge to weigh the pros and cons of decisions and reported that self-control impacted their use of HL in health decision-making in these situations. For example, one participant stated:

The choices you make when you eat, what you do with yourself physically…let’s say you know you’ve eaten like complete…garbage for the past couple of days…and you see something that you know is like bad and you’re aware that you’ve been eating unhealthy and you still do it so it’s like the power you have over it

(self-control)

Adolescents’ provided examples of low risk perception/susceptibility (adolescents’ perception of negative health consequences as low or not affecting them) as reasons for not using HL in health decision-making. This quote represents a common sentiment across participants:

I haven’t been like, following instructions [doctor’s instructions about taking medicine]. I forget. Like, if you tell me to take it like, twice every 12 hours, I am not going to remember… It’s not serious- it’s not that serious to me

(low risk perception)

Environmental factors.

This is the built and social environmental factors that influence adolescents’ acquisition and utilization of HL skills in health decision-making. Adolescents identified both positive and negative environmental factors. Subthemes included provider communication, access to resources and information, parent characteristics, media, and religion. Our participants identified characteristics of good provider communication (interactive HL) as protective factors for health decision-making. Representative quotes included:

When we get told things about our health…and we actually comprehend it…we’re like oh, I can apply this to my life…it’s not just some words that someone is throwing at me

(clarity in provider communication)

I usually have an appointment like once a month at my doctor’s and if like I know one month that I did really well, I just I think she is usually like, proud of me…it depends on if my doctor’s giving me good output

(positive reinforcement from provider)

Access to healthcare providers and health information also impacted adolescents’ acquisition and practice of HL as well as their health knowledge with good access related to more acquisition and use of HL skills. Representative quotes included:

Having like Internet at your hands where you can look anything up that makes it really easy

(access to health information via media)

School, like when you’re in health class and we learn more about like health stuff

(access to health information at school)

Not enough clinics around to talk to people and teach them about health

(poor access to healthcare providers)

Adolescents also identified parents’ characteristics as impacting HL acquisition and use. Language barriers including differences in English proficiency between caregivers and adolescents within the household impacted adolescents’ reliance on caregivers for health information and practicing interactive HL skills. Additionally, health-related encouragement from caregivers served to improve adolescents’ HL skillset and provided scaffolding for adolescents using HL in health decision-making. Adolescents also discussed that their HL skills and health knowledge were limited by that of their caregivers due to reliance on caregivers to teach them what they know. Representative quotes included:

I know Spanish, but it’s hard sometimes to translate, so sometimes when I’m talking to them [parents] about health, I don’t feel so confident talking to them and explaining things

(language barrier)

Having somebody there with me like my mom… I’ll pick something up and she’ll be like no like that’s not good for you.… she’ll kind of like explain to me how much fat there is and…sodium, all that stuff I don’t even know

(health-related encouragement and scaffolding)

If your parents are ignorant about certain subjects about health issues it influences you to be ignorant as well unless it’s presented to you in school

(parents’ health knowledge)

Adolescents discussed the role of media in providing health information and how that prompted HL and use. They described how health information is passively delivered and received through the media. Conversely, they discussed that their lack of trust in media sources encouraged them to engage in interactive HL around the media messages/content such that they sought out health information from medical professionals to corroborate what they learned through media. Representative quotes included:

Ads on TV, there’s always stuff about like certain medications or…if you have headaches all the time…and then they tell you all the symptoms all that stuff…oh it’s feeding you information even if you don’t see it

(recognition of health messages in media)

When you’re not sure about certain information [it is difficult to use HL], so if there’s something you read online and it’s something new to you, a new topic and you haven’t discussed it with someone like a medical professional, your doctor, or a teacher, you’re unsure and you might not want to…actually spread that idea around

(interactive HL around health information obtained from media)

Adolescents also identified religious restrictions as impacting HL skills use:

They [adolescents who are religious] do something that is against their religion so they in fear to open up about it

(avoidance of interactive HL use on topic due to religious expectations/restrictions on behavior)

Inadequate health knowledge.

This was defined as having insufficient health knowledge to engage in health decision-making. Themes included knowing medical terminology, not being taught HL skills or being taught too late, and misinformation about health. Medical providers’ use of unfamiliar terminology hindered adolescents’ use of interactive HL skills during medical visits. Adolescents described knowing and understanding medical terminology (functional HL) as important in health decision-making. One participant explained that:

Big words to understand…Sometimes they [doctors] put in words that you don’t really, like, [know] or, you see in your day-to-day

(low knowledge/understanding of health terminology)

Timing of receipt of health information also impacted adolescents use of HL skills in their health decision-making. Adolescents described receiving relevant health information too late or not at all. For example, one participant stated the following:

I know that we’re doing, we are going to do a curriculum or an activity on reading labels later on this year, in our senior year that, maybe should have been taught earlier on

(HL skills taught too late)

Adolescents also described situations in which they were taught or received biased health information. In some instances, the restricted information limited their use of interactive HL skills to get additional information. The implications of receiving misinformation about health included instilling enough fear that adolescents did not use their HL skills to seek out additional information. Representative quotes included:

Like the sex ed I had, it’s all about staying abstinent but most of us will not stay abstinent really, we’re probably going to do it, um and they should talk about…our health teachers should at least talk to us like about birth control, explain to us how that works

(restricted information)

[T]hings that people say about…other things that could be wrong like how birth control…makes you fat or like get breakouts so then you don’t even like go near it or wanna learn more about it

(consequence of misinformation)

Adolescents acknowledged that there was a lot they did not know regarding HL and health information. They had the expectation that they would learn HL skills and health information passively along the way. However, their uncertainty in their knowledge created self-doubt in their health decision-making. Representative quotes included:

We think we’re fine but there’s always more to learn to take care of ourselves…it’s not like I get up every day I’m like I’ll read a health article, figure out how I can do this stuff.

(limited health knowledge)

I feel like us as like adolescents… when we’re really in that zone of the unknown…we’re going on our way like we’re learning on our way…there’s always…that… self-doubt.

(acquiring health knowledge is passive process, self-doubt in health decision-making due to limited health knowledge and HL)

Confidence in HL Skills/Use

To identify potential areas of intervention, moderators asked focus group participants to provide some examples of when they were sure and unsure of their HL skills. Regarding when they were sure of their HL skills, adolescents gave examples of good interactive HL and critical HL. Major themes included making informed health decisions, good patient-provider communication, behavior and knowledge alignment, and sharing health information with others. Participants provided examples of when they considered their prior knowledge and the information presented to them to make informed decisions as occasions they were sure of their HL skills. Their responses were reflective of their ability to read and comprehend health information (functional HL), integrate multiple sources of information (interactive HL), and critically analyze health information (critical HL) in their health decision-making. One participant offered the following example:

[O]n the back of a label if I don’t understand what it means I might like look it up on my phone if I’m at the supermarket or something, so – I mean, that’s kind of cheating but it’s just looking up something so I can know more about what I’m doing

(making informed decisions; functional, interactive, critical HL)

Regarding good patient-provider communication, adolescents provided examples of when they understood what their providers said to them as well as when they were able to ask providers follow-up questions, these examples were representative of interactive HL. One participant offered the following example:

When you understand…what…the doctor is saying to you when you are communicating with them

(patient-provider communication, interactive HL)

Adolescents also provided examples that illustrated alignment of their knowledge and behaviors, and these examples demonstrated their use of functional HL to acquire health knowledge and their use of interactive HL to integrate multiple sources of information in their health decision-making and subsequent health behaviors. Their examples illustrated how HL serves as a bridge connecting health knowledge with health behaviors. Representative quotes included:

[When] you know what you should and shouldn’t do with your health…if you have asthma like if you run then you know that you’ll like be out of breath

(behavior/knowledge align, interactive HL)

When you’re eating the right things like fruits, vegetables…and their portion sizes

(behavior/knowledge align; functional and interactive HL)

Their confidence in HL skills also was based on how successful they felt they were at sharing factual health information with others and reflected interactive and critical HL skills. Representative quotes included:

If you’re trying…to educate someone about it, like if someone asks you about a topic that you may know

(sharing information with others, interactive and critical HL)

Taking what I learned today from my health class and telling it to like my mom or my dad. I know…what I’m talking about because I learned and studied it in school

(sharing information with others, interactive and critical HL)

Interestingly, when asked for examples of when they were unsure of their skills, some adolescents’ responses reflected good use of HL. For example, some reported that they questioned media content, consulted multiple sources of information, and communicated lack of understanding with providers. Regarding questioning media content, they viewed having follow-up questions to health information presented in the media as an indication of poor HL skills. However, questioning media content and questioning current information based on one’s prior knowledge of the topic are indicative of good media and interactive HL, respectively.

Adolescents’ provided examples of having additional questions during and after leaving doctors’ appointments and seeking out additional information through multiple sources as situations when they were unsure of their HL skills. However, seeking out multiple sources when unsure and engaging in follow-up conversations with providers are what would be expected of individuals with high interactive HL skills. These examples showed good critical thinking about information presented and good interactive HL skills. Representative quotes included:

Like during a commercial.…[they spend] half the time talking [a]bout certain medication and how it is not good for you……[it makes you] question things you probably aren’t sure of OR when reading something like has to do with medication or like when you go to…a doctor’s, and you see like some stuff and you go like oh, “what is this?

(question media content; interactive HL, media HL)

I think after a doctor’s appointment sometimes I got a new medication I am a bit confused, and I try to use the Internet instead of calling my doctor, and sometimes it doesn’t work out, and um if I’m very confused I just would go and call my doctor

(consult multiple sources of information; interactive HL)

The doctor might say something, and…I don’t completely understand what it means, so I might have to ask them to either like put it in simpler terms, or terms that I may understand it

(communicated lack of understanding with provider, interactive HL)

Adolescents also gave examples of deficits in their HL skills with most of their examples reflecting poor interactive and functional HL skills. Regarding poor interactive HL, adolescents reported failing to disclose information to providers due to feeling intimidated, not being able to answer friends’ health-related questions, and ignoring their knowledge or failing to question “reliable” sources when their opinions differed. Representative quotes included:

When I’m talking to her [nurse] maybe I like won’t say like one thing if I’m unsure cause I don’t wanna like make me sound like I don’t know like the content or don’t know

(failure to disclose information, poor interactive HL)

I feel kind of bad because they’re [friends] asking me all of these questions and I can’t give them any answers

(can’t answer friends’ health-related questions, poor interactive HL)

When your own opinions don’t like coincide with another… person [who] is reliable.… you might feel unsure about your own [opinions]

(failure to question sources, poor interactive HL)

Regarding poor functional HL skills, adolescents provided examples of medical non-adherence including not taking medication as directed or following providers’ guidelines regarding behaviors. In the following example, the adolescent used interactive HL skills to get information from the doctor but failed to use functional HL skills read and understand the information.

So, I always take time all to ask my doctor like “Hey, I think I have the ear infection, ‘cause my ear hurts today” or something like that you know? And then he just gives, they actually give me information sheets and stuff like that. I never read them though

(ignore information provided, poor functional HL)

Adolescents also provided examples of not doing sufficient research about medication and this is reflective of poor functional and interactive HL. One participant provided the following example:

I only read about like the good things cause that’s what they…told me, I didn’t read deeper about the side effects or what can cause different stuff, or how to treat something or not knowing how its caused

(insufficient research, poor functional and interactive HL)

Adolescents were also unsure of their HL skills when they were faced with unfamiliar terminology. Other examples reflected their insecurities (due to their age and lack of experience) and cognitive dissonance when their health behavior and health knowledge were mismatched.

DISCUSSION

This study’s goal was to improve understanding of how adolescents use HL in their health decision-making regarding health behaviors. Results confirm a strong connection between HL and health decision-making with adolescents engaging in both active and passive use of HL skills in their decision-making. The results also highlight the personal and environmental factors affecting HL use and factors affecting adolescents’ confidence in their health decision-making.

Adolescents’ perceptions of their HL use as both active and passive align with life course theorists’ perspective that HL is a form of cultural health capital that one draws on to engage in health-related actions.7 The formation of cultural health capital relies heavily on opportunities for scaffolding, modeling, and practice of health-related skills. These processes are essential for habit formation (including passive HL use) and deliberate actions (including active HL use) regarding health decision-making. To use HL actively or passively in health decision-making, one must first have necessary HL skills. Given that opportunity to acquire these skills and other forms of cultural health capital is structurally constrained and unequally distributed due to SDH,8 adolescents at risk for health disparities due to SDH will benefit from interventions that address HL skills to both improve cultural health capital and health decision-making.

Consistent with research on health behaviors,33,35,40,41 individual and environmental factors, as well as health knowledge, affected adolescents’ acquisition and use of HL in health decision-making. Within individual factors, risk perception and future orientation were the most salient subthemes. Adolescents concerned about their future health likely perceived higher risk for not making informed health decisions and thus utilized HL in their health decision-making. Given that low risk perception53 and lack of future orientation57 are characteristic of adolescence, how these and more amenable characteristics are addressed in interventions and clinical practice will impact how adolescents’ use HL in health decision-making.

Conversely, the environmental factors identified by adolescents provide ample opportunities for intervention. They judged their confidence in their HL skills on the quality of their communication with providers and parents, consultation with multiple sources of information, ability to integrate their knowledge with that of reliable sources, understanding of medical terminology, questioning of media content, and medical adherence. Adolescents also judged their confidence in their HL skills based on their ability to make informed health decisions and their health behaviors aligning with their health knowledge. The acquisition of skills through parents and providers is consistent with the cultural health capital argument.7,8 An important theme across environmental factors was how interactive HL was fostered. Specifically, adolescents identified being understood by others and reinforcement of HL use as important to their use of HL in health decision-making. Future research should explore how group differences in interactive HL (eg, by chronic condition status, sex) are related to health decision-making and health behavior to identify environmental factors most likely to result in behavior change.

Adolescents’ reliance on feedback from others (eg, parents, peers, providers) is reflective of their developmental stage – need approval of peers, but still need approval of key adult figures.58,59 It also alludes to providers’ and parents’ continued role in supporting adolescents to health decision-making independence. Specifically, providers’ and parents’ roles are to build adolescents’ confidence in their skills to act on health knowledge rather than only providing health knowledge. Our findings also suggest that adolescents may benefit from assistance with navigating multiple sources of information and more scaffolding around interacting with others around health. Furthermore, adolescents’ identification of subjective health and behavior/knowledge aligning provides an interesting area for potential intervention. Immediate gratification/results reinforce adolescents’ health decision-making; however, immediate results are rarely possible in preventive health, especially when focusing on lifestyle behaviors.

This study was not designed using a specific preventive health model. Rather, it was an inquiry of adolescents’ HL utilization to inform intervention development. However, after engaging in open-coding and developing a thematic map of the codes, it was clear that the themes fit into the Information-Motivation-Behavioral Skills (IMB) model.60 Adolescents’ explanations of how they acquire and use HL in their health decision-making align with the health-related information and personal and social motivation constructs outlined in the IMB model,60 while their confidence in their HL skills and use align with the behavioral skills construct and outcomes in the model. The IMB model is a predictive model of behavior change that was first applied to AIDS/HIV prevention and treatment research.60 The model outlines 3 core determinants of performance of health behaviors: (1) health-related information that is instrumental to engaging in health behavior; (2) personal and social motivation to act on health-related information and engage in behavior; and (3) behavioral skills necessary for engaging in behavior. The IMB model posits that when the behavior is complex to perform (eg, requires multiple steps), information and motivation operate mainly through behavioral skills to determine behavior; however, when behavior is simple (eg, taking premeasured medication), information and motivation directly impact the behavior.

Figure 1 illustrates how the focus group themes fit into the IMB model. Specifically, for the health-related information construct, adolescents discussed that inadequate knowledge (insufficient scaffolding for HL skills), and inaccurate/biased information (bias in information provided) influenced their use of HL in health decision-making directly (path a: they sometimes chose not to act on information) and indirectly (path b→e: poor information limited their HL skills and their confidence in their use of HL skills in health decision-making). The motivation construct is divided into personal motivation (beliefs and evaluations of behavior) and social motivation (perceived and actual social support for the behavior). For personal motivation, adolescent characteristics including future orientation, motivation, self-control, and risk perception determined adolescents’ use of HL in health decision-making. For social motivation, environmental factors including provider communication, access to resources and information, parent characteristics, media influence, and religion determined adolescents’ health decision-making. For both types of motivations, path c represents motivation’s direct impact on health decision-making, such that adolescents made deliberate choices to engage in health decision-making based on these characteristics. Path d→e represents the indirect impact of motivation on health decision-making, such that the motivation characteristics either hindered or supported the acquisition of HL skills and impacted adolescents’ confidence in HL skills and this impacted the HL skills they used in health decision-making. Self-efficacy is encompassed in behavioral skills. The focus group themes of when adolescents were sure and unsure of their skills provided a range of examples of their judgment of their efficacy for using HL as well as how they operationalize the HL-related behavioral skills necessary for health decision-making. Based on the focus groups, behavioral skills for health decision-making (path e) included patient-provider communication, ability to share information with others, consulting multiple sources for health information, questioning media content, critical thinking around health decisions, ability to follow medical directions, and knowing medical terminology. Note that adolescents also identified informed health decision-making and behavior and knowledge aligning as indicative of confidence in their HL skills. However, we view these as the goals of the IMB process for HL. We encourage researchers to test this model empirically in future studies. Empirical testing of the proposed IMB model should include the different types of HL (functional, interactive, critical, media) represented across the focus group themes and include specific health behavior outcomes beyond health decision-making.

Figure 1.

Figure 1

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The Information-Motivation-Behavioral Skills Model for Use of Health Literacy in Health Decision-making in Adolescents

Relatedly, most studies on adolescents’ HL focus on functional HL. However, adolescents’ responses represented a broader definition of HL. Interactive HL was most prominent across themes, followed by functional, critical, and media HL. Their responses also aligned with the 4 competencies (access, understand, appraise, apply) and the 3 parts of the health continuum (ie, healthcare, disease prevention, health promotion) as described by Sorenson et al’s6 HL model. Therefore, the current literature represents a narrowed and possibly inaccurate view of the relationship between HL and adolescents’ health behavior. Formative research is needed to develop objective measures of interactive, critical, and media HL. This will create a starting point to launch quantitative inquiry into the “true” relationships of HL, health decision-making, and health behaviors.

This study was designed to inform how HL could be leveraged to improve adolescents’ health decision-making. Adolescents’ reports of deliberate and passive use of HL suggests that once the skills are learned, some, if not all, HL skills might become habitual. This aligns with HL being considered cultural health capital.7 It also implies that a focus on HL skills development rather than HL knowledge may result in the best outcomes. Researchers should use behavior change theories to design and implement HL skills interventions. The description of how this study’s results aligns with the IMB model is a good starting point for how HL can be targeted in existing behavior change theories. Noteworthy was how adolescents’ developmental characteristics and key systems affected use of (eg, risk perception) and confidence (eg, reliance on feedback from peers, parents, providers) in their HL skills. HL interventions targeting adolescents should utilize a socioecological framework61 that considers individual and environmental characteristics, SDH, and the multiple systems that influence adolescents’ health decision-making and behaviors. HL interventions that likely would be most effective would involve intervening on multiple systems including caregivers, schools, medical providers, and policies. Adolescents’ appraised their ability to use HL skills based on behavioral outcomes. Given that immediate results are not typical for most lifestyle behaviors, interventionists should consider linking use of HL skills with interim results (eg, positive reinforcement from providers). Lastly, given the complex ways in which adolescents use and acquire HL, measurement of HL outcomes in interventions should assess multiple aspects of HL, multiple settings, and secondary outcomes such as subjective feelings about HL use.

Limitations

Our sample was relatively small, predominantly female, and restricted to the school setting. Thus, our findings may not reflect the views of all adolescents, particularly boys and those in alternative settings. Despite these limitations, the sample’s racial/ethnic and majority low-income composition is consistent with individuals at risk for health disparities and low HL, thereby representing perspectives of high-risk groups for HL interventions. The NVS was administered to adolescents prior to the interview and this might have influenced some of their responses, particularly ones related to food and nutrition label reading. Lastly, this study did not explore the relationships of individual characteristics (eg, HL score, sex, chronic illness status) and participants’ responses as focus group data preclude these types of analyses. Future studies should utilize individual interviews with adolescents to explore individual differences in response patterns and to identify additional needs that may be unique to specific populations.

Conclusions

This study qualitatively explored the use of HL in health decision-making in adolescents resulting in several major contributions to the adolescent HL literature. First, like other studies, our results highlight the complexity of adolescents’ health decision-making. HL interacts with multiple individual and environmental factors in their health decision-making process; therefore, these factors should be explored simultaneously with HL in research and clinical practice. Second, whereas most HL research focuses on functional HL, adolescents in our study used multiple types of HL in their decision-making, suggesting that current quantitative research portrays a limited picture of adolescents’ HL. Thus, an expansion of the types of HL studied and measured is required. Third, our results suggest that the IMB model may have some utility in explaining how HL is used in adolescents’ health decision-making; therefore, the use of the IMB model is a good starting point for quantitatively exploring the role of HL in adolescents’ health decision-making. This continued exploration of the relationships involving HL, health decision-making, and health behavior will inform strategies for research and clinical interventions that improve adolescents’ health decision-making and health behaviors. Lastly, adolescents’ qualitative accounts of how they use HL and how they assess their confidence in their HL skills reiterate the importance of developmental characteristics and utilizing a socioecological approach in understanding health decision-making in adolescents.

Acknowledgements

The authors thank the research assistants who transcribed the focus group data and assisted during data collection. The authors also would like to thank the study participants for their candor and enthusiasm during the focus groups. Lastly, the authors acknowledge the school administrators for allowing data collection at their schools and being invested in the research and research outcomes. This work was presented at the Society for Prevention Research Conference in San Francisco in May 2019.

Financial support for this study was provided, in part, by grants from the National Institute of Health [grant numbers 1K12HD092535, 1R21DK117345-01A1]. The funding agreement ensured the authors’ independence in designing the study, interpreting the data, writing, and publishing the report.

Footnotes

Human Subjects Statement

This study was approved by the Tufts University Social, Behavioral, and Educational Institutional Review Board Protocol #1411003.

Conflict of Interest Statement

The authors declare that they have no conflict of interests.

Contributor Information

Sasha A. Fleary, Tufts University, Eliot-Pearson Department of Child Study and Human Development, Medford MA..

Patrece Joseph, Tufts University, Eliot-Pearson Department of Child Study and Human Development, Medford MA..

References

  • 1.Kutner M, Greenberg E, Paulsen C. The Health Literacy of America’s Adults: Results from the 2003 National Assessment of Adult Literacy (NCES 2006–483). Washington, DC: US Department of Education; 2006:1–60. [Google Scholar]
  • 2.Ratzan SC, Parker RM. Introduction. In Selden CR, Xorn M, Ratzan SC, Parker RM, eds. National Library of Medicine Current Bibliographies of Medicine: Health Literacy. NLM Pub. No. CMB 2000–1 Bethesda, MD: National Institutes of Health, US Department of Health and Human Services; 2000:19–30. [Google Scholar]
  • 3.Nutbeam D Health literacy as a public health goal: a challenge for contemporary health education and communication strategies into the 21st century. Health Promot Int. 2000;15(3):259–267. [Google Scholar]
  • 4.Manganello JA. Health literacy and adolescents: a framework and agenda for future research. Health Educ Res. 2008;23(5):840–847. [DOI] [PubMed] [Google Scholar]
  • 5.Levin-Zamir D, Lemish D, Gofin R. Media health literacy (MHL): development and measurement of the concept among adolescents. Health Educ Res. 2011;26(2):323–335. [DOI] [PubMed] [Google Scholar]
  • 6.Sørensen K, Van den Broucke S, Fullam J, et al. Health literacy and public health: a systematic review and integration of definitions and models. BMC Public Health. 2012;12(1):80. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 7.Missinne S, Neels K, Bracke P. Reconsidering inequalities in preventive health care: an application of cultural health capital theory and the life‐course perspective to the take‐up of mammography screening. Sociol Health Illn. 2014;36(8):1259–1275. [DOI] [PubMed] [Google Scholar]
  • 8.Shim JK. Cultural health capital a theoretical approach to understanding health care interactions and the dynamics of unequal treatment. J Health Soc Behav. 2010;51(1):1–15. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 9.Abel T Cultural capital and social inequality in health. J Epidemiol Community Health. 2008;62(7):e13–e13. [DOI] [PubMed] [Google Scholar]
  • 10.Singh-Manoux A, Marmot M. Role of socialization in explaining social inequalities in health. Soc Sci Med. 2005;60(9):2129–2133. [DOI] [PubMed] [Google Scholar]
  • 11.Marmot M Social determinants of health inequalities. Lancet. 2005;365(9464):1099–1104. [DOI] [PubMed] [Google Scholar]
  • 12.Black JL, Macinko J, Dixon LB, Fryer GE. Neighborhoods and obesity in New York City. Health Place. 2010;16(3):489–499. [DOI] [PubMed] [Google Scholar]
  • 13.Rossen LM, Schoendorf KC. Measuring health disparities: trends in racial − ethnic and socioeconomic disparities in obesity among 2-to 18-year old youth in the United States, 2001–2010. Ann Epidemiol. 2012;22(10):698–704. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 14.Beckles GL, Chiu-Fang C. Disparities in the prevalence of diagnosed diabetes – United States, 1999–2002 and 2011–2014. MMWR Morb Mortal Wkly Rep. 2016;65(45):1265–1269. [DOI] [PubMed] [Google Scholar]
  • 15.Fleary SA, Ettienne R. Social disparities in health literacy in the United States. Health Lit Res Pract. 2019;3(1):e47–e52. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 16.Rikard R, Thompson MS, McKinney J, Beauchamp A. Examining health literacy disparities in the United States: a third look at the National Assessment of Adult Literacy (NAAL). BMC Public Health. 2016;16(1):975. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 17.Singh GK, Jemal A. Socioeconomic and racial/ethnic disparities in cancer mortality, incidence, and survival in the United States, 1950–2014: over six decades of changing patterns and widening inequalities. J Environ Public Health. 2017;2017:2819372. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 18.Nutbeam D The evolving concept of health literacy. Soc Sci Med. 2008;67(12):2072–2078. [DOI] [PubMed] [Google Scholar]
  • 19.Logan RA, Wong WF, Villaire M, et al. Health literacy: a necessary element for achieving health equity. National Academy of Mecicine. 2015. Available at: https://nam.edu/wp-content/uploads/2015/07/NecessaryElement.pdf. Accessed May 11, 2020. [Google Scholar]
  • 20.Gazmararian JA, Williams MV, Peel J, Baker DW. Health literacy and knowledge of chronic disease. Patient Educ Couns. 2003;51(3):267–275. [DOI] [PubMed] [Google Scholar]
  • 21.Sentell T, Baker KK, Onaka A, Braun K. Low health literacy and poor health status in Asian Americans and Pacific Islanders in Hawai’i. J Health Comm. 2011;16(Suppl 3):279–294. [DOI] [PubMed] [Google Scholar]
  • 22.Scott TL, Gazmararian JA, Williams MV, Baker DW. Health literacy and preventive health care use among Medicare enrollees in a managed care organization. Med Care. 2002;40(5):395–404. [DOI] [PubMed] [Google Scholar]
  • 23.Baker DW, Gazmararian JA, Williams MV, et al. Functional health literacy and the risk of hospital admission among medicare managed care enrollees. Am J Public Health. 2002;92(8):1278–1283. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 24.Williams MV, Baker DW, Honig EG, et al. Inadequate literacy is a barrier to asthma knowledge and self-care. Chest. 1998;114(4):1008–1015. [DOI] [PubMed] [Google Scholar]
  • 25.Fleary SA, Joseph P, Pappagianopoulos J. Adolescent health literacy and health behaviors: a systematic review. J Adolesc. 2018;62:116–127. [DOI] [PubMed] [Google Scholar]
  • 26.Steinberg L A dual systems model of adolescent risk‐taking. Dev Psychobiol. 2010;52(3):216–224. [DOI] [PubMed] [Google Scholar]
  • 27.Blakemore S-J, Mills KL. Is adolescence a sensitive period for sociocultural processing? Annu Rev Psychol. 2014;65:187–207. [DOI] [PubMed] [Google Scholar]
  • 28.Steinberg L. Cognitive and affective development in adolescence. Trends Cogn Sci. 2005;9(2):69–74. [DOI] [PubMed] [Google Scholar]
  • 29.Blakemore S-J, Robbins TW. Decision-making in the adolescent brain. Nat Neurosci. 2012;15(9):1184–1191. [DOI] [PubMed] [Google Scholar]
  • 30.Viner RM, Ozer EM, Denny S, et al. Adolescence and the social determinants of health. Lancet. 2012;379(9826):1641–1652. [DOI] [PubMed] [Google Scholar]
  • 31.Sansom-Daly UM, Lin M, Robertson EG, et al. Health literacy in adolescents and young adults: an updated review. J Adolesc Young Adult Oncol. 2016;5(2):106–118. [DOI] [PubMed] [Google Scholar]
  • 32.Coleman DL, Rosoff PM. The legal authority of mature minors to consent to general medical treatment. Pediatrics. 2013;131(4):786–793. [DOI] [PubMed] [Google Scholar]
  • 33.DiClemente RJ, Brown JL, Davis TL. Determinants of health-related behaviors in adolescence. In O’Donohue WT, Benuto LT, Woodward Tolle L, eds. Handbook of Adolescent Health Psychology. New York, NY: Springer; 2013:107–127. [Google Scholar]
  • 34.Fleary SA, Heffer RW, McKyer ELJ, Newman DA. Using the bioecological model to predict risk perception of marijuana use and reported marijuana use in adolescence. Addict Behav. 2010;35(8):795–798. [DOI] [PubMed] [Google Scholar]
  • 35.Fleary SA, Heffer RW, McKyer ELJ. Dispositional, ecological and biological influences on adolescent tranquilizer, Ritalin, and narcotics misuse. J Adolesc. 2011;34(4):653–663. [DOI] [PubMed] [Google Scholar]
  • 36.Standage M, Gillison FB, Ntoumanis N, Treasure DC. Predicting students’ physical activity and health-related well-being: a prospective cross-domain investigation of motivation across school physical education and exercise settings. J Sport Exerc Psychol. 2012;34(1):37–60. [DOI] [PubMed] [Google Scholar]
  • 37.Katz I, Madjar N, Harari A. Parental support and adolescent motivation for dieting: the self-determination theory perspective. J Psychol. 2015;149(5):461–479. [DOI] [PubMed] [Google Scholar]
  • 38.Oddy WH, Robinson M, Ambrosini GL, et al. The association between dietary patterns and mental health in early adolescence. Prev Med. 2009;49(1):39–44. [DOI] [PubMed] [Google Scholar]
  • 39.Schuster RM, Mermelstein R, Wakschlag L. Gender-specific relationships between depressive symptoms, marijuana use, parental communication and risky sexual behavior in adolescence. J Youth Adolesc. 2013;42(8):1194–1209. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 40.Viggiano A, Viggiano E, Di Costanzo A, et al. Kaledo, a board game for nutrition education of children and adolescents at school: cluster randomized controlled trial of healthy lifestyle promotion. Eur J Pediatr. 2015;174(2):217–228. [DOI] [PubMed] [Google Scholar]
  • 41.Swenson RR, Rizzo CJ, Brown LK, et al. HIV knowledge and its contribution to sexual health behaviors of low-income African American adolescents. J Natl Med Assoc. 2010;102(12):1173–1182. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 42.Berkman ND, Sheridan SL, Donahue KE, et al. Low health literacy and health outcomes: an updated systematic review. Ann Intern Med. 2011;155(2):97–107. [DOI] [PubMed] [Google Scholar]
  • 43.Berkman ND, Sheridan SL, Donahue KE, et al. Health literacy interventions and outcomes: an updated systematic review. Evid Rep Technol Assess (Full Rep). 2011;199(1):1–941. [PMC free article] [PubMed] [Google Scholar]
  • 44.Guerra CE, Krumholz M, Shea JA. Literacy and knowledge, attitudes and behavior about mammography in Latinas. J Health Care Poor Underserved. 2005;16(1):152–166. [DOI] [PubMed] [Google Scholar]
  • 45.Oldach BR, Katz ML. Health literacy and cancer screening: a systematic review. Patient Educ Couns. 2014;94(2):149–157. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 46.Kann L, McManus T, Harris WA, et al. Youth risk behavior surveillance – United States, 2017. MMWR Surveill Summ. 2018;67(8):1–114. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 47.Frederick CB, Snellman K, Putnam RD. Increasing socioeconomic disparities in adolescent obesity. Proc Natl Acad Sci USA. 2014;111(4):1338–1342. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 48.Svastisalee CM, Holstein BE, Due P. Fruit and vegetable intake in adolescents: association with socioeconomic status and exposure to supermarkets and fast food outlets. J Nutr Metab. 2012;2012:185484. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 49.Cutler GJ, Flood A, Hannan P, Neumark-Sztainer D. Multiple sociodemographic and socioenvironmental characteristics are correlated with major patterns of dietary intake in adolescents. J Am Diet Assoc. 2011;111(2):230–240. [DOI] [PubMed] [Google Scholar]
  • 50.Farvid MS, Chen WY, Michels KB, et al. Fruit and vegetable consumption in adolescence and early adulthood and risk of breast cancer: population based cohort study. BMJ. 2016;353:i2343. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 51.Chen L, Zhu H, Gutin B, Dong Y. Race, gender, family structure, socioeconomic status, dietary patterns, and cardiovascular health in adolescents. Curr Dev Nutr. 2019;3(11):nzz117. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 52.Quick V, Wall M, Larson N, et al. Personal, behavioral and socio-environmental predictors of overweight incidence in young adults: 10-yr longitudinal findings. Int J Behav Nutr Phys Act. 2013;10(1):37. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 53.Sawyer SM, Afifi RA, Bearinger LH, et al. Adolescence: a foundation for future health. Lancet. 2012;379(9826):1630–1640. [DOI] [PubMed] [Google Scholar]
  • 54.Weiss BD, Mays MZ, Martz W, et al. Quick assessment of literacy in primary care: the newest vital sign. Ann Fam Med. 2005;3(6):514–522. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 55.Maguire M, Delahunt B. Doing a thematic analysis: a practical, step-by-step guide for learning and teaching scholars. All Ireland Journal of Teaching and Learning in Higher Education (AISHE). 2017;9(3):3351–33513. Available at: https://ojs.aishe.org/index.php/aishe-j/article/viewFile/335/553. Accessed May 11, 2020. [Google Scholar]
  • 56.Vaismoradi M, Turunen H, Bondas T. Content analysis and thematic analysis: implications for conducting a qualitative descriptive study. Nurs Health Sci. 2013;15(3):398–405. [DOI] [PubMed] [Google Scholar]
  • 57.Steinberg L, Graham S, O’Brien L, et al. Age differences in future orientation and delay discounting. Child Dev. 2009;80(1):28–44. [DOI] [PubMed] [Google Scholar]
  • 58.Hazen E, Schlozman S, Beresin E. Adolescent psychological. Pediatr Rev. 2008;29(5):161–168. [DOI] [PubMed] [Google Scholar]
  • 59.Sanders RA. Adolescent psychosocial, social, and cognitive development. Pediatr Rev. 2013;34(8):354–358. [DOI] [PubMed] [Google Scholar]
  • 60.Fisher WA, Fisher JD, Harman J. The information-motivation-behavioral skills model: a general social psychological approach to understanding and promoting health behavior. In Suls J, Wallston KA, eds. Social Psychological Foundations of Health and Illness. Hoboken, NJ: Blackwell Publishing; 2003:82–106. [Google Scholar]
  • 61.Bronfenbrenner U Ecological models of human development. Readings on the Development of Children. 1994;2(1):37–43. [Google Scholar]

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