Addressing the Health Literacy needs of children and young people

From time to time we feature guest blogs from people whose views we find interesting, stimulating, thoughtful and provocative. Not everything they say reflects our views but we think it is important that they have a platform.

The latest guest bloggers are Kath Evans, Head of Patient Experience, Maternity, Newborn, Children & Young People at NHS England and Jo Protheroe, Senior Lecturer at Keele University, a GP Principle in Manchester and Chair of the Health Literacy Group UK.

We hope you find what they have to say as thought provoking as we do. Enjoy!


 ‘Why … Why …Why’..?!’

 It’s a plea many of us are all too familiar with, that pursuit for information, a thirst for knowledge from young children….even those children who are non-verbal seek understanding and explanations with a curiosity in their eyes often matched with an earnestness.  Whilst young people may be hesitant in coming forward with their ‘why’s’ in the same way as a child, the uncertainty about the world is deep and the quest for facts, especially about health related issues, spans the age continuum.

 Information is power, and building health literacy skills of children and young people is something which deserves greater focus if we are to meet the ambitions of the Five Year Forward View  so that society gains far greater control of their health and care.  The Children and Young People’s Health Outcomes Forum  reminds us there are over 15 million children and young people in England, making up 25% of the population and all have a need to develop health literacy skills to promote their wellbeing. Some of course have additional health needs, 6% of children and young people have a disability, 14% have a long standing illness, 10% have asthma, 66,000 have autism, 60,000 have epilepsy, 23,000 have diabetes and 68,840 are looked after children. Future in Mind the 2015 report of the Children and Young People’s Mental Health Taskforce highlights that over half of mental health problems in adult life (excluding dementia) start by the age of 14 and 75% by age 18. We also know that children and young people from Black and Minority Ethnic (BME) backgrounds report poorer experiences of care, as do children with learning disabilities and those with complex health needs. Critically 43% of children and young people in the recent Care Quality Commission Survey of Inpatient Care indicated that they were not as involved in decisions about their care as they would wish to be.  It salient to remember we also have an estimated 700,000 young carers who are not only seeking to build their health literacy skills but also require these skills to advocate for those they care for.

These statistics confirm the diverse health literacy needs of children and young people, from universal health information to more specialist subject areas. High quality developmentally appropriate information that embraces the fact children and young people are digital natives’ demands attention – children and young people are after all the whole of our future population.

A recent meeting of the Patient Liaison Group of the BMA focussed on this issue, highlighting the need to give attention to empowering children and young people to be more involved in managing their own health (Dr Selwyn Hodge, Self-Care Forum) and the importance of improving their health literacy (Dr Joanne Protheroe, Chair of Health Literacy Group , UK).  In response, the current President of the BMA, Sir Al Aysnley-Green, expressed his concern that children often get a poor deal in this country, and the emphasis needs to shift.

The discussions led us to recognise however we’re not starting from scratch; there are a number of ‘bright spots’ across the country that are worth reflecting on.

The Patient Information Forum, who tweet as @PiFonline wrote How to produce Health Information with and for Children and Young People  a guide which highlights a number of good examples from teams already addressing these challenges, it includes the work of Helen Sadler, a mum and primary school teacher who developed Monkey Wellbeing resources as a result of failing to find effective health literacy resources for her then 2 year old daughter in preparation for her surgery. The Monkey Wellbeing Resources bring health literacy to life for young children and embeds health information in schools linking it to the national curriculum in a fun and engaging way. The impact of the Monkey Wellbeing work has been evaluated by Liverpool John Moores University. There are now a range of story books available including Monkey has Asthma, Monkey has a blood test along with activity packs for use by children when visiting Emergency Departments that can be accessed, targeted at young children.  You can follow them on twitter @MonkeyWellbeing

More recently we’ve seen the growth of digital badges, yes things have moved on from Brownie & Cub sew on badges!  Digital Badges are a concept developed by Mozilla the Internet giant to recognise the informal learning that occurs day in and day out. MakeWaves is a secure online platform works with schools to bring digital badges to the classroom and whilst the ‘Will I am’ badge is their most popular, NHS badges have been developed to encourage schools to embed health discussions within the curriculum, sew on badges will never seem the same again, electronic backpacks at the ready!  You can follow them at @Makewavestweets

There’s also an opportunity for appraisal of health information and evidence to be built into school lessons, these lesson plans  developed by www.senseaboutscience_org and supported by www.evidentlycochrane assist in providing resources for teachers. @Students4BE is worth a follow on twitter too. Films of Young People’s Health Experiences too can be a great learning resource is a great site to visit and they tweet as @youthhealthtalk

It was children themselves in the CMO Report Our Children Deserve Better Prevention Pays  in chapter 4 who said that the link between health and education needs to be strengthened and there’s certainly a role for school governors in ensuring health within schools receives focused attention, this guidance  from the Children’s Outcomes Forum explores their role in making this happen.

Youth advisory groups can be wonderful advocates for the need to improve health information for and with young people. The NHS England Youth forum, who tweet at @NHSYouthForum is a group of 25 young people recruited from a range of backgrounds from across England to challenge the NHS on its focus on the issues that matter to children and young people. They’ve recently developed posters  on consent, confidentiality and feedback as these were areas that children, young people and families found difficult to understand. It’s a great example of young people identifying a need and then doing something about it by working in collaboration with those in the NHS. A discussion with Sir Bruce Keogh; Medical Director of NHS England, about the content was a highlight for the young people developing these resources and they have now been disseminated nationally.

The Teenage Cancer Trust tweeting as @TeenageCancer have recently published ‘A Young Person’s Guide to Cancer’ based on what other young people have told them about what they wanted to know when they found out they had cancer, it’s a fabulously accessible resource covering ‘med stuff, heart stuff, life stuff, life beyond cancer and handy stuff’ that is really valued by the young people it’s targeted.

Healthcare professionals of course have an essential part in building health literacy of children and young people by involving them actively in consultations. The CYP Me First resources provide a range of tools to support health care professionals in building these skills. Programmes such as transition into adult services  Ready, Steady, Go, Hello  and  Ask 3 questions  can assist Health Care Professionals in bridging the information gap and really work to build health literacy in a practical way especially in the preparation for transfer from children and young people’s services in the adult world of health care.

These resources and examples shared here are far from exhaustive – there are indeed lots of ‘bright spots’ however what we lack is a national children and young people’s health literacy strategy that secures commitment from education and health in establishing strong foundations on which to build the capacity of children and young people to take control of their health and wellbeing. Of course strategies alone don’t change the world, mind-sets do, as healthcare professionals we can all play our part in making information accessible for and with children and young people, we can nurture their curiosity and encourage them to ask ‘Why..why…why…?’ perhaps you can do this with the next child or young person you care for?

Kath Evans, RGN, RSCN, MSc (Nursing), PG Dip (Education), BSc (Hons), PG Dip (Management) is Head of Patient Experience, Maternity, Newborn, Children & Young People at NHS England.  Twitter: @kathevans2

Joanne Protheroe, MB ChB, MRes, PhD, FRCGP is Senior Lecturer at Keele University, a GP Principle in Manchester and Chair of the Health Literacy Group UK

HEY! (Healthy Eating for Young Children) Programme Briefing

Background information

The HEY! programme has been running since July 2013, following a successful pilot which ran between 2011 and March 2013. HEY! is co-ordinated by the Community Health and Learning Foundation (CHLF) and funded by Danone Nutricia Early Years Nutrition as part of their pro-active approach to Corporate Social Responsibility.

HEY! is an Early Years community health improvement project which aims to improve the health outcomes and life chances of children aged one to three years, living in areas of disadvantage, by engaging their parents in healthy eating and Skills for Life learning.

About the Community Health and Learning Foundation

CHLF is the UK’s leading Health Literacy organisation, working to create a more Health Literate Health and Social Care system. We are a Community Interest Company and a large part of our work involves supporting the reduction of health inequalities which we achieve through three main areas; training, resource development and focus groups.

You can find out more about the work of the CHLF by visiting

Vision statement

The aims of HEY! reflect Danone’s global mission and core purpose of ‘bringing health through food to as many people as possible … … because nourishing early life today really matters for tomorrow’.

The rationale for HEY! is based on a body of evidence that shows that childhood obesity is linked to parents’ eating habits. This was confirmed by recent research by the University of Exeter, published in the International Journal of Obesity in April 2015, which discovered that the rise in obesity among very young children has been largely restricted to the minority with obese parents. The research data suggest that ‘parenting is the fundamental influence on weight gain in the early years, whereas more general (peer-group) influences take over later on….and public health strategies may need to be tailored accordingly’.

The HEY! programme is targeted at families living in areas of high disadvantage. Research evidence demonstrates that families living in the most disadvantaged communities are often those who have the worst health outcomes because they face the most difficult challenges in managing their health and wellbeing. A lack of language, literacy and numeracy (LLN) skills is one of the major contributing factors to this. For this reason, HEY!  embeds Skills for Life (LLN) learning into its healthy eating topics, and this where CHLF’s expertise comes in.


The case for change

In England 43% of adults (18-65) do not have adequate literacy skills to routinely understand health information. 61% of adults (18-65) do not have adequate numeracy skills to routinely understand health information. (Rowlands G, Protheroe J, Winkley J, Seed P T, Richardson M, 2015). In relation to healthy eating, this means that people may be unable to interpret diet and nutrition messages, understand food package labelling, understand portion sizes, understand what constitutes a balanced diet, follow recipes and make informed choices about adopting healthy eating habits as part of an overall healthy lifestyle.

One in four British adults is obese (UN Food and Agriculture Organisation). Obesity levels in the UK have more than trebled in the last 30 years and, on current estimates, more than half the population could be obese by 2050.

Overweight children are more likely to become overweight adults (Susan Jebb, Professor of diet and population health at the University of Oxford). The risk of becoming obese is thought to start at an early age and obesity in a parent increases the risk of childhood obesity by 10%. In 2011, around 30% of children aged two to 15 were either overweight or obese.

Obesity is also closely linked to deprivation levels (Dr Alison Tedstone, Director of Diet and Obesity at Public Health England). The association is especially strong with children. Children in poor communities are far more likely to be obese.

Being overweight or obese increases the risk of many serious illnesses, such as type 2 diabetes, high blood pressure, heart disease, stroke, as well as cancer. Obesity has been blamed for about 30,000 deaths a year in the UK, 9,000 of those taking place before retirement age. Alongside disease, obesity can affect peoples’ ability to get and hold down work, their self-esteem and their wellbeing and mental health.

Delivery Model

HEY! courses are delivered locally by staff in Children’s Centres and Early Years settings across England.

Children’s Centres send outreach staff and/or family support workers to a one day HEY! ‘Train the Trainer’ workshop, which is delivered by CHLF.  At the workshop, participants learn how to use the HEY! resources to deliver the seven week course which covers topics such as healthy lifestyles, balanced diet, portion sizes, reading food labels, shopping smart and following recipes. All of these topics have LLN learning embedded within them. Following the workshop, the Children’s Centres deliver the course to their parents and Danone provides a grant to them of £200 per course for consumables and equipment. Parents have the opportunity to have their learning accredited as the course is mapped to the RSPH Level 1 Award in Health Improvement. CHLF continue to provide ongoing support for Children’s centres as and when required following the training. As part of the grant agreement, Children’s Centres provide feedback to CHLF about the impact of the course on the parents and children.

Benefits already achieved from the HEY! programme

Outputs from the HEY! Train the Trainer Programme since July 2013…

  • 205 staff members from 132 different Children’s Centres and Early Years Settings have been trained to deliver HEY! courses to parents;
  • Nine organisations have been involved in the delivery of HEY! courses in their local community; 4Children, Barnardo’s, Spurgeons, Action for Children; Leicestershire County Council, Buckinghamshire County Council, WEA, Aylesbury Healthy Living Centre and an Independent Children’s Centre;
  • 99% of those trained rated the HEY! training workshop as very good or good;
  • 99% of those trained rated the HEY! CHLF trainers as very good or good.

Delivery of HEY!

  • 70 HEY! courses have been delivered in 61 different Children’s Centres/Early Years Settings in 52 locations across England;
  • 614 parents have completed a HEY! course.

Outcomes for parents and their families

Increased knowledge

  • 204 parents have completed the RSPH Level 1 Award in Health Improvement and had their learning formally accredited;
  • 98% of parents know how to eat and drink healthily – compared with 66% at the start;
  • 93% said they know how to exercise – up from 77% at the start;
  • 96% of parents know how much of each type of food they should eat to have a healthy, balanced diet – three times more than at the beginning;
  • 88% of parents think it is possible to eat healthily on a small budget – double those at the start.

Behaviour change

  • 78% of parents make a shopping list either all or most of the time – nearly twice those at the start;
  • 76% keep their shopping bill within budget all or most of the time;
  • 43% of parents sit at a table as a family for their meals – up from 28% at the start;
  • 61% of parents involve their toddler in food preparation and activities (from 21%);
  • A noticeable rise in parents eating more than ‘5 a day’ fruit and vegetables – with very few still eating fewer than ‘3 a day’.

Behaviour change was continuing at 6-8 weeks after the HEY! course had ended.

The conclusion of the external evaluator was….

“We conclude that the Danone HEY! course is having a significant and sustained impact on healthy eating and healthy lifestyles for parents and their young children. This impact is largely due to the design of HEY! and the resources in place for the delivery of HEY! – which children’s centres, tutors and parents have greeted enthusiastically.”

For more information on HEY!

For more information or to get involved with HEY! please contact

Helen Baker

Associate Director, CHLF

August 2015

Personal Reflections on Women and Health Literacy

From Janet Solla, Director for Learning at the Community Health & Learning Foundation

Recently, when I was asked to contribute a blog about women and health literacy, for International Women’s Day, I spent several days really thinking hard about what I should write.

I started to think about how I have been involved in community health and well being education for thirteen years and in health literacy education for nine years.  I thought about all the women I have seen and worked with in both teaching on and managing the Skilled for Health course – England’s only health literacy programme.

This led me on to thinking about much information and knowledge I now have about the impact that having low literacy skills can have on people’s lives.  One thing really stands out for me though – that it is still in the main women who take responsibility for the health and wellbeing of their families regardless of their nationality and background.

It goes without saying then that if the women have health literacy needs the impact on their families can be quite profound.  One of the things that women have discussed in the groups I have worked with is the difficulties of turning up for doctors appointments as they cannot read the appointment letters sent.  Then when they do turn up it is hard to explain what is wrong with them or their family member as they don’t have the language skills to explain or the level and type of pain that is being experienced.

Another problem that many women talk about, is their difficulty understanding the information being given at a time when they or a member of the family is seriously ill.  It is even more difficult if they can’t understand the information that is being given or read the leaflets that are provided.  Many women feel too embarrassed or don’t have the confidence to ask questions.  The impacts of this can be that medication is not taken properly, lifestyle changes are not made and recovery is put back.

However, what I have also been privileged to witness during my work in this field is how gaining health literacy skills and knowledge transforms the lives of women.  It is truly inspirational to hear women talking about what they have learned and how they are going to apply and share it; and they mean much wider than just to themselves.

How do I know this?  Well, the evaluations that have been carried out for our Skilled for Health courses show that the health knowledge and health literacy skills gained by women on the courses is cascaded to family and friends.  I really believe that if we truly want to reduce the ever widening inequalities gap and stop people dying prematurely of preventable diseases, women need to be health literate and have the skills and knowledge to make informed decisions and changes about their own and their families health.  I would be really interested to know if you agree so please feel free to get in touch with your comments at

Impacts of Low Health Literacy

Education is a key social determinant of health and it is now acknowledged that people with lower levels of language, literacy and numeracy are often the same people who also experience the worst health outcomes.

Research[1] shows that in England 43% of adults (18-65) are at Level 1 and below and do not have adequate literacy skills to routinely understand health information.  When numeracy is involved this rises to 61%. The bar for numeracy is set even lower than literacy, which means that 61% of adults in England are at entry level 3 and below in terms of their numeracy skills i.e. what an 11 year old would be expected to do.

This means that a large proportion of adults in England lack “the personal characteristics and social resources needed for individuals and communities to access, understand, appraise and use information and services to make decisions about health” [2] In other words they will not have the level of Health Literacy required to make informed choices about their health and wellbeing.  In addition, it is highly likely that these individuals will be living in the most deprived areas of the country which in turn means that they will be struggling with a range of inequalities.

In terms of health inequalities, people with lower Health Literacy:

  • Die earlier
  • Find it more difficult to take their medication as instructed
  • Are more likely to have one or more long-term conditions
  • Are less likely to engage with disease prevention e.g. cancer screening, immunisation

They also have

  • More unhealthy behaviours
  • Fewer healthy behaviours
  • Lower levels of self-rated health
  • Lower response to public healthy living campaigns

In everyday terms this means: the person who thought that eating 5 peas a day meant they had consumed their daily recommended amount of fruit and vegetables; the person who thought a positive cancer diagnosis was a good thing; the person who sprayed their inhalers ON their throat. These are all real life examples from our work in delivering Health Literacy programmes.

Although extreme examples of the impact of lower Health Literacy what this shows is that people affected by this cannot always understand and act on health messages. This in turn can widen the health inequalities gap meaning they do not live as long or as healthily as their more health literate counterparts.

Clearly there is also a financial cost to the Health Service in terms of people not attending appointments, not understanding healthy eating messages and unused medication. Although there hasn’t been any research carried out in the UK, in America the cost of limited health literacy[3] to their health service is around 3% – 5% of total health spend.  If this is applied to the UK it equates to between £3 and £5 billion.

In light of this it would seem to make sense that health and education work together to improve the health literacy of those people most in need.  This is why we worked with the Department for Business, Innovation and Skills and the Department for Health to develop, trial and evaluate the Skilled for Health resources, a unique health literacy resource that embeds language, literacy and numeracy into health related topics

For more information please contact

[1] Rowlands, G., Protheroe, J., Richardson, M., Seed, P., Winkley, J., and Rudd, R. (2015).

The health information gap: the mismatch between population health literacy and the complexity of

health information; an observational study. British Journal of General Practice 65 e379 -e386.

[2] WHO definition of health literacy (2015).

[3] (The costs of limited health literacy – Eichler, Wieser and Brügger, 2009)