As suicide is a leading cause of death for young people, child and youth care professionals are likely to encounter adolescents who are contemplating ending their lives. Recognizing and responding to the needs of a suicidal adolescent is challenging for the professional as they attempt to balance their relationship with the young person while simultaneously following customary rules of engaging in situations involving suicide. The need for theory to deepen understanding of child and youth care professionals’ mental health literacy practices with suicidal adolescents led to this grounded theory study. Derived from interviews with 19 participants including child and youth care professionals, supervisors at youth-serving agencies, educators in schools of child and youth care, and textual analysis of policies, assessment tools, and curricula, the Balancing Perimeter and Proximity process was identified as the core category in the analysis. The Balancing process suggests professionals’ mental health literacy practices fluctuate between circling care and circling defensively. Circling defensively refers to the professional taking up literacy practices that establish a perimeter of protection; whereas literacy practices within circling care position the professional in relational proximity where they connect and attend to the adolescent holistically. The theory extends current conceptualizations of mental health literacy, and contextualizes professionals’ practice in identifying the conditions influencing the Balancing process, thereby providing an understanding for how existing structures (e.g., suicide education, agency policies) influence child and youth care professionals’ mental health literacy practices with suicidal adolescents. / Graduate

The process of creating and using participatory photonovels can empower immigrant ESL speaking women and also act as a tool to educate these women about a specific health topic. This was a qualitative case study that was conducted at an immigrant society in an urban center in British Columbia. The ESL speaking immigrant women in this study created a photonovel called From Junk Food to Healthy Eating: Tanya’s Journey to a Better Life. The findings of this research reveal some of the health experiences of ESL speaking immigrant women in Canada. The results also contribute to the growing body of knowledge that discusses effective or ineffective means to educate ESL speakers about health by improving their health literacy. Most notably, however, the photonovel project engaged the women in an educational process that raised their critical consciousness.

While there is extensive research on adult conceptualisations of mental illness, as well as on children’s understanding of physical health and illness, research on children’s conceptualisations of mental illness is limited. The primary aim of this thesis is to provide a detailed account of children’s and adolescents’ conceptualisations of depression. In the first study, individual semi-structured interviews with primary school pupils (N=105) from two age groups (mean ages: 8.9 and 11.8 years) were conducted, with the use of depression and control vignettes, to elicit children’s depression concepts, help-seeking intentions and desired social distance. Children’s depression conceptualisations were organised according to the common-sense model of illness representations (CSM). Quantitative content analysis was performed to allow for descriptive analysis; in turn, inferential statistics were used to examine age, gender and self-reported direct and indirect experience differences. Children differentiated between depression and control vignettes, however did not spontaneously label depression or recognised the mental health nature of difficulties. Children provided a wide variety of possible causes that reflected common risk factors for depression, primarily referring to interpersonal factors. Children considered negative consequences of untreated depression, and identified that depressed characters need help. They suggested numerous sources of help, which were mainly informal. Children considered depression to be curable and would seek help primarily from parents if depressed. Older children showed more sophisticated conceptualisations of depression. No substantial gender or experience differences were found. Subsequently, a single session school-based mental health literacy intervention on adolescent depression, adapted from an intervention created by NHS mental health professionals, was developed, using the mental health literacy and CSM frameworks. The second study consists of a pilot evaluation of the intervention, using a controlled before and after design, to examine the effect of the intervention on young people’s depression literacy, help-seeking and help-providing intentions as well as social distance. Young people’s depression literacy was measured by the Adolescent Concepts of Depression Questionnaire (ACDQ), developed for the purposes of this study. Exploratory factor analysis was conducted to indicate the factor structure of the ACDQ, which was in turn used to examine participants’ baseline depression literacy and the effect of age, gender, current depressive symptomatology and direct/ indirect experience with depression and other mental illness (Study 2a). In turn, the effectiveness of the intervention is presented (Study 2b). 339 adolescents (mean age: 13.4 years, 168 female) were allocated to either the intervention (N=171) or a control group (N=168), and completed the ACDQ one week before and following the intervention. Mixed results were found for gender, depressive symptoms and experience differences. Mixed ANOVA was conducted between time and group; the results show that the intervention was effective in informing young people’s depression literacy (ACDQ total score), and specifically in young people’s knowledge of treatment options for depression (treatment subscale), perceived curability of depression (curability subscale), symptom recognition, help-seeking and help-providing intentions. No significant improvements were found for social distance, perceived helpfulness of sources of help, and two of the ACDQ subscales. The contribution of this thesis lies upon the detailed examination of children and adolescent depression conceptualisations, adding to the limited evidence base, especially in children’s mental health literacy. The pilot evaluation of the intervention is promising, and upon re-evaluation could be standardised and implemented in Scottish schools. Implications for clinical practice and mental health literacy are also discussed.

Background: Health systems around the world are facing significant shifts in demographic profiles due to increasing ethnic, cultural and linguistic diversity of populations they serve. However, the provision of health care and health services in the language of the minority has been difficult and inconsistent. The concept of the health-literate organization has been developed amid growing recognition that system changes are needed to align health-care delivery with the needs, skills, and abilities of the population. Despite the recent proliferation of research on health literacy, studies of organizational health literacy are still uncommon. Objective: This dissertation addresses the concept and practical application of “organizational health literacy” in the context of an active offer of health services in French in Ontario, Canada. I attempt to answer the question “How can health literacy advance the development of health-care designs that are responsive and accessible to official language minority?” Methods: My research consists of a three-part project that used health services research methodology and has been accomplished in academic partnership with the French Language Health Services Network of Eastern Ontario. I first conducted a review both of the literature on health literacy in linguistic minorities and of the content of organizational health literacy guides. Using a practical example of an active offer of French-language services in Ontario, I applied the organizational health-literacy framework in order to examine the strategies used by health-care organizations to provide for the active offer of health services in French. My analysis focuses on health-literacy dimensions (e.g., access and navigation, communication), quality improvement characteristics (e.g., assessment, improvement actions), and also organizational-level changes (e.g., administrative strategies, direct client services, governance). A focus group of health-care administrators provided a unique insight into the planning and implementation of the active offer and organizational health literacy and associated challenges. Results: Overall, my results show that, although organizational changes may be implemented with the purpose of improving the quality of care by providing linguistically appropriate services, these changes are largely insufficient to achieve this goal. Conclusions: The concept of organizational health literacy has not yet received the attention it deserves, but its relevance is clear: Health-care organizations must be health-literate to be able to address healthcare needs of their diverse patients. There is a significant gap between where health services are and where they ought to be to satisfy the designation criteria for the active offer of services in French. The concept and the novel theoretical framework of organizational health literacy offers the potential of improving and strengthening the process of designation and planning of an active offer of health services in French.

Human immunodeficiency virus (HIV) is a virus that affects the body’s immune system (Centers for Disease Control [CDC], 2016a). HIV is a worldwide epidemic and disproportionately impacts youth in the United States. Youth living with HIV (YLWH) face significant mental health problems, namely depression, anxiety, and posttraumatic stress disorder (PTSD) with rates of these disorders discrepant from those in the general population. In addition to psychological difficulties, health literacy is another factor that influences individuals with HIV and is a priority of research with adolescents (Kalichman et al., 2000; Manganello, 2008). The National HIV/AIDS Strategy: Update 2020 (White House Office of National AIDS Policy, 2015) identified youth, ages 13 to 24 years, as a key population needing broad support not only for HIV prevention but also engagement in care including improving mental health and health literacy. The current study explored the extent to which YLWH were health literate in addition to the extent to which they exhibited psychological symptoms of depression, anxiety, and posttraumatic stress disorder. Furthermore, the study examined the extent to which health literacy and psychological symptoms were associated with health outcomes. A total of 145 YLWH between the ages of 13 and 25 years participated in the study. Participants completed the Center for Epidemiologic Studies Depression Scale (CES-D; Radloff, 1977), Generalized Anxiety Disorder-7 Item Scale (GAD-7; Spitzer, Kroenke, Williams, & Lowe, 2006), Primary Care-PTSD Screen (PC-PTSD; Prins et al., 2003), and Brief Estimate of Health Knowledge and Action-HIV Version (Osborn, Davis, Bailey, & Wolf, 2010). Of the 145 participants, 103 completed the CES-D, 144 completed the GAD-7, 131 completed the PC-PTSD, and 102 completed the BEHKA-HIV. In addition, participants’ biological markers of immune functioning (i.e., CD4 count and viral load) were obtained from medical abstraction. Results indicated the sample reported high levels of symptoms of depression, anxiety, and PTSD. Thirty-five percent of participants screened positive for depressive symptoms, 26% screened positive for anxiety symptoms, and 21% screened positive for PTSD symptoms. Participants had a moderate amount of HIV knowledge and the majority reported taking their medications under most conditions. Age was a significant predictor of CD4 count and viral load such that increasing age was associated with worse immune system functioning. Educational attainment was a significant predictor of CD4 count and to a lesser extent viral load indicating that greater education was associated with better immune system functioning. There was an interaction between mode of transmission and psychological symptoms. For perinatally infected youth, greater psychological symptoms were associated with a decline in CD4 count. The same decline was not seen for behaviorally infected youth. Health literacy (knowledge and action) added significantly to the explanation of the variance in viral load. Decreasing action scores were statistically associated with an increased likelihood of having a detectable viral load. These findings point to the need for prevention and intervention mental health services for YLWH. Future research should determine prevention and intervention strategies for mental health issues with YLWH in particular. Additionally, health literacy is an important factor that should be addressed by practitioners working with YLWH. More research needs to be conducted to determine the best way to measure health literacy in YLWH and how to intervene with improving health literacy.

Développer la compréhension de la « littératie en santé » (ou « health literacy ») est devenu une préoccupation croissante pour les professionnels de la santé et les chercheurs en santé publique. Se définissant comme l’opérationnalisation, par l’entremise de mesures et de modèles, de la capacité des individus à obtenir, comprendre et utiliser de l’information pour prendre soin de leur santé, la littératie en santé est rapidement devenue un enjeu de santé publique à l'échelle internationale. La littératie en santé – comme domaine de recherche et comme enjeu de santé publique – progresse sur l’agenda public, grâce à la mobilisation et au travail de différents groupes d'acteurs qui interagissent dans le domaine de la santé publique et la médecine. En partie à cause de sa nature interdisciplinaire, la littératie en santé a engendré un bon nombre de définitions, apportant avec elles des perspectives très différentes sur la littératie en santé et sur les systèmes de santé eux-mêmes. Plusieurs études ont mis l'accent sur le développement d'un consensus autour de la définition, de la conceptualisation et de la mesure de la littératie en santé, essayant de créer une notion qui soit commune à tous les acteurs. Toutefois, peu nombreuses sont les études qui discutent des différentes perspectives des groupes d’acteurs, de manière à mettre en évidence autant les éléments de consensus que les points de divergence. Explorer les différentes idées qui s’expriment sur le rôle du patient et celui des professionnels de la santé, sur la manière de concevoir l’autonomie et « l’empowerment » et sur le développement d’une action publique enrichit notre compréhension de la littératie en santé. L’expression de points de vue opposés sur la littératie en santé, particulièrement entre les États-Unis et l’Europe, et la manière dont ces points de vue soutiennent le débat scientifique permettent de saisir la complexité du développement de ce concept ainsi que certains conflits d’idées qu’il révèle.

Low health literacy is a public health crisis, currently, there is limited research on social worker engagement with the low health literate patient. The research questions for this study examined health literacy knowledge in medical social workers and how their MSW curricula built their knowledge of health literacy. It also explored challenges that arise when discharge planning for patients with low health literacy. It also asked what social workers can do to aid patients with limited health literacy during the discharge planning process. This basic qualitative research study used criterion sampling and was informed by the socioecological model. Data collection used 2 focus groups of 12 medical social workers comprised of 11 females and 1 male. Data analysis occurred by categorizing the data then classifying the data into themes based on the research question. Key findings include: (a) social workers have a medium to high level of health literacy; (b) MSW curricula would benefit from health literacy knowledge; and (c) challenges occur in discharge planning with people with low health literacy that include overall knowledge and attitudes of health literacy, sociodemographic variables, and lack of preventative health. Recommendations include standardizing healthcare social worker roles and providing educational opportunities in MSW curricula on health literacy. Implications for social change include improved health outcomes, empowering individuals to take personal responsibility for their healthcare which in the long run can help them overcome chronic disease and other health related anomalies. Social change may be seen with hospital health literacy screening to reduce hospital readmissions decreasing individual healthcare costs and reduce societal healthcare costs.

BACKGROUND: Obesity is an understudied, but important issue for Chinese-American children. While overall rates of child obesity among Chinese-Americans are lower than in other racial/ethnic minority populations, about 1 in 4 low-income school-aged Chinese-American children are classified as overweight or obese, with the prevalence among male children as high as 40%. Despite the need to address obesity prevention, especially among younger, pre-school-aged Chinese-American children, strategies to prevent obesity early in life have not been well-studied for this population. OBJECTIVE: To examine activity and screen time related behaviors in a low-income Chinese-American population, before and after implementation of an early childhood obesity prevention intervention (Greenlight) in a primary care setting serving predominantly low income families. METHODS: This was a pre-, post-intervention analysis of physical activity- and screen time- related outcomes associated with the implementation of the Greenlight intervention, a health literacy-informed early child obesity prevention program, which was culturally adapted for low-income Chinese-Americans, and implemented in a federally qualified health center in New York City’s Chinatown. Greenlight consists of: 1) low literacy handouts and “tangible tools” (e.g. portion size bowls) given at each well-child check (WCC), 2) physician communication training (e.g. use of written handouts to support verbal counseling, teach-back, goal-setting), and 3) 1:1 health educator encounters in waiting room. Pre-implementation parent-child dyads were consecutively enrolled at their 6- or 12-month well-child check (WCC) (n=70 and n=74 respectively). The cohort of post-implementation parent-child dyads was consecutively enrolled between 0-3 months of age (n=200) and followed at their 6-month (n=159) and 12-month (n=146) WCCs. Inclusion criteria for the dyads included: parent spoke Cantonese, Mandarin or English; parent/child of Chinese descent; and child born full term (≥37 weeks gestation). Primary outcome variables were: 1) meeting physical activity recommendations (>30 minutes of tummy time at 6 months of age; >60 minutes of active time (crawling, scooting, active play) at 12 months of age; based on American Academy of Pediatrics (AAP) recommendations), 2) meeting screen time recommendations (0 minutes of screen time, based on AAP recommendations at 6 and 12 months of age). Multiple logistic regression analysis was performed, adjusting for child age, child gender, use of out of home daycare, parent age, primary language at home, and education. RESULTS: Six-month olds in the post-implementation period had a 5-fold increased odds of meeting the physical activity recommendation compared to pre-implementation (pre vs. post: 30.3 vs. 63.0%, p<0.001; AOR=5.0[2.5-10.1]. Twelve-month olds in the post-Greenlight implementation period had a nearly 20-fold increased odds of meeting the physical activity recommendation compared to pre-implementation (pre vs. post: 76.5 vs. 98.6%, p<0.001; AOR=19.4 [4.1-91.7]). Overall, screen time minutes were low in the pre- and post-implementation periods, with median television screen time <5 minutes at 6 months and <10-15 minutes at 12 months. There were no statistically significant differences by pre- vs. post-implementation status related to meeting the AAPs screen time recommendation of no screen time, in both unadjusted and adjusted analyses. CONCLUSION: At 6 and 12 months, implementation of Greenlight was associated with parent ability to meet physical activity-related recommendations. Overall use of screen time was low, and no differences were seen in parent ability to meet screen time recommendations. Further study is needed to identify additional strategies to address screen time use in infants.

The U.S. health care system is evolving from medical centric to patient centered, augmenting the importance for patients to comprehend and process medical information. The Department of Education indicated that 77 million Americans have a basic or below basic health literacy proficiency and 12% register as health literacy proficient. Animation is a time-tested device for improving health by enhancing comprehension. Chronic constipation (CC) complexity entails physiological, anatomical, and environmental mechanisms. Using the cognitive theory of multimedia learning and dual-channel auditory and visual processing, the primary research question addressed whether an animated educational video improved health literacy for CC more than a traditional written educational pamphlet. A secondary dataset of 100 CC subjects from the University of Michigan was collected using a cross-sectional study design with a convenience sampling strategy of CC patients who underwent anorectal functional testing. Dependent variables were CC Pretest Quiz and CC Posttest Quiz scores, and independent variables included CC education intervention, demographics, health literacy proficiency, and environmental learning variables. Descriptive and analytical statistical methods were employed for data summarization and comparison. The animated educational video had minimal impact (p = 0.20) on improving health literacy; however, pretest scores (p -?¤ 0.001), age (p = 0.03) and highest level of education achievement (p = 0.03) influenced the largest variance between quiz scores. Enhancing health literacy influences social change by empowering individuals with CC to improve quality of life metrics, increase work productivity, and decrease health care utilization costs.

This body of work aspires to explore the avenues by which medical professionals can leverage adolescents' current and historic high social media usage to increase their health literacy. In order to accomplish this, several types of health literacy and the ethical implications of inadequate health literacy are discussed, specifically with adolescents in mind. Next, trends in media and social media usage by adolescents and its effects on this population are determined, and examples of interventions using these means in the literature are analyzed. Finally, the work discusses my personal experience using social media to disseminate health information, challenges our collaborative faces, and future directions for our project. / Urban Bioethics