Developing a pedagogy to support science for health literacy

The internet is the first place most students search for scientific information, and with the ever increasing volume and availability of web-based information on sites such as Wikipedia and discussion forums, it is vitally important that a scientifically literate citizen needs to be able to distinguish between science and pseudo-science, consider risks and benefits, and decide which sources of information to trust. There are numerous and diverse definitions of scientific literacy (for more comprehensive accounts see for example Bybee, 1997; Laugksch, 2000; Millar and Osborne, 1998; Millar, 2008). Although the proposed details vary, there is a general consensus that scientific literacy involves applying scientific understanding to real situations which call for evaluation and decision-making. The Organisation for Economic Co-operation and Development (OECD) Programme for International Student Assessment (PISA) defines scientific literacy as: “…the capacity to use scientific knowledge, to identify questions and to draw evidence-based conclusions in order to understand and help make decisions about the natural world and the changes made to it through human activity.” (OECD, 2003:133) Achieving this literacy involves development of an understanding of the complexity of scientific issues and the nature of science itself, concepts that have emerged as central in science curricula worldwide in recent years.

The World Health Organization defines health literacy as “the cognitive and social skills which determine the motivation and ability of individuals to gain access to, understand and use information in ways which promote and maintain good health” (Nutbeam, 1998: 357). Nutbeam (2000) makes distinctions between three types of health literacy: basic/functional literacy (reading and writing in relation to health), communicative/interactive literacy (cognitive, literacy and social skills to extract information, derive meaning and apply the information to changing circumstances), and critical literacy (skills to critically analyse information and use it to help control changing circumstances). Education for critical health literacy can lead to personal empowerment and autonomy in relation to health, and involves developing a ‘critical consciousness’ of the kind advocated by Friere (1970), supported by an individual’s orientation towards social and political action. This has the potential to facilitate individual or community action which may alter the social, economic and environmental determinants of health. This orientation reflects behavioural intention rather than an attitudinal response. Ajzen and Fishbein’s (1980) theory of reasoned action indicates that behaviour is a function of behavioural intentions rather than one of attitudes. Another important outcome of critical literacy is improved self-efficacy. Garcia and Mann (2003) tested several social-cognitive models for engaging people in health behaviours and found that models which included self-efficacy were better predictors of intentions to engage in positive health behaviours.

Scientific literacy is conceptually broader than health literacy in that it also connects with non-health related matters. Take for example, the question of where to site a new predator-free restricted access nature reserve for the conservation of endangered species. This would involve scientific, environmental, socioeconomic, cultural, and political components, but not necessarily an overriding health dimension. So it is possible to engage students in scientific literacy without necessarily considering health issues, but we argue that, at least from a normative post-positivist perspective, it is much more difficult, and indeed untenable, to disconnect health literacy from science. In discussing scientific literacy, Millar and Osborne (1998:25) recommend that students should develop “...the capability to assess the reliability and validity of evidence, to distinguish evidence from explanations, to identify obvious gaps in evidence or reasoning, and to appraise the level of confidence to be ascribed to any claims advanced.” We would contend that without this capability, students would be unable to navigate their way through health issues, and that health literacy is therefore dependent on scientific literacy. Furthermore, just as scientific literacy education should be for all students of all abilities, in addition to specialised scientific training for the minority who aspire to become scientists, we advocate a parallel approach for health literacy: it is for all young people growing up in our modern societies.

At this point adherents of scientific literacy might ask why we are making a distinction between scientific and health literacies; surely the latter is subsumed by the former. Whilst this may be a normative claim, the reality is quite different. Firstly, the two concepts lie in entirely separate bodies of literature. Health literacy definitions and documents tend to take a socio-political perspective and rarely make immediate or explicit connections with science or scientific literacy. Secondly, they assume completely separate niches and command different levels of status and attention within the school curriculum. What is currently lacking in the curriculum (and in our opinion quite tragically) is the glue that holds these two literacies together, which we are describing here as a pedagogy to support “science for health literacy”, i.e. a pedagogy for the science underpinning health literacy which acts as a vehicle for making the links explicit to students and ensuring that scientifically literate adolescents also become health literate.

The difficulties teaching science for health literacy

Many health issues can be considered socio-scientific issues (SSIs) in the sense that they that they have a basis in science and a potentially large impact on society (Ratcliffe and Grace, 2003). Sadler (2004, 2011) gives thorough reviews of research and teaching about SSIs, and Lee (2011) gives a useful overview of the nature of health and the relationship between SSI education and health contexts. Engaging in substantive discussion and decision-making about SSIs requires scientific literacy, and if these issues are health-related they also require health literacy. Over the past twenty years there has been a global move to include SSIs in science curricula (e.g. HKCDC, 2007; NRC, 1996; KMK, 2004; QCA, 2004, MoE, 1993, 2007).

At first sight, one might expect health issues to lend themselves perfectly as a context for teaching teenagers about SSIs - diseases and medical conditions can fascinate or frighten people, and teenagers are often preoccupied by (and sometimes obsessed with) health matters. Furthermore, we all have first-hand experience of health issues and can relate to them accordingly. They have attracted considerable media attention in recent years with the emergence of new contagions such as avian and swine influenza, resistance severe acute respiratory syndrome (SARS), and the burgeoning growth of NCDs such as diabetes, cardiovascular and lung diseases and certain forms of cancer.

However, as Lee (2011: 2) has pointed out “…health issues are not commonly dealt with in the SSI literature…”. So why this avoidance of health-related SSIs? Well actually there are a large number of reasons, most of which relate to the experiences, background education, and expectations of science teachers, such as:

priority given within the curriculum and national assessment systems to acquiring knowledge and understanding of concepts, rather than time for consideration of social and ethical issues;
some teachers’ perception that social issues should not be part of the science curriculum;
lack of teacher expertise or confidence in handling issues associated with large amounts of often incomplete information with no ‘correct’ answers;
lack of knowledge or expertise in teaching strategies to cope with controversial issues;
lack of teaching resources which appropriately render the latest advances in science to a level which is meaningful to school students;
philosophical and logistical barriers in achieving potentially advantageous cross-curricular collaboration;
concern that health issues might overtly or inadvertently relate directly to the lives of students in the class, which demands that the teacher employs additional skills of teaching about sensitive issues alongside potentially unreliable access to appropriate support services;
the logistical and time-consuming requirement to gain written consent from all the parents/carers of students in the class.

Engaging with SSIs is complex, involving forming opinions, making decisions at personal or societal level, critical analysis of media reports (from where most of our daily information emanates), evaluating knowledge claims, consideration of values, and ethical and moral reasoning (Fowler et al., 2009), and may require some understanding of probability and risk (Levinson et al., 2011; Rolfe, 2010) or even include humanistic perspectives (dos Santos, 2007). They are inherently based on incomplete or often conflicting information and a degree of subjectivity, and are frequently topical with a transient life and have no particular right solution. These are all inexact properties which understandably unsettle many science teachers who have been trained throughout their school and university lives to deal with, and therefore teach about, hard scientific ‘facts’, and this is also what many lay people (including politicians) expect them to teach. The constraints imposed by timetabling, compartmentalisation of subjects and organisational structures in secondary schools also makes it difficult for teachers to consider a cross-curricular approach. Hodson (2003) called for a socio-political science curriculum, training students to be both scientifically and politically literate citizens who have active critical engagement with the issues. Zeidler et al., (2005:359) argued that SSI education should “exploit the inherent pedagogical power of discourse, reasoned argumentation, explicit nature of science [NOS] considerations, emotive, developmental, cultural or epistemological connections within the issues themselves”. We fully endorse these approaches, but many (probably most) science teachers are not adequately trained or resourced to deliver it. Teachers have to contend with the uncertain, tentative, nature of science (explored thoroughly elsewhere, e.g. Lee, 2008; Abd-El-Khalick and Lederman, 2000; McComas & Olson, 1998), and this is further compounded by requiring an additional understanding of the nature of health and the complexity of the determinants of wellbeing (Dahlgren & Whitehead, 1991). This might involve taking a holistic, integrated view of biological, cognitive, affective, behavioural and social considerations, as suggested by Engel’s influential biopsychosocial model (Engel, 1977), which has been used and adapted in many psychology and medical research studies ever since (Armitage and Connor, 2000).

From the demanding breadth of knowledge and skills required of teachers to deliver the kind of curriculum described above, it is easy to see why science teachers might prefer to avoid teaching about health-related SSIs. These teaching strategies can seem alien to them and are perhaps more familiar to humanities teachers, which itself raises another problem: who teaches health education? However, the potential of these contexts for exploration of the nature and application of science is far too rich to overlook. Curricula across the world obviously vary considerably, but we briefly look at examples here from two contrasting national settings, our own countries of England and New Zealand. In both places, the nature of science takes a central role in science curricula with the potential for core concepts relevant to understanding of health issues to be explored. The devolved nature of the New Zealand curriculum offers the challenge to schools to identify and engage in learning that is of specific relevance to their community. Indications are that proposed changes to the English Curriculum (2013) will also lead to this level of community autonomy. In England, health education is mostly taught within a non-statutory subject called Personal, Social, Health and Economic Education (PSHE) for Years 1-11 / Grades K-10 and is usually taught by non-science teachers, so the underpinning science is under-represented. This may give outsiders the false impression that health science literacy is alive and well. In New Zealand Health and Physical Education are combined as one subject in the curriculum (compulsory from Years 1-10 / Grades K-9, commonly included Year 11-13 / Grades 10-12), taught in the most part by Physical Education specialists who have training in health, but not necessarily science. Connection between the health and science programmes in schools is not commonly well developed. A strong emphasis in the New Zealand Curriculum on key competencies that students need to “live, learn, work and contribute as active members of their community” (MoE 2007:12). These competencies support the development of relevant key behaviours and attitudes such as critical decision making, resilience, engagement with society and an understanding of self.