The constructs of health literacy in children: a systematic review.

BACKGROUND: Health literacy encompasses competencies enabling individuals to access, comprehend, evaluate, and use health information effectively. While research emphasizes its importance during childhood, limited consensus exists on health literacy conceptualization for children aged 9-12 years-a critical developmental period characterized by concrete operational thinking. This systematic review aimed to identify and synthesize key components of health literacy frameworks specifically used for children in this age group. METHODS: A systematic review was conducted in 2024 following PRISMA 2020 guidelines and registered in PROSPERO (CRD42024588355). Six databases (PubMed, Scopus, Web of Science, ProQuest, Google Scholar, and ScienceOpen) were searched without temporal restrictions using terms related to "health literacy" and "children." Studies were included if they detailed health literacy conceptualization for children aged 9-12 years, were peer-reviewed English publications with accessible full-text, and demonstrated high methodological quality. Hybrid deductive-inductive thematic analysis was applied using Nutbeam's framework as theoretical foundation. RESULTS: From 11,586 initial records, 18 studies met inclusion criteria representing diverse geographic contexts (66.7% Western, 33.3% Eastern) and methodological approaches (35% qualitative, 24% quantitative, 41% mixed-methods). Four overarching themes emerged: [1] Skills (functional, interactive, and critical literacy competencies); [2] Teaching-learning processes (pedagogy, educator-learner dynamics, content delivery, learning environments, and assessment methods); [3] Contextual factors (socioeconomic, cultural, and demographic influences); and [4] Individual factors (psychological traits and cognitive abilities). While Nutbeam's tripartite model was referenced in 77% of studies, it required substantial adaptation for pediatric populations. Teaching-learning processes emerged as a novel dimension in 50% of studies, highlighting pedagogical approaches absent from adult-focused frameworks. CONCLUSIONS: Health literacy in children aged 9-12 years extends beyond adult-centric models to encompass distinct developmental and educational dimensions. Teaching-learning processes emerged as a foundational component, emphasizing schools as critical platforms for health literacy development. Our findings support developing child-centered frameworks integrating cognitive development theory, educational pedagogy, and socio-ecological perspectives. Future research should focus on longitudinal studies, culturally responsive interventions, and child-specific assessment tools. This framework provides evidence-based guidance for developing age-appropriate health literacy interventions and assessment tools.