**3. Health and health literacy**

Health, a complex and multi-dimensional concept is built on behaviors that usually do not occur in a vacuum; and an array of variables influences one's health. There is no single consensus on the definition [22–24]. Establishing good health requires knowledge, skills, capacity, and resources at both the individual and community levels to support all the dimensions of health (physical, mental, social, political, economic, and spiritual) and remove the barriers to good health [23, 25]. Social determinants of health, the context in which people live, impacts health status and health outcomes. These determinants include a) health literacy skills and access to health care, b) educational attainment, c) where people live and work, d) job status, food security, and housing security, and e) a well-resourced healthy living environment (e.g., access to transportation, air, and water quality, safe neighborhoods) [26, 27]. Educational status has proven to be a predictor of health outcomes in the US and internationally [3, 25, 28].

Health literacy is an often-ignored social determinant of health [21]. This complex phenomenon focuses on providing individuals with the knowledge and skills to access and understand health information and services needed to make health-enhancing decisions for themselves, their family, and their community. Similar definitions of health literacy have been developed that provide further visualization of this concept and keywords used to define this term include confidence, empowerment, skills, a resource, and understanding of health messages [29–32]. Common to all these definitions is the expectation that health literacy means more than having knowledge or understanding of health content, but also enacting a healthy lifestyle by acting on knowledge and skills.

These skills are developed over a lifetime and enable individuals to use information gained for making well-informed decisions that lower health risks and promote quality of life [33]. Health education focused on health literacy not only helps children and youth adopt and maintain healthy behaviors, but they also learn to become self-regulated learners, critical thinkers, problem solvers, productive citizens, and effective communicators [34]. Further, leading with health literacy, within the WSCC framework highlights the importance of environments that support health enhancing behaviors. Health education programs need to be developed within the context of the whole school environment. Across the world, the development of health literacy skills in students improves health outcomes, reduces health risks, and increases academic success [35] Health literacy skills enable learners to "know and do."

The US federal government Healthy People 2030, health objectives for the nation recently updated the definition of health literacy for individuals and organizations [36]. Health literacy is the degree to which individuals can find, understand, and use information and services to inform health-related decisions and actions for themselves and others. Organizational health literacy is the degree to which organizations equitably enable individuals to find, understand, and use information and services to inform health-related decisions and actions for themselves and others [37]. Acquisition of health literacy skills represents a shift away from health content

exclusively, to the development of skills to support healthy lifestyles inclusive of accessing scientifically accurate and developmentally appropriate health information.

Reading proficiency at the fourth-grade level is another Healthy People 2030 indicator. This measure underscores the importance of a literate population overall. Fourth grade reading proficiency includes the ability to comprehend and apply information. It is an important development point in the acquisition of literacy skills. Further children who struggle with fourth grade reading skills are more likely to struggle academically throughout their schooling. Youth who struggle academically are more likely to engage in risky behaviors. While, this relationship is not correlational, there is concordance across those domains [1].

The new definition of health literacy, emphasizing the use of health information from a public health perspective, is intended to prompt new ways of studying and promoting personal health literacy. It offers a focus on skills to help people move from an understanding of concepts and content to individual action and a focus on health within communities. Further quality school health education that emphasizes skills that teaches students how to learn about their health, how to use skills that have utility across various facets of life, and why these skills are important is foundational to health literacy [38]. Academic missions, structures, and systems need to align to support effective school health education versus as an add-on [39]. Health education is a distinct subject from physical education. Dual certification in both subjects requires sound preservice preparation in both disciplines. This needs to inform preservice programs in health education as well as state certification requirements [40]. Health education has also been identified by the US Department of Health and Human Services as a mechanism for building health literacy [21].
