Assessing parents, youth athletes and coaches subjective health literacy: A cross-sectional study

Objectives: The aim was to describe levels of subjective Health Literacy (HL)


Practical implications
• Having adequate levels of context-specific HL is important as it has the potential to influence individual's health behaviours and the use of various initiatives.Adequate levels were reported by only about half of the mentors and a third of the youth athletes.
• Low levels of HL can affect the participants ability to use health information in practise.
This implies that a relatively large proportion of the mentors and youth athletes may not fully understand health advice given or the possible consequences of not participating in e.g.established programs for preventive activities.
• More than 90 % of the mentors believed that it was possible to prevent injuries, but only half of the mentors stated that they had a good knowledge of various injury prevention strategies.This indicates that there are possible shortcomings in both the translation and implementation of specific health-related knowledge in the sport.These are areas that need to be reviewed in order to make existing knowledge understandable and accessible to participants.

Introduction
Sport is proposed as an arena for establishment of a healthy lifestyle that persists in adulthood. 1However, this proposal contrasts with research among youth elite athletes who try to reach the highest level in their sport while navigating between risks of injury, illness, and abuse. 2 Thus, safeguarding the health of young athletes extends beyond musculoskeletal injuries, and the complexity of this task has recently been emphasized. 3Over the past decade, progress has been made in the area of health protection in sports, 4 at the same time, the challenges of implementing the corresponding intervention programmes into real-world environments have been addressed. 5In order to achieve successful implementation in sport it is emphasized that the reasons for key-end users adherence or non-adherence with introduced measures are identified. 6alth literacy (HL) is an important topic in public health.The World Health Organization defines HL as a person's ability to understand, evaluate and use health information to promote health. 7Literacy is content and context specific, e.g.media, Information Technology (IT) and HL, and is also related to age and stage in life.A person might be highly literate in one area, e.g.IT, but still have limited understanding in how to apply health information in a specific health context.Today, there are more than 100 tools for measuring an individual's HL, most of them available in English, to explore different areas such as nutrition, diabetes, cancer, concussion and drugs. 8Health literacy is separated into 3 health domains: health care, disease prevention and health promotion. 9The concept can be further divided into functional, communicative and critical literacy. 7,9For functional HL, facts are communicated via oneway communication from information material.Communicative HL is based on collaboration and dialogue that strive for independence.This is done through the development of personal abilities that enable the individual to use knowledge independently.Critical HL refers to being able to relate critically to the knowledge in addition to being able to apply knowledge.
The different HLs are usually graded on the basis of three levels; high, moderate or low, or equivalent.
Health literacy is referred to as being an asset that can be enhanced and thereby can support the individual's empowerment in disease prevention and health decision making. 10Having sufficient levels of HL is emphasized as important both for adults and adolescents. 10,11,12udies examining relationships between HL and various health outcomes in adults and in the general youth population have identified association with low HL and unfavourable health outcomes, e.g.chronic illness, smoking and obesity. 10,13,14Moreover, low levels of HL are also associated with difficulty following instructions for self-care, reduced ability to use and act on health information, lack of engagement with caregivers and poorer use of preventive health care services. 7,13 ven in sports, it can therefore be important that the participants have sufficient levels of HL as it can consequently affect how they act in accordance with proposed protocols. 13For example, a study examining parents' own perceived knowledge of sports concussion displayed that most respondents had knowledge of concussion symptoms but were not familiar with concussion protocols and lacked knowledge of actions to take following an incident. 15mited research has been conducted in sport describing the participants levels of healthrelated competencies. 15,16 o enable sustainable health protection in sport communities it is important to recognize the individual athlete's immediate developmental environment that have a pronounced impact on her/his health, regardless of age. 17,18 he aim of this study was to describe levels of subjective HL, and to examine possible differences in prevalence proportions between sexes, age groups and level of educations among youth athletes and their mentors (coaches, parents/caregivers) in Swedish Athletics.

Methods
This study used a cross-sectional design including youth athletics athletes aged 12-15 years and their mentors.Ethical approval for the study was obtained from the Ethical Committee in Linköping (Dnr 2017/175-31) and is reported according to the Strengthening the Reporting of Observational studies in Epidemiology guidelines for cross-sectional research. 19The study was also registered at ClinicalTrials.gov(NCT03459313).The research is a part of the KLUB project addressing health promotion in youth athletics. 20e recruitment of the participants was organized in collaboration with Swedish Athletics.
To be eligible for the study, the youth athlete had to be member of a club affiliated to Swedish Athletics.The mentors were recruited through their involvement with the youth athlete.Clubs that had participated in an earlier study in the KLUB project were contacted during the spring of 2017 via e-mail and telephone by the primary researcher (JJ) who informed about the upcoming part of the project.In addition, JJ visited these clubs (n=10) during autumn 2017 and gave a presentation for coaches and parents/caregivers about the planned study.The primary researcher also visited the Swedish Athletics coach educational programmes for children aged 12-16 years that were arranged in the various districts in Sweden during autumn 2017 with the aim of reaching additional clubs that might be interested in participating.E-mail addresses for mentors were made available from 21 clubs with a geographical spread throughout Sweden.An invitation, with two reminders, with information about the KLUB research project was sent to mentors and youth athletes in March 2018; 165 youth athletes, 118 of the parents/caregivers and 58 coaches consented to participate in the project.
For data collection, a web-survey system was used (Briteback AB, Linköping, Sweden; www.briteback.com).The questionnaire collected data from parents and coaches, including demographic data, e.g.gender, age, country of birth, level of education, coach experience, attending coach programmes and subjective HL.Youth athlete-specific questions included demographic data on gender, age, country of birth, number of sports they participated in and subjective HL.
The Swedish Communicative and Critical Health Literacy (S-CCHL) instrument was chosen for examination of HL among mentors, because it is designed to evaluate health promotions efforts. 21Each item is rated on a 5-point scale, ranging from 1 (strongly disagree) to 5 (strongly agree).Items 1-3 measure communicative HL and items 4 and 5 measure critical HL.The results of the S-CCHL-instrument are presented in 2 ways.First, according to Ishikawa et al. 22 each question is summed and the mean is reported.Second, according to Wångdahl et al., 20 the scores are summed and 3 cut-off levels are used for interpretation of the CCHL level: insufficient (≥1000), problematic (≥100 to <1000), and sufficient (<100).In addition, 5 questions used by Turner et al. 16 (Turner-HL) in a study examining parents concussion literacy were included.These questions aim to assess participants' sports-injury and return-to -play literacy for youth sports.The questions were slightly modified to fit the context of athletics and translated into Swedish using a back-translation method.Each item was rated on a 7-point scale, ranging from 1 (extremely impossible/inadequate) to 7 (extremely possible/good).
The Health Literacy for School-Aged Children (HLSAC) instrument was used for youth athletes. 23This instrument includes 10 questions covering 5 items: theoretical knowledge (questions 1 and 5), practical knowledge (questions 4 and 7), critical thinking (questions 3 and 9), self-awareness (questions 8 and 10) and citizenship (questions 2 and 6).Each question was rated on a 4-point scale ranging from 1 (not at all true) to 4 (absolutely true).The HLSAC instrument was translated from English to Swedish and was validated using a back-translation method for validation.In addition, the original Finnish instrument was reviewed by 2 native Finnish speakers who verified that the back-translated Swedish version corresponded to the original Finnish version.Response options 1 and 2 were collapsed for the analysis as described by Paakkari et al. 23 The responses were scored, summed (range 10-40) and divided into the following levels of HL: low (score 10-25), moderate (score 26-35) and high (score 36-40).

Statistical analysis
Initially, the frequencies and the percentages of the categorical variables and the mean values and standard deviations of the continuous variables used in the study were calculated.
The percentage distribution of the response alternatives was displayed for all questions included in the S-CCHL (divided into parents/caregivers and coaches), the Turner-HL (divided into parents/caregivers and coaches) and the HLSAC (for youth athletes).
Furthermore, frequencies and percentages per category for sex (female/male), age group (<50 years/≥50 years for parents/caregivers and coaches; 12-13 years/14-16 years for youth athletes) and education level (elementary school or high school/Bachelor's degree/Master's or Doctoral degree) were obtained for each level of S-CCHL for parents/caregivers and coaches, and for each level of HLSAC for youth athletes (education not available/applicable for youth athletes).Comparisons of S-CCHL, for parents/caregivers and coaches separately, were performed between sex and between age groups using Mann-Whitney U tests and between different levels of highest education using Kruskal-Wallis one-way ANOVA.Comparisons of HLSAC for youth athletes were performed between sex and between age groups using Mann-Whitney U tests.
The Statistical Package for the Social Sciences (SPSS) for Windows version 26.0 was used for the analyses.All statistical tests were two-sided and outcomes with p < 0.05 were considered to be statistically significant.

Results
One hundred and forty-three youth athletes (87%), 107 (91%) parents/caregivers and 52 (90%) coaches completed the cross-sectional survey (Table 1).Females accounted for 186 (62%) of all respondents, and 289 (96%) of the participants were born in a Nordic country, mainly in Sweden.Of the mentors 46 (29%) reported high school as the highest education level and 109 (69%) reported having a degree from university.One hundred and twenty-eight (81%) of the mentors reported having a background as a former athlete.Thirty (58%) of the coaches had been a coach for 1-5 years and 44 (85%) had participated in coach training programmes.
With regard to HL of mentors, the mean score on the S-CCHL scale was 4.0 for parents/caregivers and 3.8 for coaches on a 5-point scale (Table 2).The categorization into 3 levels showed that a sufficient level was reported by 66 (62%) of the parents/caregivers and 23 (44%) of the coaches; 33 (31%) of the parents/caregivers and 26 (50%) of the coaches had a problematic level; the remaining 8 parents/caregivers (7%) and 3 coaches (6%) had an insufficient level of CCHL (Table 2).Comparison of CCHL for sex, age groups and level of educations showed no significant difference for mentors (Table 2).
For the specific questions in the S-CCHL instrument, reported at least 69% of the mentors a high communicative HL (questions 1-3) and at least 66% of the mentors a high critical HL (questions 4 and 5) (Fig. 1A, B).
For the Turner-HL questions, most of the mentors, 98 (92%) of the parents/caregivers and 50 (96%) of the coaches, stated that they believed that it is quite possible or very possible to prevent injuries related to athletics (Fig. 2A, B).Forty-seven (44%) of the parents/caregivers and 32 (61%) of the coaches said they perceived they have a very good or extremely good knowledge about how to prevent injuries.Eighty-three of the parents/caregivers (78%) trusted coach's knowledge on when to return to athletics after an injury.Fifty-five (51%) of the parents/caregivers and 21 (41%) of the coaches stated that they perceived having a very good or extremely good knowledge of return to sport criteria.
With regard to the HL of the youth athletes, the overall mean score for youth athletes' HL was 32.4.No statistically significant differences were found between sex or age groups.The HL of youth athletes was categorized into 3 levels.Forty (28%) had a high level, 92 (64%) had a moderate level and 11 (8%) had a low level of HL (Table 3).
Health literacy relating to critical thinking was low, with 34 (24%) and 24 (17%) youth responding to have high HL in question 3 and 9 respectively.

Discussion
Health literacy is an under-researched topic in sport and the most significant finding of this study was that only half of the mentors had a sufficient level of HL.In general adult and youth populations few studies have explored CCHL, none of them in Sweden.In a study in Japan of a general adult population, the mean CCHL score was 3.6, which is lower than the mean of 3.9 among mentors in this study. 24A study at the European Union level on multidimensional HL showed that inadequate levels of HL varied between 2% and 27 % by country. 25In our study, about half of the mentors stated a sufficient level of CCHL, the remaining mentors thus had what is defined as a problematic or insufficient CCHL.Low levels of HL can affect the mentor's ability to use health information in practise.For instance, lack of HL is associated with underutilization of preventive services such as participation in vaccination and screening programs. 12,13In a sporting context, mentors (and athletes) may not fully apprehend the possible consequences of not participating in established injury prevention programs or anti-doping activities.Only about 4 out of 10 coaches in our study expressed having good or very good knowledge about return to sport criteria after injury, this somewhat surprising as 85% of them had undergone coach education programmes/courses.This observation signals, similar to that observed by Turner et al, 15 and Perera and Hägglund, 26 that there may be shortcomings in both the translation and the implementation of specific health-related knowledge in sports, which in turn may unintentionally affect the youth athlete's health and ability to perform.
For the youth athletes we used an instrument that examines various HL items including e.g.theoretical and practical knowledge as well as critical thinking. 23Critical health literacy is specifically considered to be the core dimension of HL incorporating the skills that are important for successful self-management. 7,10,22A Finnish study, using the same instrument as in this study, showed that about 41% of sport club members reported a high HL in comparison with non-members 32%. 16In our study, we found that about 3 of 10 youth athletes perceived having a high HL, which is slightly lower than in the Finnish study for nonsport club members.It is noteworthy that the item in the present study where about 2 out of 10 youth athletes perceived having a limited HL was on the questions examining critical thinking.Having sufficient critical literacy includes the ability to evaluate if health information is accurate and to use the information to solve problems. 9Lack of understanding of the significance of instructions regarding e.g.Anti-doping, injuries and illness prevention can affect the athlete's future compliance with developed programs.Moreover, as young people get older they also prepare for the transition to adult life and a greater independence.
This includes e.g.planning for future needs such as education, employment and health care.
For the youth athlete, this means also preparing for a possible future career as an elite athlete.
The significant association between HL and health behaviours of young people, 7 should also apply to the context of youth sports.Improving youth athletes HL can support longevity in sport as these skills may, among other things, affect future health-related behaviours and how the athletes manage to navigate complex health-care systems. 11,12Furthermore, assessment of youth athletes HL provides an opportunity to follow how HL develops over time. 7e relationship between HL and health is complex, interventions that account for and address the HL needs of the targeted population may improve outcomes of various prevention initiatives. 7,12In communities, approaches that are suggested to support CCHL include collaborative learning, where individuals interact and exchange health knowledge with other members of the community, and social support. 27Such methods could have the potential to empower members of a sport community to make better informed health decisions that support the needs expressed by elite athletes. 28A first step in facilitating knowledge translation and improving HL is to make knowledge accessible and the information provided should address the targeted users. 29,30 our knowledge this is the first study that has examined HL within an organized sport, and a number of potential limitations should be acknowledged when interpreting the results of the study.Conducting research in smaller individual sports encounters various challenges, one is to reach and recruit participants.The main limitation in this study is a relatively small sample size and the results obtained can therefore not be immediately generalised to youth athletics populations.The participants were invited to the study and chose whether they wanted to participate or not, which could indicate that a selection bias may be present in the study.In addition, sports in Sweden tend to recruit families with higher socioeconomic status, and thus, both the recruitment and the results might be explained by differences in the health and living habits among socioeconomic groups (i.e. a bias in the study population).The results of this study may therefore be context specific and must be treated with caution if applied to other age groups, sports and cultural settings other than Sweden and Scandinavia.
Despite these limitations, this study provides one of the first accounts of mentors and youth athletes perceived HL.Nevertheless, further research is needed to validate the results of this study.

Conclusions
The level of health literacy was low with half of the mentors and one out of three youth athletes having adequate HL levels.Only half of the mentors had good knowledge of various injury prevention strategies.Improved HL skills in both mentors and youth athletes may enhance an individual's ability and motivation to apply health information in practice.Our findings emphasise the need to place a greater focus and investment in health promotion and injury prevention strategies.Also, more work is needed to understand the facilitators and barriers for implementation of these interventions.

Fig. 1 .
Fig. 1.Percentage distribution displayed per question of the S-CCHL for (A)

Fig. 2 .
Fig. 2. Percentage distribution displayed per question of Turner-HL for (A) parents/caregivers
How familiar are you with the procedures when your child can return to track and field following an injury?1.To what extent do you think it is possible to prevent injuries related to track and field?2.Your knowledge of preventing injuries related to track and field?