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Influence of Health Literacy on Health Promoting Behaviour of Adolescents

with and without Obesity

Kehinde O. Adewole, Adesola A. Ogunfowokan, Monday Olodu

PII: S2214-1391(21)00065-2
DOI: https://doi.org/10.1016/j.ijans.2021.100342
Reference: IJANS 100342

To appear in: International Journal of Africa Nursing Sciences

Received Date: 26 October 2020

Revised Date: 23 July 2021
Accepted Date: 24 July 2021

Please cite this article as: K.O. Adewole, A.A. Ogunfowokan, M. Olodu, Influence of Health Literacy on Health
Promoting Behaviour of Adolescents with and without Obesity, International Journal of Africa Nursing Sciences
(2021), doi: https://doi.org/10.1016/j.ijans.2021.100342

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Influence of Health Literacy on Health Promoting Behaviour of Adolescents with and

without Obesity

1. Kehinde O. Adewole, RN, M.Sc.1

2. Adesola A. Ogunfowokan, FWACN, RN, PhD2

3. Monday Olodu, RD, M.Sc.3 (Public Health Nutrition)
1Clinical Nursing Unit
Obafemi Awolowo University Teaching Hospitals Complex
Ile-Ife, Osun State,
Nigeria.
E-mail: Kumuyi70@gmail.com
2Department of Nursing Science
College of Health Sciences
Obafemi Awolowo University
Ile-Ife, Osun State,
Nigeria.
E-mail: solafowokan@oauife.edu.ng
Twitter handle: solafowokan1
3 Department of Community Health
Faculty of Clinical Sciences
Obafemi Awolowo University
Ile-Ife, Nigeria
E-mail: mondayolodu@gmail.com

Correspondence:
Kehinde O. Adewole, M.Sc.
Clinical Nursing Unit
Obafemi Awolowo University Teaching Hospitals Complex
Ile-Ife, Osun State,
Nigeria.
E-mail: Kumuyi70@gmail.com

1
Influence of Health Literacy on Health-Promoting Behaviour among Adolescents with and

without Obesity: Mixed Method Study

Introduction
Health literacy and health promotion are variables that promote good health outcomes and assure
positive developmental trajectory for adolescents. As adolescents move towards young adulthood,
they start making independent health decisions and determine many things about their health. The
cognitive ability and skills that are required to take good care of their health and make important
decisions are developed during this period (World Health Organisation [WHO], 2020; National
Institute of Correction, 2020). However, adolescents do not have adequate understanding and lack
the expertise needed to maintain good health, but having good health literacy skills is important to
the acquisition of this knowledge and skills (Manganello, Devellis, Davis, & Sshotter-Thal, 2015).
Health literacy could be described as ‘the social and cognitive competencies which determine the
motivation and ability of an individual to approach, comprehend and use health-related services
and information to make correct health decisions which promote and maintain good health’(WHO,
2018a). More broadly, an individual can approach, comprehend and use health-related services
and information when managing one’s health environment (WHO, 2018b). Health literacy skills
can help adolescents recognise their health needs; process information about their health status and
understand where to go for support when necessary (Hagel, 2015). It also enables them to adopt
health-promoting behaviour early in life (Fleary, Joseph, & Pappagianopoulos, 2017). However,
studies have shown that health literacy is low generally among adolescents (Shabi &Oyewusi,
2017; Ye, Yang, Gao, Chen &Xu, 2014). While adolescents may be keen to obtain information
about their health, it may be difficult for them to understand such information due to their low
level of health literacy (Manganello et al., 2015).
Furthermore, health-promoting behaviour, which involves activities motivated by a desire to
protect or promote fitness and comfort, is considered as the cheapest method to control and avert
morbidity and mortality among adolescents (Chasse, 2017). Literature have reported that about
60% of an individual’s health and quality of life depends on their lifestyle and health behaviour
(Farhud,2015).The health-promoting activities include participating in regular physical activity,
consuming an adequate diet, keeping physically fit, refraining from substance use, sleeping well
and using preventative health and dental care (South Australia Health, 2020). In addition, eating
habit is established as the most important of all the health-promoting behaviour (Holmberg,
Larsson, Korp, Lindgren, Froberg,et al., 2018).
According to Ndumele et al., (2016), health-promoting behaviour have been shown to correlate
with optimal health and to prevent conditions such as cardiovascular disease (CVD), hypertension,
diabetes, stroke and accumulation of excessive body weight among adolescents. However,
previous researchers reported that health-promoting behaviour among adolescents globally are
very poor (Musavian, Pasha, Rahebi, Ghanbari, & Roushan, 2014; WHO, 2018b). Nigerian studies
also indicate poor health-promoting activities among adolescents (Onyebuchi, 2015).

2
Furthermore, it is observed that adolescents generally engage in hazardous health behaviour more
than they engage in health-promoting behaviour (El Achhab, El Ammari, El Kazdouh, Najdi,
Barraho, et al., 2016). Poor eating habits and a lack of physical activity rank high among the factors
that predispose adolescents to the problem of overweight and obesity (Sedibe, Pisa, Feeley, Pedro,
Kahnb, & Norris, 2018; Ssewanyana, Abubakar, van Baar, Mawangala, & Newton, 2018).
Adolescents try to control their weight by skipping meals; however, those who skip meals have
been found to have a higher tendency of becoming obese (Okada, Tabuchi, & Iso, 2018).
Moreover, a sudden increase in physical and psychological growth has made adolescents to be
nutritionally vulnerable with unhealthy eating behaviour. Some adolescents are malnourished
predisposing them to diseases and untimely death. On the other hand, overweight and obesity are
other types of nutritional problems with serious health consequences (Christian, & Smith, 2018).
Overweight and obesity have become an epidemic among adolescents in both lower and higher
income countries because obesity can affect adolescents’ immediate health, educational attainment
and quality of life (WHO, 2018a). Globally, over 170 million children who are less than 18 years
of age are reported to be overweight (WHO, 2018b), while one in five children who are 6 -19years
old in the USA is obese (CDC,2018). Toriola, Ajayi-Vicent, Oyeniyi, Akindutire, Adeagbo, et al.,
(2017) also reported the prevalence of obesity among adolescents in Nigeria to be 1.1%.
Though obesity statistics from Nigeria do not pose a serious health concern to the adolescent
population, it is, however, becoming an issue of concern among the children of the affluent. This
is evidenced by the fact that obese children are hardly seen in the public schools but are found
mainly in private schools where the children of the affluent are found (Adetunji, Adeniran, Olomu,
Odike, Ewah-Odiase, et al., 2019). Obesity is a significant cause of many disease conditions and
it also increases the risk of psychological distress among adolescents. These are reflected in
negative body image perceptions, lowered self-esteem and development of psychopathology such
as eating disorders, substance abuse, sexual risk, truancy and gangsterism (Toriola et al, 2017).
As adolescents adopt the western culture in Nigeria, the occurrence of obesity is expected to
increase with many negative outcomes to their health generally. There have been a lot of physical
and mental health consequences for obesity which are closely related to health-promoting
behaviour. It is of utmost importance to equip adolescents with a good level of health literacy
which is a precursor of good health-promoting behaviour. While health literacy is very important
for good quality of life in adolescents, generally, it is found to be more important for those with
chronic health conditions such as obesity. Interventions or activities that prevent overweight and
obesity in the population of adolescents can save their lives and make them productive adults later
in life. Therefore, it is important to assess the level of health literacy, identify health-promoting
behaviour, and determine the influence of health literacy on health-promoting behaviour among
adolescents with and without obesity.

3
Material and Method

Study Design

The study adopted a concurrent mixed-method design (QUAN-QUAL) and was conducted

among adolescents aged10 -19years in15 private secondary schools in Osun State, Nigeria.

Mixed method was used in this study so that qualitative data could be used to buttress

quantitative data and to also reflect the participants’ points of view as they relate to the study

setting.

Sampling

A multi-stage sampling technique was employed in the selection of participants for this study.

Three Local Government Areas (LGAs) from each of the three Senatorial Districts in Osun

State were randomly selected followed by a purposive sampling technique of five private

secondary schools from each of the LGAs. Selection of the adolescents based on their body

weight was done to recruit the adolescents into the study. Those who agreed to participate in

the study had their weight and height measured to determine their BMI (ratio of weight to

height) based on WHO standard. Participants’ heights were measured using Stadiometer (a

medical equipment used for measuring human height usually constructed out of a ruler and a

sliding horizontal headpiece which is adjusted to rest on the top of the head), while their

weights were measured using a weighing scale (CAMRY J1007878903). In accordance with

WHO standard, those with a BMI greater than or equal to 30kg/m2 were taken as adolescents

with obesity while those with a BMI less than 30kg/m2 were taken as adolescents without

obesity (WHO, 2021).

4
A total of 300 adolescents were recruited with equal numbers for those with obesity (150) and

those without obesity (150) from the study schools. The number of obese adolescents selected

from each school determined the number of non-obese adolescents selected from the school

because of variation in the population of obese adolescents in each of the selected schools. In

addition, one adolescent with obesity and one without obesity were elected randomly from the

adolescents that were recruited for the study in each of the 15 schools, thereby, giving a total

of 30 adolescents who participated in the qualitative data collection. During the interview,

saturation of data was achieved by the time the 20th adolescent was interviewed. To ensure

trustworthiness of the data, information given by the adolescents were cross-checked and

clarified with the adolescents at the end of each interview.

Pilot Study

A pilot study was conducted in Ife East LGA using one private and one public secondary school

because this study was initially intended to be done in both private and public secondary

schools. The result of the pilot study showed that adolescents with obesity were hardly seen in

public schools which also confirmed the report of Adetunji et al.(2019). The adolescents

categorised as obese in the public school used for pilot study were only overweight according

to WHO standard. Therefore, the study was delimited to private secondary schools where

adolescents with obesity could be found. Cronbach’s Alpha for All Aspect of Health Literacy

Scale (AAHLS) was found to be 0.705 and 0.930 for Adolescents Health Promoting Scale

(AHPS), while the internal consistency was found to be 0.854. The pilot study result further

showed that the empirical sub-scale on the AAHLS did not directly relate to adolescent’s stage;

therefore, the sub-scale was removed from the AAHLS

5
Instruments

The instruments used for data collection were a structured self-administered questionnaire and

an interview guide (in-depth). The questionnaire consisted of three sections: Section one

elicited information on the adolescent’s socio-demographic profile. Section two collected

information on health literacy level using the ‘All Aspects of Health Literacy Scale’ (AAHLS)

developed by Chinn and McCarthy (2012). The AAHL is a 3-point Likert scale of ‘Rarely’ (1),

‘Sometimes’ (2), and ‘Often’ (3) and 3 sub-scales of Functional, Communication, and Critical

literacy were used. The three sub-subscales consisted of 13 questions with 39 as the maximum

obtainable score. Using a mean score of 20, 0 -19.99 was rated as poor health literacy while a

score of 20 -39 was rated as good health literacy.

Section three assessed information on health-promoting behaviour using the ‘Adolescent

Health Promoting Scale’ (AHPS) developed by Chen, Wang, Yang and Liou (2003) with the

sub-scales of nutritional, social support, health responsibility, appreciation, physical activity

and stress management. The AHPS is a 5-point Likert scale indicating Never(1), Seldom(2),

Quite often(3), Very often(4) and Always(5). It consists of 40 questions with 200 as maximum

obtainable score. Using a mean score of 130, 0-129.9 was rated as poor health-promoting

behaviour while 130—200 was rated as good health-promoting behaviour. The interview guide

comprised questions that explored the adolescents’ sources of health information and activities

they carried out to promote their health.

Data Collection and Analysis

Data were collected for a period of three months (October—December, 2017). Adolescents

who had given their consent to participate in the research were gathered in the school hall of

each selected school and copies of the questionnaire were distributed to them. Items on the

questionnaire were explained to them by the researcher, and participants were given

6
opportunity to ask questions when in doubt or confused. The questionnaire administration

lasted about one hour in each of the selected schools. The Principal Investigator (PI) and the

trained Research Assistant ascertained the completeness of the questionnaire copies after

collecting them from the students.

Two adolescents (with and without obesity) that were selected randomly in each school for the

qualitative phase were interviewed by the Principal Investigator after the collection of

quantitative data using the prepared interview guide. The interview was recorded using a sound

recorder on the Investigator’s cell phone. The interview lasted about 15 minutes for each of the

participants. Both quantitative and qualitative data were collected one after the other on the

same day. Quantitative data generated from the study were analysed using the Statistical

Product for Service Solution (SPSS) version20 (IBMCorp, 2016). Levels of health literacy and

health-promoting behaviour were calculated in percentage and were represented in bar chart.

Pearson’s Correlation Coefficient was used to determine the mean and to derive the statistical

significance of health literacy on health-promoting behaviour. Qualitative data were

transcribed verbatim and content analysis was carried out using ATLAS ti version 7.

Themes from the qualitative data were: Adolescents’ sources of health information, Health
promotion activities and Frequency of health promotion activities.

Ethics

Ethical approval was obtained from the Health Research and Ethics Committee of the Institute
of Public Health, Obafemi Awolowo University, Ile-Ife (HREC No: IPH/OAU/16/997).
Written informed consent was obtained from parents of adolescents who were less than 18
years old, while those who were 18years and older signed the informed consent form
personally. Assent was also obtained from adolescents less than 18years before participating
in the study. Concepts of health literacy, health-promoting behaviour and obesity were clearly
explained to the respondents, as well as the WHO standard for measuring BMI. Privacy was
ensured while checking weight and calculating BMI to avoid embarrassment especially for
adolescents with obesity.

Results

The mean age of adolescents with obesity was 13.79 years with a standard deviation of 1.68,
while the mean age of adolescents without obesity was 13.36 years with a standard deviation

7
of 1.69 (Table1). Also, more than two-thirds of the respondents (adolescents with and without
obesity) were females.

The findings showed that adolescents without obesity had a higher level of health literacy
(70%) compared to their counterparts with obesity (59%) (Figure1). Adolescents with obesity
had lower mean scores compared to those without obesity for all the sub-scales of the health
literacy scale. Overall, adolescents with obesity had a mean of 19.82 (±2.86) while those
without obesity had a mean score of 21.14 (±3.07) (Table 2).

Moreover, more than half (55.3%) of adolescents with obesity and 35.7% of those without
obesity scored low on the health-promoting behaviour scale (Figure 11). Adolescents with
obesity had lower mean scores for all the sub-scales of health-promoting behaviour compared
to those without obesity. Overall, adolescents with obesity had a mean of 125.3±21 compared
to 136.3±24 for adolescents without obesity (Table2). Using Pearson’s Correlation Coefficient,
a significant relationship was found between health literacy and health-promoting behaviour
among adolescents with obesity (r = 0.29; p = 0.001) and those without obesity (r = 0.85, p =
0.015) (Table 2).

Results from the interview (Table 3) showed that the adolescents, irrespective of their obesity
status, seek health information mostly from their parents, hospitals and the Internet. The school
nurse and other relations were least identified sources of health literacy. Below are the excerpts
from some of the students:
‘When I need information about health, I usually get
information from my parents especially my Mum and
also from our family friends who are Doctors and
Nurses or I go on the Internet to get information.’
(A15-year-old SS2 Female student with BMI of
34.5kg/m2)

‘I usually get health information from the hospital, my

parents, friends and Internet. Occasionally, I ask
from my teacher and school Nurse.’(A14-year-old
SS1 student with BMI of 19.5kg/m2)

Moreover, many (66.6%) of the adolescents without obesity (Table 3) reported that they
regularly provide sufficient health information whenever they visit their health care providers.
However, only few of the adolescents with obesity (33.3%) gave such information. Below are
excerpts from the interview:
‘When I talk to a doctor or a nurse, I do not give them
all the information because there are things they may
not understand so it is better not to say it. You know
there are certain things you do just because you
cannot help it but if you tell people especially adult
they would not believe you’ (A 16-year-old male SS2
student with BMI of40.5kg/m2.)

8
 ‘Yes I give all the information to the doctor/nurse
because they will need it to treat me.’ (A14-year-old
female SS1 student with BMI of15.5kg/m2)

Findings from the interview (Table 4) further showed that adolescents without obesity reported
a higher level of good health-promoting behaviour than adolescents with obesity. The majority
of adolescents without obesity engage in positive habits such as eating well, taking enough
fruits and vegetables, as well as drinking plenty of water. Many adolescents with obesity
engaged in negative habits such as skipping meals, eating non-nutritional food (junk food), and
taking of drugs for weight reduction, among other things. Also, all the adolescents with obesity
reported they do not engage in regular exercise. It is obvious from the result that
adolescents, irrespective of their obesity status, do not engage in health-promoting
activities on regular basis. Some of the excerpts from the interview are stated below:

‘I skip meal, I am using slimming tea, my parents also

help me to buy Tiansh product that can help me to slim
down and I also do some exercises’ (A16-year-old
male SS2 student with BMI of 40.5kg/m2)

‘I Skip breakfast, eat fruits and I eat junks and sugary

things a lot.’ (A15-year-old female student with BMI
of 34.5kg/m2)

‘I eat well, eat fruits, take plenty of water and exercise

to promote my health but I don’t have enough time to
do all these things because there are lots of school
work to do’ (A 13-year-old female student with BMI
of13kg/m2)

9
Discussion

In this study, the health literacy levels of adolescents with and without obesity were assessed
and compared. Adolescents without obesity had better health literacy in all the domains of the
health literacy scale used, compared to adolescents with obesity. The study found a significant
association between low levels of health literacy and obesity. This finding is in congruence
with the study by Chisolm et al.(2017) who found out that there is a significant association
between health literacy and obesity among Chinese obese adolescents.

It has been observed that while health literacy has the potential to influence adolescents, it is
especially more relevant for teens with chronic illnesses (Chisolm et al., 2017; Kim & White,
2017). Previous studies on adolescents’ health literacy level with no reference to a particular
disease condition have shown that adolescents generally have low health literacy levels (Shabi
& Oyewusi, 2017; Ye-Xiao-Hua, Yang, Gao & Xu, 2014).

In addition, previous reports have shown that adolescents with obesity engaged in high
sedentary behaviour, moderate physical activities and have poor eating habits which account
for their low levels of health-promoting behaviour (Ssewanyana, Abubakar, van Baar,
Mawangala & Newton, 2018).This is also evidenced in this study as many adolescents with
obesity engaged in lesser health-promoting behaviour compared to their counterparts.

The adolescents with obesity in this study employed negative habits such as skipping meals,
eating non-nutritional food (junk food) and missing breakfast regularly to reduce their weight,
despite the fact that these activities have a more negative impact on their health than weight
reduction. The study of Okada et al.(2018) showed that children who skip meals have a higher
tendency to be obese compared to their counterparts who do not skip meals. Another study
among urban South African adolescents established that poor eating habits within the home,
community and school environment resulted in poor dietary patterns in adolescents with
obesity (Sedibe et al., 2018).This suggests that habits which are most important for health
promotion, according to Holmberg et al.(2018), should be given high priority in adolescents’
health education at all levels. This plays an important role in the prevention of chronic diseases
such as obesity, diabetes mellitus, hypertension, cardiovascular disease, and some types of
cancers.

Moreover, the qualitative results showed that adolescents without obesity give more
information to health care workers when receiving care compared to adolescents with obesity.
This is supported by Gudbjørg, Bente, Kari & Anne-Grethe (2018) who discovered that
adolescents with obesity were ambivalent regarding disclosing their concerns and seeking help
because they feared that health care providers would demand too much from them. Therefore,
Care providers need to be skilled in assessing each adolescent’s resources and interpretations
of their condition, to be able to communicate in a patient-centered manner and to assist them
to explore their ambivalence and set their own realistic goals.

Furthermore, the study found a significant relationship between health literacy and health-
promoting behaviour. This is corroborated by the study of Chahardan-Cherik et al., (2018) who
found that there is a significant relationship between health literacy and all dimensions of the
health-promotion scale in patients with type-2 diabetes. Limited health literacy is associated

10
with less participation in health-promoting and disease detection activities, riskier health
choices, poor adherence to medication, increased hospitalisation and re–hospitalisation,
increased morbidity and premature death (Papalois & Theodosopoulou, 2018). It is important
to pay more attention to adolescents with obesity in the area of health literacy and health-
promoting behaviour so that they can have improved quality of life and become productive
citizens.

Conclusion

Adolescents with obesity had a lower level of health-promoting behaviour despite their high
level of health literacy, compared to those without obesity. Irrespective of the adolescent
obesity status, their health-promoting behaviour is significantly associated with their health
literacy. Adolescents are at the prime of their life and are expected to enjoy good health at its
peak. Since health literacy has been identified as a low cost and effective method in tackling
the rising problem of obesity and other chronic diseases among adolescents, effort must be put
in place by people, and places that significantly influence adolescents such as parents, teachers,
schools, religious centres, health institutions and media houses to improve the health literacy
of this age group.

Implications for School Health Nursing

School nurses have significant roles to play in reducing obesity among school adolescents.
They educate them on the prevention of obesity, create awareness on health literacy and also
encourage health-promoting behaviour. Most importantly, they also need to focus on obese
adolescents by supporting them in imbibing health-promoting behaviour towards improved
health. Obese adolescent also need to be literate about health-related issues that can reduce
incidence of obesity among them. Education of these adolescents can be one-on-one or group
education, it can as well be a classroom education or at the school health office. Adolescents
with obesity should also be encouraged to engage in physical activities as they scored low in
the physical activity domain of the health-promoting behaviour. School nurses should also
carry out routine health screening to detect obesity among adolescents and also carry out
appropriate necessary interventions.

Study Limitation

The study can only be generalised among adolescents in private secondary schools as obese
adolescents were found mostly in these schools. Also, the study was limited to Osun State
because of financial constraints.

11
Summary

The study assessed the influence of health literacy on the health-promoting behaviour of
adolescents with and without obesity in selected private schools in Osun State. It employed
multi-stage sampling technique to select 150 adolescents with obesity, and 150 adolescents
without obesity. The result showed that adolescents without obesity have good levels of health
literacy and health-promoting behaviour compared to adolescents with obesity. The study also
established a significant association between health literacy and health-promoting behaviour.

12
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Table 1: Socio-Demographic Distribution of Adolescents With or Without Obesity
Adolescent with Obesity Adolescent without
Obesity
Variable χ2,df, p
Frequency Percentage Frequency Percentag
e
n=150 (%) n=150
(%)
Age in year: Mean: 13.79±1.68 13.36±1.69
10-13 62 41.3 80 53.3 χ2 = 4.78
14-16 79 52.7 65 43.4 df= 2
17-18 9 6.0 5 3.3 p= 0.09
Class
JSS 1 16 10.7 17 11.3 χ2 = 9.77
JSS 2 12 8.0 24 16.0 df= 5
JSS 3 19 12.7 13 8.7 p= 0.08
SSS 1 30 20.0 40 26.7
SSS 2 38 25.3 34 22.7
SSS 3 35 23.3 22 14.7
NB: JSS: Junior
Secondary School
SSS: Senior Secondary
School
Sex χ2 = 1.79
Male 32 21.3 42 28.0 df= 1
Female 118 78.7 108 72.0 p= 0.18

Religion χ2 = 0.20
Christian 122 81.3 125 83.3 df= 1
Muslim 28 18.7 25 16.7 p= 0.65

Father’s occupation
Unemployed 1 0.7 2 1.3 χ2 = 1.62
Unskilled 19 12.7 22 14.7 df= 3

13
Skilled 8 5.3 12 8.0 p= 0.65
Professional 122 81.3 114 76.0
Mother’s Occupation
Unemployed 0 0.0 2 1.3 χ2 = 3.33
Unskilled 34 22.7 29 19.3 df= 3
Skilled 23 15.3 18 12.0 p= 0.34
Professional 93 62.0 101 67.3
BMI
Underweight 0 0.0 40 26.7 χ2 =
30.00
Normal 0 0.0 81 54.0
df= 3
Overweight 0 0.0 29 19.3
p= 0.01
Obesity 150 100.0 0 0.0
Average mean: 27.02±1.95

13
Table 2: Pearson’s Correlation Coefficient Showing Influence of Health Literacy on Health-
Promoting Behaviour of Adolescents With and Without Obesity
Variable N Mean SD Df R P value

With obesity

Health literacy 150 19.82 2.86

Health promoting behaviour 150 125.25 20.99 148 0.29 0.001

Without obesity

Health literacy 150 21.14 307

Health promoting behaviour 150 136.28 23.98 148 0.85 0.015

Table 3: Qualitative Result on Health Literacy of Adolescents With and Without Obesity

13
 Adolescent sources of health information Extent to which
adolescents give
information to health care
providers

Variable Parent Hospital Interne Scho Teacher Relatio Friends Give all Do not give
t ol ns information all
nurse information
S

Adolescent +++++ + + + + + ++++ ++ ++ ++ ++ +++++ +++++++

with obesity ++++ ++ +++

Adolescent +++++ + + + + + ++++ ++ ++++ ++ ++++ ++++++ +++++

without ++++ +++ ++++
obesity

Table 4: Qualitative Result on Health-Promoting Behaviour of Adolescents With and

Without Obesity

13
 Health promoting activities adopted by the adolescents Frequency

Variables Eating Avoiding Drinking Skipping Sleeping Exercise Regular Not regular
adequate junks plenty of meal well
diet water

Adolescent + + + + + + + ++ +++++ ++ + + + + + --- ++++++

with ++ +++ +++ ++++++
obesity +++

Adolescent + + + + + + + + + + + + + + ++ ++++ +++++ ++++ ++++++

without +++++ +++++ +++++ +++++
obesity +++ ++ +++

Key: + Number of adolescents who mentioned the variable

List of figures
Figure I: A Bar Chart Representation of Health Literacy Levels of Adolescents With and
Without Obesity

Figure II: A Bar Chart Representation of Health-Promoting Behaviour of Adolescents With and
Without Obesity

13
80
70.0%

70
59.3%

60

50 40.7%

40 30.0% With obesity

Without Obesity
30

20

10

0
Poor Health literacy Good Health literacy

Figure I

13
13
 70

60

50

40 Adolescents with obesity

30
Adplescents without
20 obesity

10

0
Good Health Poor Health
Behaviour Behaviour

Figure II

ABSTRACT

Background: Learning has been associated with human behaviour, and health literacy is vital

in an individual’s health promotion and maintenance activities.

Purpose: This study aimed at comparing the health literacy and health-promoting behaviour of

13
adolescents with and without obesity, and to also identify the association between health literacy

and health-promoting behaviour of these two groups of adolescents.

Methods: A concurrent mixed-method design was adopted and the study was conducted

among150 adolescents with obesity and 150 adolescents without obesity from 15 private

secondary schools in Osun State, Nigeria. A structured self-administered questionnaire and an

in-depth interview guide were used to collect data on their health literacy levels and health-

promoting behaviour.

Results: The findings showed that adolescents without obesity had a higher level of health

literacy (70%) compared to their counterparts with obesity (59%). More than half (55.3%) of

those with obesity and 35% of those without obesity scored low on health-promoting behaviour

scale. Also, there was a significant relationship between health literacy and health-promoting

behaviour among adolescents with obesity (r = 0.29; p = 0.001) and those without obesity (r =

0.85, p =0.015).

Conclusion: The study concluded that adolescents with obesity had lower level of health-
promoting behaviour despite their high level of health literacy, compared to those without obesity.
Irrespective of the adolescent’s obesity status, their health-promoting behaviour is significantly
associated with their health literacy. Implication for school nursing practice is documented.
Keywords:
Health-literacy, Health-promoting behaviours, Adolescent, Obesity, School Health

ACKNOLEDGEMENT
This paper and the research behind it would not have been possible without the exceptional support
of my supervisor: Dr (Mrs)Ogunfowokan A.A, her enthusiasm, knowledge and exciting attention
to details have been an inspiration and kept the work on track from the beginning till the end.

13
The effort of Mr Olodu, my co-supervisor and co-author is highly appreciated for prompt response
and review of the manuscript
The efforts of Miss Oyelade and Miss Adebiyi are worth mentioning for their valuable and selfless
contributions during the conduct of this research and writing of this paper.
We are also grateful for the insightful comments offered by the anonymous peer reviewers at
International Journal of Africa Nursing Sciences
The generosity and expertise of one and all have improved the study in numerous ways and saved
us from many errors; those that inevitably remain are entirely our own responsibilities.

Influence of Health Literacy on Health Promoting Behaviour of Adolescents with and

without Obesity: A Mixed Method Study

Authors Statement

There are three authors for this study. The conceptualization, data collection and drafting of the

manuscript was done by Kehinde Olunike Adewole, the first and the corresponding author. Proof

reading, formatting and scrutiny of the instrument was done by Adesola Adenike Ogunfowokan.

Expert advice and editing was done by Monday Olodu.

All the authors agreed to the publication of this study and order of authorship.

4. Kehinde O. Adewole, RN, M.Sc.1

5. Adesola A. Ogunfowokan, FWACN, RN, PhD2

6. Monday Olodu, RD, M.Sc.3 (Public Health Nutrition)
1Clinical Nursing Unit
Obafemi Awolowo University Teaching Hospitals Complex
Ile-Ife, Osun State,
Nigeria.
E-mail: Kumuyi70@gmail.com

13
Influence of Health Literacy on Health-Promoting Behaviour among Adolescents with and

without Obesity: Mixed Method Study

Introduction
Health literacy and health promotion are variables that promote good health outcomes and assure
positive developmental trajectory for adolescents. As adolescents move towards young adulthood,
they start making independent health decisions and determine many things about their health. The
cognitive ability and skills that are required to take good care of their health and make important
decisions are developed during this period (World Health Organisation [WHO], 2020; National
Institute of Correction, 2020). However, adolescents do not have adequate understanding and lack
the expertise needed to maintain good health, but having good health literacy skills is important to
the acquisition of this knowledge and skills (Manganello, Devellis, Davis, & Sshotter-Thal, 2015).
Health literacy could be described as ‘the social and cognitive competencies which determine the
motivation and ability of an individual to approach, comprehend and use health-related services
and information to make correct health decisions which promote and maintain good health’(WHO,
2018a). More broadly, an individual can approach, comprehend and use health-related services
and information when managing one’s health environment (WHO, 2018b). Health literacy skills
can help adolescents recognise their health needs; process information about their health status and
understand where to go for support when necessary (Hagel, 2015). It also enables them to adopt
health-promoting behaviour early in life (Fleary, Joseph, & Pappagianopoulos, 2017). However,
studies have shown that health literacy is low generally among adolescents (Shabi &Oyewusi,
2017; Ye, Yang, Gao, Chen &Xu, 2014). While adolescents may be keen to obtain information
about their health, it may be difficult for them to understand such information due to their low
level of health literacy (Manganello et al., 2015).
Furthermore, health-promoting behaviour, which involves activities motivated by a desire to
protect or promote fitness and comfort, is considered as the cheapest method to control and avert
morbidity and mortality among adolescents (Chasse, 2017). Literature have reported that about
60% of an individual’s health and quality of life depends on their lifestyle and health behaviour
(Farhud,2015).The health-promoting activities include participating in regular physical activity,
consuming an adequate diet, keeping physically fit, refraining from substance use, sleeping well
and using preventative health and dental care (South Australia Health, 2020). In addition, eating
habit is established as the most important of all the health-promoting behaviour (Holmberg,
Larsson, Korp, Lindgren, Froberg,et al., 2018).
According to Ndumele et al., (2016), health-promoting behaviour have been shown to correlate
with optimal health and to prevent conditions such as cardiovascular disease (CVD), hypertension,
diabetes, stroke and accumulation of excessive body weight among adolescents. However,

13
previous researchers reported that health-promoting behaviour among adolescents globally are
very poor (Musavian, Pasha, Rahebi, Ghanbari, & Roushan, 2014; WHO, 2018b). Nigerian studies
also indicate poor health-promoting activities among adolescents (Onyebuchi, 2015).
Furthermore, it is observed that adolescents generally engage in hazardous health behaviour more
than they engage in health-promoting behaviour (El Achhab, El Ammari, El Kazdouh, Najdi,
Barraho, et al., 2016). Poor eating habits and a lack of physical activity rank high among the factors
that predispose adolescents to the problem of overweight and obesity (Sedibe, Pisa, Feeley, Pedro,
Kahnb, & Norris, 2018; Ssewanyana, Abubakar, van Baar, Mawangala, & Newton, 2018).
Adolescents try to control their weight by skipping meals; however, those who skip meals have
been found to have a higher tendency of becoming obese (Okada, Tabuchi, & Iso, 2018).
Moreover, a sudden increase in physical and psychological growth has made adolescents to be
nutritionally vulnerable with unhealthy eating behaviour. Some adolescents are malnourished
predisposing them to diseases and untimely death. On the other hand, overweight and obesity are
other types of nutritional problems with serious health consequences (Christian, & Smith, 2018).
Overweight and obesity have become an epidemic among adolescents in both lower and higher
income countries because obesity can affect adolescents’ immediate health, educational attainment
and quality of life (WHO, 2018a). Globally, over 170 million children who are less than 18 years
of age are reported to be overweight (WHO, 2018b), while one in five children who are 6 -19years
old in the USA is obese (CDC,2018). Toriola, Ajayi-Vicent, Oyeniyi, Akindutire, Adeagbo, et al.,
(2017) also reported the prevalence of obesity among adolescents in Nigeria to be 1.1%.
Though obesity statistics from Nigeria do not pose a serious health concern to the adolescent
population, it is, however, becoming an issue of concern among the children of the affluent. This
is evidenced by the fact that obese children are hardly seen in the public schools but are found
mainly in private schools where the children of the affluent are found (Adetunji, Adeniran, Olomu,
Odike, Ewah-Odiase, et al., 2019). Obesity is a significant cause of many disease conditions and
it also increases the risk of psychological distress among adolescents. These are reflected in
negative body image perceptions, lowered self-esteem and development of psychopathology such
as eating disorders, substance abuse, sexual risk, truancy and gangsterism (Toriola et al, 2017).
As adolescents adopt the western culture in Nigeria, the occurrence of obesity is expected to
increase with many negative outcomes to their health generally. There have been a lot of physical
and mental health consequences for obesity which are closely related to health-promoting
behaviour. It is of utmost importance to equip adolescents with a good level of health literacy
which is a precursor of good health-promoting behaviour. While health literacy is very important
for good quality of life in adolescents, generally, it is found to be more important for those with
chronic health conditions such as obesity. Interventions or activities that prevent overweight and
obesity in the population of adolescents can save their lives and make them productive adults later
in life. Therefore, it is important to assess the level of health literacy, identify health-promoting
behaviour, and determine the influence of health literacy on health-promoting behaviour among
adolescents with and without obesity.

13
Material and Method

Study Design

The study adopted a concurrent mixed-method design (QUAN-QUAL) and was conducted

among adolescents aged10 -19years in15 private secondary schools in Osun State, Nigeria.

Mixed method was used in this study so that qualitative data could be used to buttress

quantitative data and to also reflect the participants’ points of view as they relate to the study

setting.

Sampling

A multi-stage sampling technique was employed in the selection of participants for this study.

Three Local Government Areas (LGAs) from each of the three Senatorial Districts in Osun

State were randomly selected followed by a purposive sampling technique of five private

secondary schools from each of the LGAs. Selection of the adolescents based on their body

weight was done to recruit the adolescents into the study. Those who agreed to participate in

the study had their weight and height measured to determine their BMI (ratio of weight to

height) based on WHO standard. Participants’ heights were measured using Stadiometer (a

medical equipment used for measuring human height usually constructed out of a ruler and a

sliding horizontal headpiece which is adjusted to rest on the top of the head), while their

weights were measured using a weighing scale (CAMRY J1007878903). In accordance with

WHO standard, those with a BMI greater than or equal to 30kg/m2 were taken as adolescents

with obesity while those with a BMI less than 30kg/m2 were taken as adolescents without

obesity (WHO, 2021).

13
A total of 300 adolescents were recruited with equal numbers for those with obesity (150) and

those without obesity (150) from the study schools. The number of obese adolescents selected

from each school determined the number of non-obese adolescents selected from the school

because of variation in the population of obese adolescents in each of the selected schools. In

addition, one adolescent with obesity and one without obesity were elected randomly from the

adolescents that were recruited for the study in each of the 15 schools, thereby, giving a total

of 30 adolescents who participated in the qualitative data collection. During the interview,

saturation of data was achieved by the time the 20th adolescent was interviewed. To ensure

trustworthiness of the data, information given by the adolescents were cross-checked and

clarified with the adolescents at the end of each interview.

Pilot Study

A pilot study was conducted in Ife East LGA using one private and one public secondary school

because this study was initially intended to be done in both private and public secondary

schools. The result of the pilot study showed that adolescents with obesity were hardly seen in

public schools which also confirmed the report of Adetunji et al.(2019). The adolescents

categorised as obese in the public school used for pilot study were only overweight according

to WHO standard. Therefore, the study was delimited to private secondary schools where

adolescents with obesity could be found. Cronbach’s Alpha for All Aspect of Health Literacy

Scale (AAHLS) was found to be 0.705 and 0.930 for Adolescents Health Promoting Scale

(AHPS), while the internal consistency was found to be 0.854. The pilot study result further

showed that the empirical sub-scale on the AAHLS did not directly relate to adolescent’s stage;

therefore, the sub-scale was removed from the AAHLS

13
Instruments

The instruments used for data collection were a structured self-administered questionnaire and

an interview guide (in-depth). The questionnaire consisted of three sections: Section one

elicited information on the adolescent’s socio-demographic profile. Section two collected

information on health literacy level using the ‘All Aspects of Health Literacy Scale’ (AAHLS)

developed by Chinn and McCarthy (2012). The AAHL is a 3-point Likert scale of ‘Rarely’ (1),

‘Sometimes’ (2), and ‘Often’ (3) and 3 sub-scales of Functional, Communication, and Critical

literacy were used. The three sub-subscales consisted of 13 questions with 39 as the maximum

obtainable score. Using a mean score of 20, 0 -19.99 was rated as poor health literacy while a

score of 20 -39 was rated as good health literacy.

Section three assessed information on health-promoting behaviour using the ‘Adolescent

Health Promoting Scale’ (AHPS) developed by Chen, Wang, Yang and Liou (2003) with the

sub-scales of nutritional, social support, health responsibility, appreciation, physical activity

and stress management. The AHPS is a 5-point Likert scale indicating Never(1), Seldom(2),

Quite often(3), Very often(4) and Always(5). It consists of 40 questions with 200 as maximum

obtainable score. Using a mean score of 130, 0-129.9 was rated as poor health-promoting

behaviour while 130—200 was rated as good health-promoting behaviour. The interview guide

comprised questions that explored the adolescents’ sources of health information and activities

they carried out to promote their health.

Data Collection and Analysis

Data were collected for a period of three months (October—December, 2017). Adolescents

who had given their consent to participate in the research were gathered in the school hall of

each selected school and copies of the questionnaire were distributed to them. Items on the

questionnaire were explained to them by the researcher, and participants were given

13
opportunity to ask questions when in doubt or confused. The questionnaire administration

lasted about one hour in each of the selected schools. The Principal Investigator (PI) and the

trained Research Assistant ascertained the completeness of the questionnaire copies after

collecting them from the students.

Two adolescents (with and without obesity) that were selected randomly in each school for the

qualitative phase were interviewed by the Principal Investigator after the collection of

quantitative data using the prepared interview guide. The interview was recorded using a sound

recorder on the Investigator’s cell phone. The interview lasted about 15 minutes for each of the

participants. Both quantitative and qualitative data were collected one after the other on the

same day. Quantitative data generated from the study were analysed using the Statistical

Product for Service Solution (SPSS) version20 (IBMCorp, 2016). Levels of health literacy and

health-promoting behaviour were calculated in percentage and were represented in bar chart.

Pearson’s Correlation Coefficient was used to determine the mean and to derive the statistical

significance of health literacy on health-promoting behaviour. Qualitative data were

transcribed verbatim and content analysis was carried out using ATLAS ti version 7.

Themes from the qualitative data were: Adolescents’ sources of health information, Health
promotion activities and Frequency of health promotion activities.

Ethics

Ethical approval was obtained from the Health Research and Ethics Committee of the Institute
of Public Health, Obafemi Awolowo University, Ile-Ife (HREC No: IPH/OAU/16/997).
Written informed consent was obtained from parents of adolescents who were less than 18
years old, while those who were 18years and older signed the informed consent form
personally. Assent was also obtained from adolescents less than 18years before participating
in the study. Concepts of health literacy, health-promoting behaviour and obesity were clearly
explained to the respondents, as well as the WHO standard for measuring BMI. Privacy was
ensured while checking weight and calculating BMI to avoid embarrassment especially for
adolescents with obesity.

Results

The mean age of adolescents with obesity was 13.79 years with a standard deviation of 1.68,
while the mean age of adolescents without obesity was 13.36 years with a standard deviation

13
of 1.69 (Table1). Also, more than two-thirds of the respondents (adolescents with and without
obesity) were females.

The findings showed that adolescents without obesity had a higher level of health literacy
(70%) compared to their counterparts with obesity (59%) (Figure1). Adolescents with obesity
had lower mean scores compared to those without obesity for all the sub-scales of the health
literacy scale. Overall, adolescents with obesity had a mean of 19.82 (±2.86) while those
without obesity had a mean score of 21.14 (±3.07) (Table 2).

Moreover, more than half (55.3%) of adolescents with obesity and 35.7% of those without
obesity scored low on the health-promoting behaviour scale (Figure 11). Adolescents with
obesity had lower mean scores for all the sub-scales of health-promoting behaviour compared
to those without obesity. Overall, adolescents with obesity had a mean of 125.3±21 compared
to 136.3±24 for adolescents without obesity (Table2). Using Pearson’s Correlation Coefficient,
a significant relationship was found between health literacy and health-promoting behaviour
among adolescents with obesity (r = 0.29; p = 0.001) and those without obesity (r = 0.85, p =
0.015) (Table 2).

Results from the interview (Table 3) showed that the adolescents, irrespective of their obesity
status, seek health information mostly from their parents, hospitals and the Internet. The school
nurse and other relations were least identified sources of health literacy. Below are the excerpts
from some of the students:
‘When I need information about health, I usually get
information from my parents especially my Mum and
also from our family friends who are Doctors and
Nurses or I go on the Internet to get information.’
(A15-year-old SS2 Female student with BMI of
34.5kg/m2)

‘I usually get health information from the hospital, my

parents, friends and Internet. Occasionally, I ask
from my teacher and school Nurse.’(A14-year-old
SS1 student with BMI of 19.5kg/m2)

Moreover, many (66.6%) of the adolescents without obesity (Table 3) reported that they
regularly provide sufficient health information whenever they visit their health care providers.
However, only few of the adolescents with obesity (33.3%) gave such information. Below are
excerpts from the interview:
‘When I talk to a doctor or a nurse, I do not give them
all the information because there are things they may
not understand so it is better not to say it. You know
there are certain things you do just because you
cannot help it but if you tell people especially adult
they would not believe you’ (A 16-year-old male SS2
student with BMI of40.5kg/m2.)

13
 ‘Yes I give all the information to the doctor/nurse
because they will need it to treat me.’ (A14-year-old
female SS1 student with BMI of15.5kg/m2)

Findings from the interview (Table 4) further showed that adolescents without obesity reported
a higher level of good health-promoting behaviour than adolescents with obesity. The majority
of adolescents without obesity engage in positive habits such as eating well, taking enough
fruits and vegetables, as well as drinking plenty of water. Many adolescents with obesity
engaged in negative habits such as skipping meals, eating non-nutritional food (junk food), and
taking of drugs for weight reduction, among other things. Also, all the adolescents with obesity
reported they do not engage in regular exercise. It is obvious from the result that
adolescents, irrespective of their obesity status, do not engage in health-promoting
activities on regular basis. Some of the excerpts from the interview are stated below:

‘I skip meal, I am using slimming tea, my parents also

help me to buy Tiansh product that can help me to slim
down and I also do some exercises’ (A16-year-old
male SS2 student with BMI of 40.5kg/m2)

‘I Skip breakfast, eat fruits and I eat junks and sugary

things a lot.’ (A15-year-old female student with BMI
of 34.5kg/m2)

‘I eat well, eat fruits, take plenty of water and exercise

to promote my health but I don’t have enough time to
do all these things because there are lots of school
work to do’ (A 13-year-old female student with BMI
of13kg/m2)

13
Discussion

In this study, the health literacy levels of adolescents with and without obesity were assessed
and compared. Adolescents without obesity had better health literacy in all the domains of the
health literacy scale used, compared to adolescents with obesity. The study found a significant
association between low levels of health literacy and obesity. This finding is in congruence
with the study by Chisolm et al.(2017) who found out that there is a significant association
between health literacy and obesity among Chinese obese adolescents.

It has been observed that while health literacy has the potential to influence adolescents, it is
especially more relevant for teens with chronic illnesses (Chisolm et al., 2017; Kim & White,
2017). Previous studies on adolescents’ health literacy level with no reference to a particular
disease condition have shown that adolescents generally have low health literacy levels (Shabi
& Oyewusi, 2017; Ye-Xiao-Hua, Yang, Gao & Xu, 2014).

In addition, previous reports have shown that adolescents with obesity engaged in high
sedentary behaviour, moderate physical activities and have poor eating habits which account
for their low levels of health-promoting behaviour (Ssewanyana, Abubakar, van Baar,
Mawangala & Newton, 2018).This is also evidenced in this study as many adolescents with
obesity engaged in lesser health-promoting behaviour compared to their counterparts.

The adolescents with obesity in this study employed negative habits such as skipping meals,
eating non-nutritional food (junk food) and missing breakfast regularly to reduce their weight,
despite the fact that these activities have a more negative impact on their health than weight
reduction. The study of Okada et al.(2018) showed that children who skip meals have a higher
tendency to be obese compared to their counterparts who do not skip meals. Another study
among urban South African adolescents established that poor eating habits within the home,
community and school environment resulted in poor dietary patterns in adolescents with
obesity (Sedibe et al., 2018).This suggests that habits which are most important for health
promotion, according to Holmberg et al.(2018), should be given high priority in adolescents’
health education at all levels. This plays an important role in the prevention of chronic diseases
such as obesity, diabetes mellitus, hypertension, cardiovascular disease, and some types of
cancers.

Moreover, the qualitative results showed that adolescents without obesity give more
information to health care workers when receiving care compared to adolescents with obesity.
This is supported by Gudbjørg, Bente, Kari & Anne-Grethe (2018) who discovered that
adolescents with obesity were ambivalent regarding disclosing their concerns and seeking help
because they feared that health care providers would demand too much from them. Therefore,
Care providers need to be skilled in assessing each adolescent’s resources and interpretations
of their condition, to be able to communicate in a patient-centered manner and to assist them
to explore their ambivalence and set their own realistic goals.

Furthermore, the study found a significant relationship between health literacy and health-
promoting behaviour. This is corroborated by the study of Chahardan-Cherik et al., (2018) who
found that there is a significant relationship between health literacy and all dimensions of the
health-promotion scale in patients with type-2 diabetes. Limited health literacy is associated

13
with less participation in health-promoting and disease detection activities, riskier health
choices, poor adherence to medication, increased hospitalisation and re–hospitalisation,
increased morbidity and premature death (Papalois & Theodosopoulou, 2018). It is important
to pay more attention to adolescents with obesity in the area of health literacy and health-
promoting behaviour so that they can have improved quality of life and become productive
citizens.

Conclusion

Adolescents with obesity had a lower level of health-promoting behaviour despite their high
level of health literacy, compared to those without obesity. Irrespective of the adolescent
obesity status, their health-promoting behaviour is significantly associated with their health
literacy. Adolescents are at the prime of their life and are expected to enjoy good health at its
peak. Since health literacy has been identified as a low cost and effective method in tackling
the rising problem of obesity and other chronic diseases among adolescents, effort must be put
in place by people, and places that significantly influence adolescents such as parents, teachers,
schools, religious centres, health institutions and media houses to improve the health literacy
of this age group.

Implications for School Health Nursing

School nurses have significant roles to play in reducing obesity among school adolescents.
They educate them on the prevention of obesity, create awareness on health literacy and also
encourage health-promoting behaviour. Most importantly, they also need to focus on obese
adolescents by supporting them in imbibing health-promoting behaviour towards improved
health. Obese adolescent also need to be literate about health-related issues that can reduce
incidence of obesity among them. Education of these adolescents can be one-on-one or group
education, it can as well be a classroom education or at the school health office. Adolescents
with obesity should also be encouraged to engage in physical activities as they scored low in
the physical activity domain of the health-promoting behaviour. School nurses should also
carry out routine health screening to detect obesity among adolescents and also carry out
appropriate necessary interventions.

Study Limitation

The study can only be generalised among adolescents in private secondary schools as obese
adolescents were found mostly in these schools. Also, the study was limited to Osun State
because of financial constraints.

13
Summary

The study assessed the influence of health literacy on the health-promoting behaviour of
adolescents with and without obesity in selected private schools in Osun State. It employed
multi-stage sampling technique to select 150 adolescents with obesity, and 150 adolescents
without obesity. The result showed that adolescents without obesity have good levels of health
literacy and health-promoting behaviour compared to adolescents with obesity. The study also
established a significant association between health literacy and health-promoting behaviour.

13
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between Health Literacy and Health Promoting Behaviours in Patients with Type2
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Table 1: Socio-Demographic Distribution of Adolescents With or Without Obesity
Adolescent with Obesity Adolescent without
Obesity
Variable χ2,df, p
Frequency Percentage Frequency Percentag
e
n=150 (%) n=150
(%)
Age in year: Mean: 13.79±1.68 13.36±1.69
10-13 62 41.3 80 53.3 χ2 = 4.78
14-16 79 52.7 65 43.4 df= 2
17-18 9 6.0 5 3.3 p= 0.09
Class
JSS 1 16 10.7 17 11.3 χ2 = 9.77
JSS 2 12 8.0 24 16.0 df= 5
JSS 3 19 12.7 13 8.7 p= 0.08
SSS 1 30 20.0 40 26.7
SSS 2 38 25.3 34 22.7
SSS 3 35 23.3 22 14.7
NB: JSS: Junior
Secondary School
SSS: Senior Secondary
School
Sex χ2 = 1.79
Male 32 21.3 42 28.0 df= 1
Female 118 78.7 108 72.0 p= 0.18

Religion χ2 = 0.20
Christian 122 81.3 125 83.3 df= 1
Muslim 28 18.7 25 16.7 p= 0.65

Father’s occupation
Unemployed 1 0.7 2 1.3 χ2 = 1.62
Unskilled 19 12.7 22 14.7 df= 3

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Skilled 8 5.3 12 8.0 p= 0.65
Professional 122 81.3 114 76.0
Mother’s Occupation
Unemployed 0 0.0 2 1.3 χ2 = 3.33
Unskilled 34 22.7 29 19.3 df= 3
Skilled 23 15.3 18 12.0 p= 0.34
Professional 93 62.0 101 67.3
BMI
Underweight 0 0.0 40 26.7 χ2 =
30.00
Normal 0 0.0 81 54.0
df= 3
Overweight 0 0.0 29 19.3
p= 0.01
Obesity 150 100.0 0 0.0
Average mean: 27.02±1.95

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Table 2: Pearson’s Correlation Coefficient Showing Influence of Health Literacy on Health-
Promoting Behaviour of Adolescents With and Without Obesity
Variable N Mean SD Df R P value

With obesity

Health literacy 150 19.82 2.86

Health promoting behaviour 150 125.25 20.99 148 0.29 0.001

Without obesity

Health literacy 150 21.14 307

Health promoting behaviour 150 136.28 23.98 148 0.85 0.015

Table 3: Qualitative Result on Health Literacy of Adolescents With and Without Obesity

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 Adolescent sources of health information Extent to which
adolescents give
information to health care
providers

Variable Parent Hospital Interne Scho Teacher Relatio Friends Give all Do not give
t ol ns information all
nurse information
S

Adolescent +++++ + + + + + ++++ ++ ++ ++ ++ +++++ +++++++

with obesity ++++ ++ +++

Adolescent +++++ + + + + + ++++ ++ ++++ ++ ++++ ++++++ +++++

without ++++ +++ ++++
obesity

Table 4: Qualitative Result on Health-Promoting Behaviour of Adolescents With and

Without Obesity

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 Health promoting activities adopted by the adolescents Frequency

Variables Eating Avoiding Drinking Skipping Sleeping Exercise Regular Not regular
adequate junks plenty of meal well
diet water

Adolescent + + + + + + + ++ +++++ ++ + + + + + --- ++++++

with ++ +++ +++ ++++++
obesity +++

Adolescent + + + + + + + + + + + + + + ++ ++++ +++++ ++++ ++++++

without +++++ +++++ +++++ +++++
obesity +++ ++ +++

Key: + Number of adolescents who mentioned the variable

List of figures
Figure I: A Bar Chart Representation of Health Literacy Levels of Adolescents With and
Without Obesity

Figure II: A Bar Chart Representation of Health-Promoting Behaviour of Adolescents With and
Without Obesity

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13
Figure I

13
Figure II

13
70
80
70.0%
60
70
59.3%
50
60
40 Adolescents with obesity
50 40.7%
30
Adplescents without
40 30.0% obesity With obesity
20
Without Obesity
10
30

0
20
Good Health Poor Health
Behaviour Behaviour
10

0
Poor Health literacy Good Health literacy

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 ACKNOLEDGEMENT
This paper and the research behind it would not have been possible without the exceptional support
of my supervisor: Dr (Mrs)Ogunfowokan A.A, her enthusiasm, knowledge and exciting attention
to details have been an inspiration and kept the work on track from the beginning till the end.
The effort of Mr Olodu, my co-supervisor and co-author is highly appreciated for prompt response
and review of the manuscript
The efforts of Miss Oyelade and Miss Adebiyi are worth mentioning for their valuable and selfless
contributions during the conduct of this research and writing of this paper.
We are also grateful for the insightful comments offered by the anonymous peer reviewers at
International Journal of Africa Nursing Sciences
The generosity and expertise of one and all have improved the study in numerous ways and saved
us from many errors; those that inevitably remain are entirely our own responsibilities.

ABSTRACT

Background: Learning has been associated with human behaviour, and health literacy is vital

in an individual’s health promotion and maintenance activities.

Purpose: This study aimed at comparing the health literacy and health-promoting behaviour of

adolescents with and without obesity, and to also identify the association between health literacy

and health-promoting behaviour of these two groups of adolescents.

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Methods: A concurrent mixed-method design was adopted and the study was conducted

among150 adolescents with obesity and 150 adolescents without obesity from 15 private

secondary schools in Osun State, Nigeria. A structured self-administered questionnaire and an

in-depth interview guide were used to collect data on their health literacy levels and health-

promoting behaviour.

Results: The findings showed that adolescents without obesity had a higher level of health

literacy (70%) compared to their counterparts with obesity (59%). More than half (55.3%) of

those with obesity and 35% of those without obesity scored low on health-promoting behaviour

scale. Also, there was a significant relationship between health literacy and health-promoting

behaviour among adolescents with obesity (r = 0.29; p = 0.001) and those without obesity (r =

0.85, p =0.015).

Conclusion: The study concluded that adolescents with obesity had lower level of health-
promoting behaviour despite their high level of health literacy, compared to those without obesity.
Irrespective of the adolescent’s obesity status, their health-promoting behaviour is significantly
associated with their health literacy. Implication for school nursing practice is documented.
Keywords:
Health-literacy, Health-promoting behaviours, Adolescent, Obesity, School Health

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