Knowledge-driven or motivation-driven? Validation and comparison of health participation pathways across different...

Childhood and early adolescence are critical periods for promoting health literacy (HL), a foundational factor that influences health-promoting participation throughout life. Evidence-based, theory-informed interventions to improve participation in school-aged children are scarce. This study aims to clarify the HL framework and to understand its role in guiding tailored interventions.

Within the HL framework, this study conceptualized health participation improvement through knowledge, skills, and motivation. Two pathways, knowledge-driven and motivation-driven, were proposed and validated for their relative contributions. From January to July 2023, a multistage cluster sampling method was used to recruit 3,325 elementary school students in China, including 1,070 students in Grades 1-2, 1,190 in Grades 3-4, and 1,065 in Grades 5-6. HL was assessed using the Chinese Rapid Health Literacy Questionnaire (CRHLQ) for Elementary School Students, a validated assessment tool comprising three sub-questionnaires. Chain mediation models were constructed to examine the two pathways, with gender, academic performance, and personality included as control variables. Indirect effects were estimated using a bootstrap method with 5,000 replications.

In Grades 1-2, health participation is primarily mediated through motivation and skills for the knowledge-driven pathway, while motivation exerts a strong direct effect in the motivation-driven pathway. In Grades 3-4, knowledge has a total direct effect on health participation, whereas motivation influences participation indirectly via knowledge. In Grades 5-6, the knowledge-driven pathway operates mainly through motivation, with no direct effect, while motivation again shows a strong direct effect on participation. To sum up, pathways for improving health participation differ across elementary grade levels: motivation-driven in lower grades, knowledge-driven in middle grades, and combined knowledge- and motivation-driven in upper grades.

Guided by the HL framework, patterns of health participation improvement differ across grade levels. HL interventions should be tailored using developmentally appropriate strategies and tools. Adapting health education content to grade level, balancing motivation-driven and knowledge-driven strategies, can maximize its educational effectiveness.