A Comparative Study on Adolescents' Health Literacy in Europe: Findings from the HBSC Study

Effectiveness of health literacy education on health literacy in early adolescence: A randomized controlled trial

OBJECTIVES

The present study was conducted to measure the effectiveness of health literacy education on the health literacy level of children in early adolescence.

STUDY DESIGN

A parallel group randomized controlled trial was conducted.

METHODS

The study group consisted of sixth and seventh-grade students (aged 12-13 years) studying in a secondary school in Ankara. The study was completed by 80 students, 40 in the intervention group and 40 in the control group. The Health Literacy Education program, consisting of four sessions, was presented to the intervention group. The instruments were administered to both groups before the intervention (pre-test), one month (post-test), and three months after the intervention (follow-up test). The data was analyzed using the chi-square test, and the two-way mixed-design variance analysis with Bonferroni Multiple Comparison Test.

RESULTS

Before the study, the adolescents in the intervention and control groups were similar regarding descriptive characteristics (p > 0.05). There was no statistically significant difference between the pre-test health literacy mean scores of the intervention and control groups (p > 0.05). After the health literacy education, health literacy post-test scores and follow-up test mean scores of the intervention group increased significantly compared to the control group (p < 0.05). The intervention had a large effect size (F = 414.683; η2 = 0.91) at the 95 % confidence interval.

CONCLUSIONS

The study revealed that health literacy education was effective in increasing the level of health literacy in early adolescence. It is recommended that health literacy education be added to the school education curriculum of adolescents.

The effect of health literacy-grounded web-based education on nutrition and exercise behaviours in adolescents: A randomized controlled trial

AIM

The research was conducted to measure the effect of health literacy-grounded web-based education program on health literacy, nutrition and exercise behaviours in adolescents.

BACKGROUND

The increasing prevalence of obesity in adolescents is explained by a sedentary lifestyle and unhealthy diet. Health literacy is essential for adolescents to maintain their healthy behaviours.

METHODS

The research was conducted as a parallel group randomized controlled trial. The study was completed by 114 adolescents (experimental = 42, control = 72). The Personal Information Form, the Health Literacy Scale for School-Age Children and the Nutrition and Exercise Subscales were used to collect data. A web-based education program was implemented. Two-way mixed design ANOVA with Bonferroni test was used to examine the group, time and group * time interaction of the measurements.

RESULTS

There was no statistically significant difference between the experimental and control groups regarding health literacy level, nutrition and exercise behaviours pre-test mean scores (p > 0.05). In the post-test, the mean scores of health literacy and nutrition behaviours in the experimental group were higher than the control group (p < 0.001). However, there was no significant difference in exercise behaviours (p > 0.05). The power and effect size in mean scores changes for health literacy (99.8%, η2 = 0.039) and nutrition (99.8%, η2 = 0.039) were moderate.

CONCLUSION

The study concluded that health literacy-grounded web-based education program increased the health literacy levels of adolescents and improved their nutritional behaviours; however, there was no sufficient change in exercise behaviours.

Associations of health literacy and sleep quality with depressive symptoms in Turkish adolescents: A descriptive cross-sectional study

PURPOSE

The purpose of this study was to determine the associations of health literacy and sleep quality with depressive symptoms in adolescents.

DESIGN AND METHODS

This descriptive cross-sectional study was conducted with 1081 high school students in Turkey. The data were collected online using the Health Literacy for School-Aged Children Scale, Pittsburg Sleep Quality Index, and the Center for Epidemiological Studies Depression Scale for Children. The chi-square test and binary logistic regression analysis were used to analyze the data obtained from the scales.

RESULTS

The prevalence of depressive symptoms, sleep problems, and low health literacy was 78.4%, 70.6%, and 11.3%, respectively. Sleep problems were significantly positively correlated with depressive symptoms (OR = 4.187, 95% CI: 2.998 -5.848). The students who were experiencing sleep problems and had low health literacy were at risk of the most severe depressive symptoms (OR = 12.696, 95% CI: 5.122-31.474).

CONCLUSIONS

Overall, depressive symptoms and sleep problems were common among the adolescents in the study sample. The students who had sleep problems and low health literacy were at an increased risk for depressive symptoms.

PRACTICAL IMPLICATIONS

To prevent mental health problems in adolescents, intervention programs focused on increasing the health literacy levels and improving sleep quality in this population are recommended.

The core competencies of a health education teacher

Teachers play a crucial role in students' learning and in the development of health literacy. Hence, the aim of this study was to identify the core competencies needed for teachers of health education in supporting student learning. A three-round Delphi study was carried out over an 8-week period, through consultation with 25 Finnish experts in health education. An open-ended question was used to identify the core competencies for school health educators. The data were analysed using inductive content analysis. In subsequent rounds, experts were asked to assess the importance of the identified competencies on a 7-point Likert scale, and finally to rank the most important competencies. In total, 52 competencies were identified and categorized into eight core competence domains. Thereafter, 40 competencies were assessed and selected for the third round, in which the experts ranked the 15 most important competencies, encompassing four core domains, i.e. pedagogic and subject-specific didactic, social and emotional, content knowledge and continuous professional development. Other domains of competence identified in the present study were ethical competence, competence in school health promotion, contextual competence and professional well-being competence. The study defines health education teacher core competencies and domains, and the information can be used in teacher education programmes, for developing teaching and for teachers' self-evaluation.

Physical Education Teachers' Health Literacy: First Evidence from Lithuania

BACKGROUND

Promotion of health literacy is an important goal in the context of promoting whole school health. Physical education teachers are of particular importance in achieving this goal. However, very limited empirical studies have addressed the health literacy of physical education teachers. This research aimed to test the structural validity and reliability of the HLS19-Q12, to measure health literacy among physical education teachers, and to evaluate associations of health literacy with health- and lifestyle-related indicators.

METHODS

We conducted a cross-sectional study of Lithuanian physical education teachers. The participants completed a self-administered online survey that collected information on socio-demographics and health literacy (HLS19-Q12 for general health literacy and the optional package HLS19-DIGI to measure digital health literacy) as well as health behavior.

RESULTS

A total of 332 participants completed the survey. The HLS19-Q12 demonstrated acceptable internal consistency (Cronbach's α of 0.73 and McDonald's ω of 0.75) and satisfactory structural validity (CFI = 0.924, TLI = 0.917, RMSEA = 0.081). Participants had an average score of 85.09 (SD = 17.23) when using the HLS19-Q12, with 19.3% and 48.8% displaying excellent and sufficient levels of health literacy, respectively. Regression analyses revealed that a higher level of health literacy was significantly associated with better health evaluation (β = 0.15, p < 0.01), but no significant association was found with other health behavior and lifestyle indicators.

CONCLUSIONS

Overall, the results suggest that teachers' general health literacy is relatively high. Our findings highlight the importance of conducting more in-depth studies to pursue the understanding of the whole school teachers' health literacy.

Digital health literacy among primary and secondary school teachers-a quantitative study

Introduction

Digital health literacy (DHL) is a key competency for individuals' daily decisions toward their health behavior and wellbeing. While there is much focus on health literacy (HL) among the general population, teachers have been rarely addressed. Given the shortages in the teaching workforce in Europe and the impact of demanding working conditions on their health, it is important to address DHL in teachers. This paper examines the DHL of primary and secondary teachers and its associations with sociodemographic and school-related factors.

Methods

An online cross-sectional study was conducted with 1,600 German primary and secondary school teachers between October and December 2022. To assess DHL, the Digital Health Literacy Instrument (DHLI) including seven subscales was used. Statistical analyses were conducted on item and subscale level and an overall DHL score was calculated. Next to descriptive analyses, bivariate and regression analyses were conducted to explore potential associations with sociodemographic and school-related factors.

Results

The frequency of difficulty in using digital health information varied across DHL dimensions and was greatest for protecting privacy (70.9%) and evaluating reliability (40.0%). In multivariate analysis, females more often reported a sufficient ability of adding content (OR = 1.61, CI = 1.05-2.48), while males more often reported a sufficient ability to protect their privacy (OR = 0.45, CI = 0.27-0.75). Teachers with leadership positions more often reported a sufficient ability in adding content (OR = 1.78, CI = 1.07-2.98). Regarding the ability to determine the relevance of online health-related information, no associations with a predictor variable were found.

Discussion

The results suggest that it is important to examine the individual dimensions of DHL and their distinct associations with sociodemographic and school-level factors, rather than just to rely on the overall level of DHL. The differential patterns identified in this study suggest a greater intervention need for teachers from higher age groups, primary and secondary general schools, and those without leadership roles. However, based on the limited predictive power of the variables included, further individual and school-level factors and their potential association with DHL should be investigated in the future. The promotion of DHL should be integrated into both teacher education and in-service training.

Subjective health literacy skills among Greek secondary school students: results from a national-wide survey

Health literacy is a significant element of education and is inextricably linked to children's and adolescents' growth and prosperity. It is critical to monitor students' health literacy on a nationwide scale and identify the factors that influence it in order to create policies that advance it. The purpose of this study was to determine the health literacy level of Greek secondary school students and to correlate it with possible determinants such as personal and family characteristics, social support and personal and/or family illness experiences. A representative sample of 2749 seventh-, ninth-, and tenth-grade students was involved. Results showed that a higher motivation to learn about health topics and having positive social interactions and support were strongly associated with a higher level of health literacy. Gender, high academic achievement, absence of learning disabilities, gender, preference for biology and informatics and primary source of health information were also found to influence the skills' level. In order to enhance health literacy, the Greek educational system should take measures to include health literacy skills development goals in their curricula.

Predisposing factors of health promotion behaviors and health literacy in adolescents: A cross-sectional design

OBJECTIVE

This study was designed to measure health promotion behaviors, health literacy (HL) levels, and their predisposing factors among adolescents.

DESIGN

A cross-sectional design was used.

SAMPLE

The study was completed by 1046 students aged 11-14 years.

MEASUREMENTS

Data were collected via the HL for School-Aged Children Scale and the Adolescent Health Promotion Scale.

RESULTS

HL was significantly associated with gender, participation in sport activities, and health promotion behaviors. There was no confounding factor for HL. Adolescent health promotion behaviors were significantly associated with academic level, weight perception, participation in sport activities, and HL.

CONCLUSIONS

Nurses could improve communication and decision-making skills related to health behaviors and learn how to obtain health-related knowledge to promote the health of adolescents.

Adolescents' understanding of the Nepalese version of HLS-CHILD-Q15: qualitative pre-testing in ninth-graders

INTRODUCTION

Research on health literacy is still at an early stage, lacking a dedicated measurement instrument for assessing children's and adolescents' health literacy. Such tools are necessary to generate the evidence required for informed intervention development. This study translated the validated German HLS-Child-Q15 into the Nepalese context, creating the HLS-Child-Q22-NEP.

METHODS

The research team initially created the HLS-Child-Q22-NEP using an additional item pool. We conducted thirteen one-on-one cognitive interviews with adolescent students from community schools in three districts of Nepal during the pre-test. We employed verbal probing techniques and deductively analysed the interviews based on Tourneau's model, uncovering four main themes: (1) comprehension (with the two sub-categories: a) item comprehension and b) word comprehension); (2) retrieval; (3) judgement; and (4) response.

RESULTS

Overall, participants responded positively to the HLS-Child-Q22-NEP. However, this study revealed comprehension challenges such as unfamiliarity, misunderstandings, and translation issues. Additionally, the study identified retrieval challenges and poor judgement, indicating limitations in the assessment. Participants experienced varying levels of difficulty with some items, emphasising the need for revised instructions. Subsequent revisions, guided by pretest insights, led to the development of the HLS-Child-Q24-NEP.

CONCLUSION

The development of the HLS-Child-Q22-NEP is a significant step in addressing Nepali adolescents' lack of health literacy measurement. Despite its generally positive reception, this study encountered challenges in comprehending the scale, prompting enhancements, and developing the HLS-Child-Q24-NEP. Further research, both qualitative and quantitative, is necessary to evaluate the validity and reliability of the modified items.

Health literacy of students in Germany - Results of the HBSC study 2022

Background

Health literacy (HL) encompasses knowledge and skills for dealing critically and confidently with health information in individual and social contexts. Current studies show that a high proportion of children and adolescents have limited health literacy, depending on aspects of their social background. Health literacy is considered an important factor influencing health. Little is known about the development of health literacy over time and its connection with psychosomatic complaints in young people.

Methods

Based on the results of the Health Behaviour in School-aged Children (HBSC) study, this article focusses on the level of HL in 11-, 13-, and 15-year-old students (N = 6,475) over time and taking social differences into account. Finally, the relationship between HL and psychosomatic complaints is analysed. Univariate, bivariate, and multivariate analyses were carried out for this purpose.

Results

At 24.4 %, slightly more students have low HL in 2022 than in 2017/18 (21.4 %). There are differences in HL according to gender, age, type of school, and family affluence. Low HL is associated with a high psychosomatic burden.

Conclusions

The results highlight the need for target group-specific measures to promote young people's HL, which address individual and organisational aspects of HL.

The Brief Health Literacy Scale for Adults: Adaptation and Validation of the Health Literacy for School-Aged Children Questionnaire

The Health Literacy for School-Aged Children (HLSAC) is a brief, generic instrument measuring health literacy among school-aged children. Given its brevity and broad conceptualization of health literacy, the HLSAC is a potentially valuable measuring instrument among adults as well. This validation study aimed to adapt the HLSAC questionnaire to an adult population through assessment of content validity and subsequently determine the structural validity of the adapted instrument, the Brief Health Literacy scale for Adults (B-HLA). The content validity of the HLSAC was assessed through interviews with respondents and experts, and the structural validity of the adapted instrument (B-HLA) was evaluated using Rasch analysis. The content validity assessment (n = 25) gave rise to adjustments in the wording of five items. The B-HLA demonstrated an overall misfit to the Rasch model (n = 290). Items 6 and 8 had the poorest individual fits. We found no signs of local dependency or differential item functioning concerning sex, age, education, and native language. The B-HLA demonstrated unidimensionality and ability to discriminate across health literacy levels (PSI = 0.80). Discarding items 6 or 8 resulted in an overall model fit and individual fit of all items. In conclusion, the B-HLA appears to be a valid and reliable instrument for assessing health literacy among adults.

Health literacy and the role of social support in different age groups: results of a German cross-sectional survey

BACKGROUND

Scholars demand more focus on context-related factors of health literacy as the management of health information is seen as a social practice. One prominent factor is social support that is expected to be particularly relevant for persons vulnerable for low health literacy. It was shown that health literacy can differ across the life span and especially older people have been demonstrated to be vulnerable for low health literacy. Therefore, health literacy and the relation of social support on health literacy in different age groups should be investigated.

METHODS

In a German nationwide survey 2,151 adults were interviewed face-to-face. General comprehensive health literacy was measured with the HLS19-Q47 which differentiates single steps of health information management - access, understand, appraise, and apply. Social support was measured with the Oslo 3 Social Support Scale. Bivariate and multivariate analyses were performed for all respondents and for five age groups.

RESULTS

Health literacy is relatively low in all age groups but particularly low among old-old people (76 + years). Also, the youngest adults (18-29 years) have slightly lower health literacy than middle-aged adults. On average, health literacy is higher among people with higher social support but this association varies between age groups. It tends to be quite strong among younger adults (18-45 years) and young-old persons (65-75 years) but is weak among older middle-aged (46-64 years) and old-old persons. The association also differs between steps of information management. It is stronger for accessing and applying information but there are differences in age groups as well.

CONCLUSIONS

Social support is a relevant aspect to improve individuals' health literacy and therefore should be addressed in interventions. However, it is necessary to differentiate between age groups. While both young adults and particularly old-old persons are challenged by health information management, young adults can strongly profit from social support whereas it can barely compensate the low health literacy of old-old persons. In addition, different challenges in information management steps in different age groups need to be considered when designing health literacy interventions. Thus, target group specific services and programs are needed.

The development and cross-national validation of the short health literacy for school-aged children (HLSAC-5) instrument

Health literacy is an asset for and indicator of adolescents' health and wellbeing, and should therefore be monitored and addressed across countries. This study aimed to develop and validate a shorter version of the original 10-item health literacy for school-aged children instrument in a cross-national context, using data from the health behaviour in school-aged children 2017/18 survey. The data were obtained from 25 425 adolescents (aged 13 and 15 years) from seven European countries. Determination was made of the best item combination to form a shorter version of the health literacy instrument. Thereafter, the structural validity, reliability, measurement invariance, and criterion validity of the new 5-item instrument were examined. Confirmatory factor analysis showed a good model fit to the data across countries and in the total sample, confirming the structural validity (CFI = 0.995, TLI = 0.989, SRMR = 0.011, RMSEA = 0.031). The internal consistency of the instrument was at a good level across countries (α = 0.87-0.98), indicating that the instrument provided reliable scores. Configural and metric invariance was established across genders, ages, and countries. Scalar invariance was achieved for age and gender groups, but not between countries. This indicated that the factor structure of the scale was similar, but that there were differences between the countries in health literacy levels. Regarding criterion validity, structural equation modelling showed a positive association between health literacy and self-rated health in all the participating countries. The new instrument was found to be valid and reliable for the purposes of measuring health literacy among adolescents in a cross-national context.

#EntreViagenseAprendizagens: study protocol of a school-based intervention to promote well-being and healthy lifestyles among adolescents

Background

Adolescence is a critical period of development in which well-being usually decreases, mental health problems (e.g., depression, anxiety) increase, and lifestyles become less healthy. Schools are a primary setting for the promotion of the well-being and overall health of adolescents, and preventive actions should be a priority within the scope of health-promoting schools. #EntreViagenseAprendizagens is a school-based intervention aiming to promote well-being and healthy lifestyles among adolescents based on social and emotional learning, positive psychology, and health education approaches.

Methods

This protocol describes a school-based intervention, #EntreViagenseAprendizagens, that will be implemented in several schools in Portugal. The program is aimed at 8th and 9th grade students (14-16 years old) and comprises 20 weekly sessions. One of the sessions is aimed at the students' parents/guardians. The intervention content targets social and emotional skills, health literacy (physical and mental health), healthy lifestyles, character strengths, and well-being. An experimental design will be used in the intervention evaluation. Eighth grade classes will be randomly assigned to the intervention group or the control group. All students complete the same assessment protocol at baseline, post-intervention, and 9-month follow-up. The impact assessment protocol includes measures related to well-being, health literacy, health-related knowledge, attitudes and behaviors, relationships with others, social and emotional skills, and sociodemographic data. Process evaluation includes evaluation forms at the end of each session and at the end of the program and focus groups with students, parents, and teachers at the end of the program.

Discussion

This school-based intervention may play an important role in promoting students' well-being and in preventing unhealthy lifestyles and socio-emotional maladjustment, by focusing on the development of social and emotional skills and health literacy among adolescents, empowering them to face the changing future and grow up healthy. Furthermore, this project aims to provide relevant scientific findings that can contribute to the development of better health-promoting schools.

Health literacy among adolescents and young adults in the Eastern Mediterranean region: a scoping review

OBJECTIVES

For adolescents and young adults, most health literacy research has been conducted in Western countries, but few studies have been conducted in the Eastern Mediterranean region (EMR). This review aimed to explore the existing health literacy research in the EMR in addition to the levels of health literacy and its associated factors among adolescents and young adults.

METHODS

The search, conducted using the PubMed/MEDLINE, EBSCOhost/CINAHL plus, Web of Science and J-STAGE databases, was initially performed on 16 June 2022 and later updated on 1 October 2022. Studies that targeted 10-25 years old persons, conducted in any of the EMR countries and that used the health literacy concept and/or described its levels or predictors were included in the review. Content analysis was used for data extraction and analysis. Data related to the study methods, participants, outcome variables and health literacy were extracted.

RESULTS

The review included 82 studies, most of which were conducted in Iran and Turkey and adopted a cross-sectional design. Half of the studies showed that more than half of adolescents and young adults had low or moderate health literacy. Nine studies applied university-based or school-based health education interventions to improve health literacy, which was also predicted by demographic and socioeconomic factors and internet usage. Little attention was paid to assessing the health literacy of vulnerable people, such as refugees and those with a disability and exposed to violence. Finally, various health literacy topics were investigated, including nutrition, non-communicable diseases, media and depression.

CONCLUSION

Health literacy levels were low-to-moderate in adolescents and young adults in the EMR. To promote health literacy, it is recommended to use school-based health education and attempt to reach adolescents and young adults through social media platforms. More attention should be paid to refugees, people with disabilities and those exposed to violence.

Improving adolescent health literacy through school-based health literacy intervention: a mixed-method study protocol

BACKGROUND

Health-promoting actions might benefit from adolescent health literacy (AHL), however, there is scant research on it in Nepal. This study identifies adolescent students' health literacy (HL) needs and trials an intervention to improve their HL and intention to take health-promoting actions.

METHODS

This study employs a pre-and post-test mixed-method intervention involving three phases. First, we will conduct a formative and summative evaluation to identify participants' HL needs and design an intervention using quantitative and qualitative methods. Second, the intervention will be administered to the intervention group. Finally, formative and summative post-tests will be conducted to assess the effectiveness of the intervention. We will select four community schools from Birendranagar municipality based on random sampling. In quantitative research, data will be collected from adolescents selected through a census with standardized scales such as the HLS-Child-Q15, self-efficacy, social support, and health-promoting actions. A framework analysis was conducted to analyze qualitative data collected from focus group discussions with purposively chosen adolescents and key informant interviews with Health and Physical Education teachers and school nurses. The difference in difference approach will be used to analyze the intervention's outcome, i.e., the participants' improved HL, and health-promoting actions.

DISCUSSION

This is one of the first studies to explore HL in this group in Nepal. This study will provide the first insights into the overall level of AHL, potential AHL determinants, and the relationship between AHL and the intention to participate in health-promoting activities. The data can then be used to inform health promotion and health literacy initiatives.

Involving Children in Health Literacy Research

Despite the volume and breadth of health literacy research related to children, children's involvement in that research is rare. Research with children is challenging, but the principles of involvement and engagement underpin all health promotion work, including health literacy. This commentary reflects on the process of setting up a Children's Advisory Group to consult on an institutional ethnography study of health literacy work from children's standpoint. The Children's Advisory Group contributed feedback on the study ethics and design and piloted methods for rapport-building and data collection, including livestreamed draw-and-describe and modified Interview to the Double. Consulting with the Children's Advisory Group highlighted the importance of listening to children and recognizing and valuing children's imaginative contributions to methods for involving children in health literacy research. Insights from this commentary can be used to foreground equity-focused approaches to future research and practice with children in the field of health literacy.

A teacher professional development programme to enhance students’ critical health literacy through school-based health and physical education programmes

Health literacy is a critical asset for adolescents to develop given its positive impact on health outcomes. The few studies that have targeted teacher knowledge and attitudes show that teachers themselves find it difficult to: navigate the multi-modal nature of health information; critically evaluate the different modes and texts; and apply health-related information in a variety of contexts. This research study aimed to address this issue through developing and implementing a teacher professional development (PD) programme for three Australian secondary schools and nine Health and Physical Education (HPE) teachers to improve health literacy, particularly critical health literacy, content and pedagogies embedded in current HPE programmes. Fifteen HPE programmes were analysed using Nutbeam’s health literacy hierarchy and the Australian Curriculum: HPE outcomes and content, with this analysis informing a personalized PD programme. To evaluate how teachers experienced the personalized PD programme, interviews conducted at the completion of the PD programme were analysed using Braun and Clarke’s thematic approach. According to the teachers, the PD had improved their knowledge and understanding of the three levels of HL, including how to implement it into their practice. The personalized nature was a key strength of the PD programme as it allowed for changes to be made in a time-efficient manner, a known challenge for teachers. Teachers recommended the provision of additional resources that foster students’ critical health literacy levels and an additional session to ensure sustainable changes in planning and teaching practices.

Level of health literacy in Latvia and Lithuania: a population-based study

Background

Measuring and understanding the level of health literacy serves as a starting point for developing various policies in health care. The consequences of weak health literacy competencies are severe; they result in riskier health behaviour, poorer health status, more frequent emergency visits and hospitalizations. This research has three aims: i) measure the level of health literacy in the populations of Latvia and Lithuania; ii) investigate which demographic and socioeconomic determinants are associated with it; and iii) discuss the means of improving its current level.

Methods

We employ a validated survey tool, the 47-item European Health Literacy Questionnaire (HLS-EU-Q). In addition to the 47 questions in the domains of health care, disease prevention, and health promotion, the participants’ demographic and socioeconomic characteristics are assessed. Face-to-face paper-assisted surveys are conducted with randomly selected residents from Latvia and Lithuania. The level of health literacy is measured by the health literacy index. Spearman correlation analyses and multiple regressions models are employed for investigating the association between the health literacy level and its determinants. The survey tool is complemented with in-depth interviews with six healthcare industry experts in order to assess the most promising ways to improve the level of health literacy.

Results

The stratified random sampling with quota elements assured a representative sample in terms of gender, urban/rural distribution and regions. In Latvia, 79% of the population possesses weak health literacy competencies. In Lithuania, 73% of the population can be characterized with inadequate or problematic level of health literacy. The most important determinants of the health literacy level include age, financial situation, social status, and ethnicity. In particular, elderly (aged 76 and over) and the Latvian-speaking population are less health literate, while those having better financial situation and higher social status are more health literate. The three most promising ways to improve the level of health literacy, as suggested by the healthcare industry experts, include health education in schools, provision of structured health-related information in Latvian and Lithuanian, and guidelines for the most common health problems.

Conclusions

The proportion of population with inadequate or problematic level of health literacy is higher in Latvia and Lithuania than in several other European countries. There is an urgent need to develop policies to improve it.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13690-022-00886-3.

Adolescents' Nutrition: The Role of Health Literacy, Family and Socio-Demographic Variables

Adolescent obesity rates are increasing on an epidemic level and food intake is one of the most important causes of this condition. From an ecological perspective, food intake is, in turn, influenced by many factors that need to be considered. This study aims to evaluate the associations between socio-demographic factors (gender, family origin, socio-economic status, parent's education level), which consist of social stratifiers, health literacy and family context, as independent variables, and food intake (consumption of fruits, vegetables, soft drinks and sweets and breakfast frequency) and outcomes (Body Mass Index category), as dependent variables. Data were retrieved from 2145 students (13 and 15 years old) from the Lombardy region (Italy) who participated in the 2018 edition of Health Behaviour in School-Aged Children (HBSC). Six multiple binary logistic regression models were used in this study. Fruit, vegetable and soft drinks consumption models were related to all three-factor levels. Breakfast consumption frequency was associated with socio-demographic variables. BMI category was associated with socio-demographic and family variables. The results confirmed the existence of social inequalities, the importance of health literacy in predicting healthy behaviours and the relevance of the family context. The study confirms the importance of the ecological approach to understanding food intake and overweight/obesity status in adolescents.

Measuring Health Literacy in Basic Education in Finland: The Development of a Curriculum- and Performance-Based Measurement Instrument

This paper describes the development of an objective curriculum- and performance-based health literacy (HL) measurement instrument to assess Finnish 9th graders' learning outcomes in the school subject termed Health Education (HE). There were four phases: (i) construction of the theoretical framework for the measurement, (ii) item generation, (iii) the field test (n = 252), and (iv) item analysis and item selection for the main study, in which 3652 ninth grade pupils (aged 15-16) participated. Initially, 303 HL test items were formulated, of which 107 were tested in two different field test versions. Both versions exhibited high reliability as measured by Cronbach's alpha coefficient. The main study contained 55 items. Testing and item analysis enabled the development of a comprehensive competence- and curriculum-based HL measurement instrument for school-aged children. Measurement of HL in schools provides information for national policies, and for developing HE as a school subject.

School water, sanitation, and hygiene (WaSH) intervention to improve malnutrition, dehydration, health literacy, and handwashing: a cluster-randomised controlled trial in Metro Manila, Philippines

BACKGROUND

The impacts of multicomponent school water, sanitation, and hygiene (WaSH) interventions on children's health are unclear. We conducted a cluster-randomized controlled trial to test the effects of a school WaSH intervention on children's malnutrition, dehydration, health literacy (HL), and handwashing (HW) in Metro Manila, Philippines.

METHODS

The trial lasted from June 2017 to March 2018 and included children, in grades 5, 6, 7, and 10, from 15 schools. At baseline 756 children were enrolled. Seventy-eight children in two clusters were purposively assigned to the control group (CG); 13 clusters were randomly assigned to one of three intervention groups: low-intensity health education (LIHE; two schools, n = 116 children), medium-intensity health education (MIHE; seven schools, n = 356 children), and high-intensity health education (HIHE; four schools, n = 206 children). The intervention consisted of health education (HE), WaSH policy workshops, provision of hygiene supplies, and WaSH facilities repairs. Outcomes were: height-for-age and body mass index-for-age Z scores (HAZ, BAZ); stunting, undernutrition, overnutrition, dehydration prevalence; HL and HW scores. We used anthropometry to measure children's physical growth, urine test strips to measure dehydration, questionnaires to measure HL, and observation to measure HW practice. The same measurements were used during baseline and endline. We used multilevel mixed-effects logistic and linear regression models to assess intervention effects.

RESULTS

None of the interventions reduced undernutrition prevalence or improved HAZ, BAZ, or overall HL scores. Low-intensity HE reduced stunting (adjusted odds ratio [aOR] 0.95; 95% CI 0.93 to 0.96), while low- (aOR 0.57; 95% CI 0.34 to 0.96) and high-intensity HE (aOR 0.63; 95% CI 0.42 to 0.93) reduced overnutrition. Medium- (adjusted incidence rate ratio [aIRR] 0.02; 95% CI 0.01 to 0.04) and high-intensity HE (aIRR 0.01; 95% CI 0.00 to 0.16) reduced severe dehydration. Medium- (aOR 3.18; 95% CI 1.34 to 7.55) and high-intensity HE (aOR 3.89; 95% CI 3.74 to 4.05) increased observed HW after using the toilet/urinal.

CONCLUSION

Increasing the intensity of HE reduced prevalence of stunting, overnutrition, and severe dehydration and increased prevalence of observed HW. Data may be relevant for school WaSH interventions in the Global South. Interventions may have been more effective if adherence was higher, exposure to interventions longer, parents/caregivers were more involved, or household WaSH was addressed.

TRIAL REGISTRATION NUMBER

DRKS00021623.

Investigating knowledge structure and research trends in child and adolescent health literacy research through network text analysis

PURPOSE

This study aims to investigate the knowledge structure and research trends in child and adolescent health literacy research over the past 30 years by using network text analysis.

METHOD

The study was conducted in four steps: 1) collecting abstracts, 2) keyword extraction and preprocessing, 3) creation of co-occurrence matrix, and 4) text network analysis.

RESULTS

As a result of the centrality analysis, the upper-ranked core keywords were "health care," "health behavior," "prevention," "treatment," and "health promotion." In contrast to earlier times, "barrier," "caregiver," "school setting," and "QOL" have recently emerged as core keywords.

CONCLUSIONS

Over the past 30 years, child and adolescent health literacy has been importantly addressed in both clinical and public health approaches. The results of the current study provide references for future research in child and adolescent health literacy.

IMPLICATION FOR PRACTICE AND RESEARCH

This study suggests the need for additional research on school-based practices that can improve health literacy and for identifying validated and reliable multidimensional health literacy assessment instruments.

Measuring Health Literacy in Childhood and Adolescence with the Scale Health Literacy in School-Aged Children – German Version

Abstract. Health literacy can help explain health inequalities in childhood and adolescence. However, suitable instruments for assessing health literacy in this age group are rare, especially in the German-speaking countries. One economical measure is the 10-item Health Literacy in School-Aged Children (HLSAC) scale, developed and reviewed as part of the WHO Child and Adolescent Health Study (HBSC, Health Behavior in School-Aged Children). In the present study, we tested dimensionality, measurement invariance, and associations with health-related measures of the German version of the scale (HLSAC–German), using data from the 2018 national German HBSC study ( N = 4,347 students aged 11, 13, and 15 years). We also tested HLSAC–German with 11-year-olds, representing an expansion of the original scale. Exploratory and confirmatory factor analyses consistently demonstrated the unidimensionality of the scale (α = .88). Complete scalar measurement invariance was found for sex and partial scalar measurement invariance for age groups and school type, allowing for the comparison of means. Associations with indicators of health and health behavior further demonstrate the construct validity of the scale. The analyses show that the scale is suitable for the economic measurement of a general factor of health literacy in 11- as well as in 13- and 15-year-olds.

Förderung der mentalen Gesundheitskompetenz im Jugendalter

Hintergrund

International und national wird der Ruf laut, Gesundheitsförderung in Schulen zu verankern, nicht erst, aber insbesondere im Zusammenhang mit dem Anstieg der Rate psychischer Auffälligkeiten seit dem Beginn der „coronavirus disease 2019“(COVID-19)-Pandemie. Die Förderung mentaler Gesundheitskompetenz (mGeKo) erfährt in den vergangenen Jahren als möglicher Ansatzpunkt zunehmende Aufmerksamkeit.

Fragestellung

Welche Evidenzen gibt es für die Förderung der mGeKo im Jugendalter im schulischen Setting, und wie gestaltet sich die praktische Umsetzung in Deutschland?

Methode

Literaturübersicht, Recherche in Datenbanken zu Programmen zur Förderung der mGeKo im schulischen Kontext (Sekundarstufe I).

Ergebnisse

Die Förderung der mGeKo erscheint, gerade bei einer Implementierung im Schulkontext, als ein vielversprechender Ansatz: Erste Programme existieren, Metaanalysen weisen auf signifikante Effektstärken im unteren bis mittleren Bereich hin. Es bestehen jedoch ein weiterer Forschungsbedarf (z. B. hinsichtlich distaler Endpunkte) und Schwierigkeiten bei der Umsetzung in die Praxis.

Schlussfolgerungen

Durch eine theorie- und evidenzbasierte Umsetzung kann Schule als Lern- und Lebensort für das wichtige Thema psychische Gesundheit sensibilisiert und für unterstützende Maßnahmen motiviert werden; eine Berücksichtigung der Hürden im deutschen Schulsystem erscheint für eine erfolgreiche Umsetzung maßgeblich.

Zusatzmaterial online

Die Online-Version dieses Beitrags (10.1007/s00278-022-00622-w) enthält eine Liste mit universellen Programmen zur Förderung der mentalen Gesundheitskompetenz (mGeKo) im Schulkontext.

Who Is Able to Resist What Is Forbidden?—The Relationship between Health Literacy and Risk Behaviours in Secondary School Students in the Broader Social and Educational Context

In the last Health Behaviour in School-Aged Children (HBSC) survey conducted in Poland in 2018, a group of 17-year-old adolescents (n = 1663; mean age 17.63 ± 0.36 years) was included outside the international protocol. This allowed an assessment to be made of their level of health literacy (HL) using the 10-point HBSC research tool. The aim of the study was to investigate the relationship between HL and risk behaviours (RB). A standardised index of RB in the last 30 days was considered as an outcome measure. This index was significantly higher in the group with low HL (0.318 ± 1.269) in comparison with the group with high HL (−0.083 ± 0.962). In a multivariate linear regression model, the strongest predictors of RB were gender, academic performance and level of regional deprivation, but the association with HL remained significant. This significant association persisted in general schools and in girls but disappeared in vocational schools and in boys. It was also shown that in rural areas, good academic performance has a less significant impact on RB if the HL level is low. The analyses led to the conclusion that when examining the relationship between HL and RB in older adolescents, it is advisable to take into account gender, the educational track and neighbourhood characteristics.

Self-Rated Health Status of Upper Secondary School Pupils and Its Associations with Multiple Health-Related Factors

Health is an essential part of any individual, and gains particular importance in youth, as a good health at this age is more likely to reduce health risks both in the short and long term. The aim of this study was to assess the impact of physical and contextual parameters on youths’ perceived health. A total of 919 adolescents completed questionnaires on self-rated health status, electronic media use, leisure time and club physical activity, alcohol and tobacco consumption, and back pain, as well as performed the German Motor Performance Test. Participants with very good health had significantly higher physical fitness, leisure time exercise, and participated in sports clubs more often than those with poorer health. Electronic media use was significantly higher for those with poor/very poor health. Future intervention programs to improve youth health status should not only focus on active lifestyle but might also consider the impact of socioenvironmental factors, such as daily media use.

[Digital health literacy of pupils. Level and associations with physical activity and dietary behavior]

Hintergrund

Während vermehrt Studienbefunde zur allgemeinen Gesundheitskompetenz (GK) vorliegen, mangelt es an Erkenntnissen zur digitalen GK im Jugendalter und deren Assoziationen mit Indikatoren des Gesundheitsverhaltens.

Methodik

Empirische Basis bildet eine von Oktober 2019 bis Februar 2020 im Bundesland Hessen durchgeführte Querschnittstudie mit 490 Schülerinnen und Schülern der Klassenstufe 8 und 9. Die digitale GK wurde mithilfe von 5 Subskalen des Digital Health Literacy Instrument (DHLI) erfasst, während der Verzehr von Obst, Gemüse und Softdrinks sowie die körperliche Aktivität als Indikatoren des Gesundheitsverhaltens herangezogen wurden. Als soziales Merkmal wurde neben dem Geschlecht und der Klassenstufe der subjektive Sozialstatus (SSS) berücksichtigt. Die Datenauswertung erfolgte uni-, bi- und multivariat, wobei binärlogistische Regressionen für das Geschlecht und den SSS adjustiert wurden.

Ergebnisse

Über alle Items hinweg berichten 15,3–37,5 % der befragten Jugendlichen Schwierigkeiten bei der Beschaffung von und im Umgang mit digitalen Informationen. Differenziert nach sozialen Merkmalen finden sich für 2 Dimensionen der digitalen GK Unterschiede zuungunsten der Mädchen sowie durchgehend ein sozialer Gradient zuungunsten von Befragten mit niedrigem SSS. Jugendliche mit mittlerer und geringer digitaler GK weisen ein höheres Maß an geringer körperlicher Aktivität, nichttäglichem Obstverzehr und täglichem Konsum von zuckerhaltigen Getränken auf.

Diskussion

Die Befunde weisen auf einen Interventionsbedarf zur Förderung der digitalen GK insbesondere bei Jugendlichen mit geringem SSS hin. Die differenziellen Zusammenhangsmuster mit dem Gesundheitsverhalten bieten Ansatzpunkte für die Entwicklung spezifischer Interventionen. Als Lehr- und Lernort stellt die Schule u. a. aufgrund der Passung mit verpflichtenden Strategien der schulischen Medienkompetenzbildung ein geeignetes Setting dar.

The Development and Evaluation of an e-Learning Course That Promotes Digital Health Literacy in School-age Children: Pre-Post Measurement Study

Background

Experts agree that the promotion of (digital) health literacy should be an integral part of the school curriculum. However, promoting (digital) health literacy within the German school system is difficult because (digital) health education is not a mandatory school subject in all the German states. Therefore, experts suggest that (digital) health literacy could be addressed as part of the mandatory framework for digital education and digital literacy in schools developed by the German Conference on Education Ministries and Cultural Affairs (Kultusministerkonferenz).

Objective

The goal of this study was to evaluate a newly developed e-learning course that was designed to improve (digital) health literacy in school-age children and concurrently to teach skills specified in the mandatory framework for digital education and digital literacy in schools. It was hypothesized that participants’ health literacy and digital health literacy levels would be higher after completing the e-learning course than they were before doing the course. Furthermore, it was hypothesized that after completing the e-learning course, participants’ subjective and objective knowledge in the domain of (digital) health literacy would be higher than it was before doing the course.

Methods

The pre-post measurement study was conducted online. After participants (N=323) gave their informed consent to participate in the study, they provided demographic information and answered all measures (premeasurement). Following this, participants had 7 days to complete the e-learning course. After finishing the e-learning course, participants answered all the measures again (postmeasurement).

Results

To test the hypotheses, Bayesian paired samples t tests (1-sided) were conducted. After completing the e-learning course, participants showed higher health literacy levels. Specifically, they showed higher competency levels in the domains of theoretical knowledge (Bayes factor [BF]_–0=676,000; δ=–0.316), practical knowledge (BF_–0=92,300; δ=–0.294), critical thinking (BF_–0=7.42e+13; δ=–0.482), self-awareness (BF_–0=11,500,000; δ=–0.345), and citizenship (BF_–0=266,000; δ=–0.306). Furthermore, participants achieved higher digital health literacy levels. Specifically, they achieved higher competency levels in the domains of information searching (BF_–0=2.339; δ=–0.135), evaluating reliability (BF_–0=2.03e+11; δ=–0.434), and determining relevance (BF_–0=316,000; δ=–0.308). Moreover, participants demonstrated higher subjective (BF_–0=3.58e+82; δ=–1.515) and objective knowledge (BF_–0=3.82e+97; δ=–1.758) in the domain of (digital) health literacy.

Conclusions

The newly designed e-learning course provides an easy way for schools and teachers from all German states to integrate (digital) health literacy education into their school curriculums and lessons. The evaluated course is especially attractive because it was designed to improve (digital) health literacy and at the same time to teach skills specified in the mandatory framework for digital education and digital literacy in schools developed by the German Conference on Education Ministries and Cultural Affairs (Kultusministerkonferenz).

A cross-sectional study examining self-reported anthropometric measurements with adolescents' nutrition attitudes, obesity awareness and diet quality indices during the pandemic

PURPOSE

The purpose of this study is to evaluate the relationship between adolescents' nutritional attitudes, obesity awareness, and diet quality with their self-reported anthropometric measurements taken during the COVID-19 pandemic.

DESIGN AND METHODS

This cross-sectional type of study was conducted in a district in the south of Turkey. The research was carried out online with 907 adolescents who agreed to participate voluntarily.

RESULTS

Among the adolescents, 28.5% considered themselves overweight, and 32.1% were currently trying to lose weight. According to BMI, 16.1% were affected by overweight/obesity. Adolescents' nutritional attitudes and obesity awareness levels were moderate, while their KIDMED nutritional habits were also moderate. In this study, a negative relationship was found between the adolescents' ASHN mean scores and their body weight, waist circumference, hip circumference, neck circumference, waist/hip ratio and waist/height ratio measurements; and between their OAS mean scores and their body weight, waist circumference, waist/hip ratio and waist/height ratio measurements; and between their KIDMED index scores and their waist/height ratio measurements (p < 0.001).

CONCLUSIONS

The rate of adolescents who perceive themselves as overweight is higher than the results obtained from the measurement values. BMI levels and other anthropometric measurement values of adolescents with positive nutrition attitudes and physical activity behaviours are also positively affected.

PRACTICE IMPLICATIONS

This study may have a significant impact on the formulation and implementation of interventions to prevent obesity and increase physical activity for school health nurses. Since the pandemic is still continuing, healthcare providers must stress the risk of obesity in adolescence.

Using Co-Design to Develop a Health Literacy Intervention with Socially Disadvantaged Adolescents

The aim of this study was to initiate a co-design process with adolescents to inform the development of a targeted health literacy intervention for implementation in designated socioeconomically disadvantaged post-primary schools in Ireland. Purposely developed vignettes were explored in a series of eight workshops that were conducted separately with staff (n = 26) and students (n = 33) across four schools. Data was analysed using content analysis. A number of key health topics were identified as important and influential for the participants in this context: food choices, mental health and wellbeing, physical activity and sedentary behaviour, sleep and substance misuse. Participants also suggested many health-related capacity building actions. Participants recognized that many of these health topics and capacity building actions were intertwined and also highlighted that some of these actions may be more feasible and/or impactful than others. For example, students and school staff both indicated the need to use relevant, applied and engaging approaches to improve health literacy and subsequent health behaviour. The co-design process adopted empowered stakeholders to actively engage in the design and development of future intervention strategies, which may increase the likelihood of acceptability, effectiveness and sustainability of the resulting intervention.

Is Adolescent Risk Behavior Associated With Cross-Household Family Complexity? An Analysis of Post-separation Families in 42 Countries

We examine whether complex cross-household structures of post-separation families are associated with higher risk-taking behavior in adolescence (substance use, bullying, early sexual onset) and whether the proportion, and thus statistical normality, of complex family types in a certain country is a potential moderator of this association. Drawing on representative data from 42 countries and regions from the Health Behavior in School-aged Children (HBSC) study in 2001, 2006, and 2010 (N = 506,977), we provide detailed analyses on adolescent risk behavior even for very rare family types, thereby accounting for the complex cross-household structure present in many post-separation families. We combine logistic and count regression models to analyze risk incidence and intensity. Controlling for relevant child and family characteristics, our results reveal a gradient along which adolescent risk-taking increases with family complexity: The incidence and intensity of risk-taking among adolescents is lowest in two-biological-parent and highest in two-household families with stepparents in both households. The association decreases with a higher proportion of the respective family type in a country. However, the differences between family types, other than the two-biological parent family, are not as pronounced as expected.

How children in Sweden accessed and perceived information during the first phase of the Covid-19 pandemic

AIM

To describe how children in Sweden accessed and perceived information about SARS-CoV2 and Covid-19 during the first phase of the outbreak.

METHODS

This study is a substudy of an international cross-sectional online mixed methods survey examining elements of children's health literacy in relation to Covid-19. The survey included multiple-choice questions, open-ended questions and drawings and collected information from 50 Swedish children (7-12 years). Data were analysed concurrently on a descriptive level using statistics and content analysis. Quantitative and qualitative data, including the drawings, were considered equally important and resulted in six categories, illuminating how children accessed and perceived information about the pandemic.

RESULTS

The survey showed that children accessed information mainly from school but also from TV. They preferred information from reliable sources. Children reported the information they accessed as easy to understand and it prompted them to ask new questions. They reported they knew a lot about the pandemic, for example, the potential danger to themselves and others and how to act to protect themselves and others. They perceived the pandemic as an intrusion on their lives.

CONCLUSIONS

This study indicates that Swedish children between 7 and 12 years old were well informed about SARS-CoV2 and Covid-19 during the first phase of the pandemic. School was shown to be an important source of information. The children could explain how to act to protect themselves and others from becoming infected by the virus.

The role of health literacy in the association between academic performance and substance use

BACKGROUND

To address social inequalities in adolescent substance use and consequent disparities in health, it is important to identify the mechanisms of the association between substance use and academic performance. We study the role of health literacy (HL) in the association between academic performance and weekly smoking, monthly alcohol use and cannabis ever-use among adolescents in Europe.

METHODS

SILNE-R school survey data, which was collected in 2016-17 with paper-and-pencil-method from Hanover (GE), Amersfoort (NL) and Tampere (FI), were used (N = 5088, age 13-19). Health Literacy for School-aged Children instrument was used to assess students' HL. Logistic regression analyzed the association of substance use with academic performance and HL, separately and in the same model. Linear and multinomial logistic regression analyzed the association between academic performance and HL.

RESULTS

Poor academic performance compared with high was associated with smoking [odds ratio (OR) 3.94, 95% confidence interval (CI) 2.83-5.49], alcohol use (OR: 2.94, 95% CI: 2.34-3.68) and cannabis use (OR: 2.56, 95% CI: 1.89-3.48). Poor HL was also associated with each substance use (with ORs of 2.32, 1.85 and 1.29). HL was positively associated with academic performance (β = 1.04, 95% CI: 0.89-1.20). The associations between academic performance and substance use were only slightly attenuated after controlling for HL.

CONCLUSIONS

Academic performance and HL were both determinants of substance use, confirming their role in tackling the disparities in substance use. However, HL did not demonstrably mediate the association between academic performance and substance use. A wider set of factors needs to be tackled to address emerging social inequalities in adolescent substance use.

Change in children's perception of cancer in the last 10 years in Japan

BACKGROUND

Social awareness of cancer can be changed with cancer education and proper distribution of cancer information. This study addressed the current situation and historical changes to children's perception of cancer.

METHODS

Questionnaire surveys were conducted among healthy school children aged 10-15 years in 2008 and 2018. Knowledge of cancer was surveyed and compared with that of asthma, tuberculosis, and measles. The children were asked about their health information resources.

RESULTS

The numbers of participants and collection rates were 438 and 63.9% in 2008, and 320 and 44.7% in 2018. Children's perception of cancer changed significantly in the last decade. The proportion of respondents answering "cancer affects children" changed from 78.3 to 89.5% (P = 0.0001), "cancer is preventable" from 42.0 to 49.7% (P = 0.0425), and "cancer is curable," from 52.4 to 66.0% (P = 0.0003). Significantly more junior high school students answered that cancer is preventable than elementary school children in 2018 (55.9 vs 42.7%, P = 0.0028). The major resources of information on health were television, parents, and books. The proportion of children choosing the Internet significantly increased from 15.3 to 47.8% (P < 0.0001). Significantly more junior high school students selected television and the Internet than elementary school children (94.5 vs 86.9%, P = 0.0202 for television; 57.1 vs 37.9%, P = 0.0007 for the Internet).

CONCLUSIONS

The proportion of children correctly perceiving cancer information had increased in the last decade. Junior high school students better understood the information. The Internet is of increasing importance as an information resource for school children.

Adolescents' online communication and well-being: Findings from the 2018 health behavior in school-aged children (HBSC) study

BACKGROUND

Digital transformation has influenced all areas of adolescents' lives, including the ways adolescents maintain friendships. Interpersonal communication is one of the most common activities while online. Online communication may provide adolescents with opportunities to expand their social contacts, but these encounters can be risky, especially when the communication is with unknown people on the internet. This study examined the associations between different forms of online communication behavior and well-being.

MATERIALS AND METHODS

Data were collected from Finnish adolescents as part of the Health Behavior in School-Aged Children (HBSC) study in 2018. The participants were 3,140 Finnish adolescents aged 11-15 years. Descriptive analyses were used to examine the frequency of different forms of online communication behaviors. The associations between online communications and individual factors were analyzed using the X² test and 95% confidence intervals. Structural equation modeling (SEM) was used to analyze the extent to which adolescents' online communication behavior explained the variance in adolescents' well-being indicators.

RESULTS

Overall, 60% of the adolescents reported communicating intensively with close friends, with higher rates of intensive communication reported by girls, higher age groups, and the high health literacy group. 22% of adolescents reported intensive communication with friends they got to know through the internet (online friends), while intensive online communication with unknown people was reported by 13% of adolescents. Overall, around one-fourth of adolescents preferred sharing personal matters online rather than in face-to-face encounters, and 10% of adolescents reported using the internet daily to get to know new people, and to look for like-minded company. The SEM analysis showed that keeping online contact with offline friends was linked to a positive outcome in all the measured well-being indicators; however, intensive communication with people contacted only online (online friends and unknown people) was negatively associated with well-being indicators (lower self-rated health, lower life satisfaction, higher loneliness, and problematic social media use).

CONCLUSION

Both positive and negative associations were observed between online communication and well-being, depending on the target and content of the communication. The results indicate that online communication has benefits for adolescents who have more offline social life. Overall, one should ensure that the impact of interventions is proportionately greater for adolescents at the bottom end of the health gradient.

Promoting Navigation Health Literacy at the Intersection of Schools and Communities. Development of the Game-Based Intervention Nebolus

Emerging empirical evidence indicates a limited health literacy for a substantial proportion of children and adolescents. Although it is generally agreed upon promoting health literacy as early as possible in the lifespan, there is a lack of interventions addressing children and adolescents and their primary living environments. This article describes the development of Nebolus, a game-based intervention aiming to promote navigation health literacy at the intersection of schools and communities. Its intervention foundation lies in a socio-ecological understanding of health as well as in the Entertainment Education approach. Following an extensive literature search on health-related location-based games, a co-creation process was initiated that involved adolescents, community stakeholders, and design/IT professionals in all phases of the intervention development. The final Nebolus intervention includes three core activities: (1) a Nebolus rally app for adolescents aged 12 to 16 years, (2) an online planning tool allowing local health service providers/professionals to set up own Nebolus rallies, and (3) accompanying teaching material on health literacy in the school setting to be used before and after the Nebolus rallies. This article provides an overview of the intervention layout and discusses strengths and challenges of its development and implementation.

Association between health literacy and leisure time physical activity among Lithuanian adolescents

Recently, discussion of the potential of health literacy (HL) for health promotion has increased; however, clear evidence illuminating the relationship between adolescents' HL and their physical activity (PA) remains scarce. This study aimed to assess the association between adolescents' HL and leisure time PA. A representative cross-sectional study was conducted with 2,369 Lithuanian adolescents aged 13-16 years. A self-reported questionnaire gathered information regarding HL, leisure time PA, and other confounders (gender, age, family affluence and parents' exercise). Descriptive statistics and the probabilities of being physically active were estimated using logistic regression. The results revealed that almost 60% of the participants were not sufficiently physically active. Having moderate or high levels of HL was positively associated with leisure time PA. Additionally, being male, belonging to a more affluent family, and having a father who exercise were significant predictors of adolescents' leisure time PA. This study revealed that moderate and high HL positively related to leisure time PA among Lithuanian adolescents. The study results highlighted the importance of encouraging schoolchildren's PA and including HL promotion in a school curriculum.

A Study on the Reliability and Validity of the Korean Health Literacy Instrument for Late School-Aged Children

This study aimed to develop and validate the Korean Health Literacy Instrument, which measures Korean late school-aged children's understanding capacity. The construct's concepts were drawn from the literature review and interviews with school nurses and teachers. A survey was then conducted in 552 fifth and sixth graders in nine elementary schools, from 1 to 9 May 2014. The KR-20 coefficient for reliability, difficulty index, discrimination index, item-total correlation, and known group technique for validity were performed. An exploratory factor analysis was performed to test the construct validity of the instrument and its unidimensionality. The results reveal that a two-factor structure was appropriate for the Korean school-age health literacy tool (root mean square error of approximation = 0.06, Comparative Fit Index = 0.96, and Tucker-Lewis Index = 0.95). From the remaining 16 items, the internal consistency reliability coefficient of this instrument was 0.85, and the criterion-related validity was 0.62 (p < 0.001). The Korean health literacy instrument for late school-aged children was suitable for screening individuals who have limited health literacy. Based on the findings of this study, future studies must continue to conduct empirical investigations on the Korean health literacy instrument for late school-aged children.

Health Literacy Levels among Italian Students: Monitoring and Promotion at School

Health literacy was identified as an important determinant of health, particularly for adolescents. However, more efforts are needed to monitor this construct and provide inputs for policy development. This study aims to: (a) Assess the validity and reliability of the Italian version of the Health Literacy for School-Aged Children (HLSAC-I); (b) Identify the health literacy levels among Italian students and compare them with other countries’ levels; and (c) Identify the associations between health literacy and multiple social determinants (social stratifiers, family, and school connectedness). Data came from the Health Behaviour School-Aged Children survey, carried out in the Lombardy region in northern Italy in 2018. A representative sample of 2,287 13- and 15-year-old Lombardian students was involved. The results support the validity and reliability of the HLSAC-I. A total of 18.7% of the sample reported low levels, and only 6.8% reported high levels. Italian students reported the lowest levels of health literacy compared with other countries. School connectedness and educational approach are the most relevant associated factors. This study confirms a school’s role in reducing inequalities and promoting health. It highlights the importance of monitoring health literacy and implementing health promotion policies at school through a whole-school approach.

Childhood Socioeconomic Position, Adult Educational Attainment and Health Behaviors: The Role of Psychological Capital and Health Literacy

Socioeconomic circumstances during childhood and adulthood are known to negatively affect health promoting behaviors. On the other hand, psychological capital (PsyCap) and health literacy are positively associated with these lifestyle behaviors. We, therefore, reasoned that PsyCap and health literacy might “buffer” the negative influences of socioeconomic circumstances on health-promoting behaviors. Method: We measured subjective childhood socioeconomic position (SEP) and adult educational attainment (as a proxy for adult socioeconomic circumstances), health literacy, PsyCap, and health behaviors (fruits and vegetables consumption, exercise, and sweets and cookies consumption) in a sample of N = 150 individuals (mean age 34.98 years, 66.7% female). Results: Bootstrapped mediation analyses including PsyCap and health literacy as parallel mediators revealed that: (I) The relationship between childhood SEP and (a) fruits and vegetables consumption and (b) exercise was mediated by PsyCap, and (II) the relationship between adult educational attainment and (a) fruits and vegetables consumption and (b) exercise was mediated by PsyCap and health literacy. We found no significant effects for consumption of sweets and cookies. Conclusion: These results suggest that larger studies are warranted that confirm the potential of PsyCap and health literacy in mitigating the negative effects of lower SEP on health behaviors and health outcomes.

Adolescent Health Literacy and Neighbourhood Features: HBSC Findings from Czech Republic, Poland, and Slovakia

The role of supportive environments on health, wellbeing, and longevity has been widely recognized. However, there is no strong empirical evidence on the association between health literacy (HL) as a particular health-related competence and neighbourhoods. Therefore, the aim of the study was to assess the association between the features of neighbourhoods and the level of HL competencies of young people from three countries (Czech Republic, Poland, Slovakia). Self-reported data from an international sample of 11,521 students aged 13-15 years participating in the Health Behaviour in School-aged Children Study (HBSC) in the year 2018 were included in the analyses. The level of HL shows a strong positive relationship with family wealth, and a significant relationship is maintained in all studied countries. Both social and structural features of neighbourhoods turned out to have an impact on students' HL. However, HL is most clearly explained by the school environment. This study confirms the school effect on higher levels of HL competences in adolescents. This indicates the need to invest in schools located in less affluent areas to generally improve the level of education, implement modern health education combined with HL, and strengthen the social and health competencies of students.

Addressing Health Literacy in Schools in Germany: Concept Analysis of the Mandatory Digital and Media Literacy School Curriculum

It is generally agreed upon that the development of health literacy should be addressed from an early age onwards in order to empower children to develop their full health potential. Schools can be seen as an ideal venue for strengthening health literacy because they reach almost all school-aged children throughout their school years. The development of health literacy at a young age is a catalyst for healthy development throughout across the life span. Evidence shows that health and education are intertwined with favorable effects for health (e.g., health behavior, knowledge) and education outcomes (e.g., academic achievement). However, health literacy is often not sufficiently integrated into the school curriculum despite its importance to health and education. Integrating health literacy into schools is challenging, as both schools and teachers already face numerous educational requirements that may prevent them from addressing health in the classroom because they perceive it as an additional task. This is why taking a sensitive approach is important, adapted to the needs of schools and highlighting the benefits of health literacy. Installing health literacy in schools succeeds more easily if it can be linked to existing curricular requirements. In this context, curriculum and instruction on media literacy, information literacy, and digital literacy are most promising subjects to include health literacy because these concepts share many commonalities with health literacy and often are already part of the school curriculum. The aim of this article is to (1) analyze a mandatory curriculum on media literacy in the state of North-Rhine-Westphalia in Germany, (2) highlight its intersections with health literacy, and (3) show how it can be used to address health literacy. The state media literacy framework is based on the federal standards for “digital education” developed by the German Conference on Education Ministries und Cultural Affairs (KMK). As education policy and practice is decentralized with sixteen federal states in Germany, each of them has got their own media literacy framework, or they are currently developing it. This curriculum analysis may serve as a methodological blueprint for educationalists, teachers, and policy-maker elsewhere in order to include health literacy into existing curricula both health and non-health. It may help to integrate health literacy into schools when combined with existing curricula.

What Role Does Body Image in Relationship between Level of Health Literacy and Symptoms of Eating Disorders in Adolescents?

(1) Background: The aim of this study was to explore the associations between health literacy and symptoms for eating disorders among adolescents, taking into consideration age and gender and whether this association is mediated by body image. (2) Methods: We used data on 5054 adolescents (mean age = 13.9, 51.7% boys) from the Health Behaviour in School-Aged Children study conducted in 2018 in Slovakia. We used logistic regression models to examine associations between level of health literacy and symptoms for eating disorders mediated by body image. (3) Results: Adolescents with low and medium levels of health literacy had a higher occurrence of reporting two or more symptoms of eating disorders (odds ratio (OR)/95% CI: 2.25/1.78-2.84 and 1.37/1.15-1.65). Adjustment for body image reduced the significance of association between low level of health literacy and symptoms for eating disorders by 26.4%, and association between medium level of health literacy and symptoms for eating disorders by 29.7%. (4) Conclusions: Adolescents who have a low health literacy level were found to have a higher probability of having symptoms for eating disorders, especially when they perceive themselves as fat. The study refers to potential theoretical frameworks for health literacy intervention that may provide guidelines for the intervention design and materials.

Health Promoting Schools in Germany. Mapping the Implementation of Holistic Strategies to Tackle NCDs and Promote Health

Noncommunicable diseases (NCDs) and their underlying risk factors are seen as major public health problems that threaten health and welfare systems worldwide. The holistic and resource oriented Health Promoting School (HPS) approach can serve as an appropriate framework for the prevention and control of NCDs. The paper aimed to map the implementation of HPS activities in German schools and to examine associations with potential influencing factors. A series of cross-sectional online studies including five federal states and 5006 school principals (40.2% males, 50.8% females) from primary and secondary public schools was conducted from 2013 to 2018. Principal component analysis (PCA) resulted in two factors of HPS implementation (F1: concrete HPS action, F2: capacity building for HPS). Comparing both factors, a lower implementation level could be identified for HPS capacity building with lowest mean values found for regular teacher training and intersectoral collaboration. Multiple binary regression analyses revealed significant associations between low HPS implementation and male gender (OR: 1.36 to 1.42), younger age (OR: 1.47 to 1.90), secondary school (OR: 1.78 to 3.13) and federal state (Lower Saxony = OR: 1.27 to 1.45; Schleswig-Holstein = OR: 1.95 to 2.46). Moreover, low access to resources, decision-latitude and perceived educational benefits were independently associated with both factors of HPS implementation. Based on the results of this study, there is a need to support schools in their capacity building for health (e.g., regular teacher training, cooperation with local health services). Moreover, considering the core mission of schools, more evidence of the educational impact of health promotion and its translation into the language of education is needed for secondary schools in particular.

Health Literacy in Schools? A Systematic Review of Health-Related Interventions Aimed at Disadvantaged Adolescents

Socioeconomically disadvantaged populations are at greater risk of adopting unhealthy behaviours and developing chronic diseases. Adolescence has been identified as a crucial life stage to develop lifelong healthy behaviours, with schools often suggested as the ideal environment to foster healthy habits. Health literacy (HL) provides a possible solution to promote such healthy behaviours. The aim of this study was to review school-based HL-related interventions targeting socioeconomically disadvantaged adolescents and to identify effective intervention strategies for this population. Searches were performed in six databases. Inclusion criteria included age: 12–16; the implementation of a school-based intervention related to HL aimed at socioeconomically disadvantaged populations; an intervention focused on: physical activity (PA), diet, mental health, substance abuse or sleep. Forty-one articles were included, with the majority focusing on PA and diet (n = 13), PA (n = 9) or mental health (n = 7). Few interventions focused solely on substance abuse (n = 2) or sleep (n = 1), and none targeted or assessed HL as an outcome measure. There was huge heterogeneity in study design, outcomes measures and effectiveness reported. Effective intervention strategies were identified that can be used to guide future interventions, including practical learning activities, peer support and approaches targeting the school environment, the parents or that link the intervention to the community.

Promotion of Elementary School Students' Health Literacy

Health literacy is an important outcome of the discussion of school-related health education and health promotion in the 21st century. Although the improvement of health literacy at an early age is increasingly recognized and few interventions show the development of children´s health literacy, still there is little research in this area. The purpose of the study was to examine the enhancement of health literacy among children in a physical activity-based program at elementary school. In total, 137 students aged 6–12 years participated in the program, which included health knowledge transfer in child-appropriate games and exercises. Participants´ health literacy was assessed using the HLS-Child-Q15-DE at the beginning and the end of the program. The instrument measures the access, understanding, appraisal and application of health-related information on a four-point Likert-type scale. As expected, the Wilcoxon signed-rank test revealed significant increases in self-reported health literacy over time. The results show that the degree of change in health literacy was not associated with gender or age. The results suggest that the physical activity-based program has the potential to improve elementary school children´s health literacy, even though in a single group pilot study.

Moving Health Literacy Research and Practice towards a Vision of Equity, Precision and Transparency

Over the past two decades, health literacy research has gained increasing attention in global health initiatives to reduce health disparities. While it is well-documented that health literacy is associated with health outcomes, most findings are generated from cross-sectional data. Along with the increasing importance of health literacy in policy, there is a lack of specificity and transparency about how to improve health literacy in practice. In this study, we are calling for a shift of current research paradigms from judging health literacy levels towards observing how health literacy skills are developed over the life course and practised in the real world. This includes using a life-course approach, integrating the rationale of precision public health, applying open science practice, and promoting actionable knowledge translation strategies. We show how a greater appreciation for these paradigms promises to advance health literacy research and practice towards an equitable, precise, transparent, and actionable vision.

A pilot study of adolescent health literacy research in Melbourne: Implementation and reflections

ISSUES ADDRESSED

While adolescent health literacy research has gained momentum, there is little evidence regarding its implementation and data collection in school settings. This study explored the feasibility of collecting health literacy data from Australian secondary schools and piloted three health literacy instruments.

METHODS

A cross-sectional study was designed to recruit four government secondary schools in Melbourne. Active, opt-in consent was obtained from parents and students in Years 7-9, and an online survey was conducted. Three health literacy instruments were used: the 8-item Health Literacy Assessment Tool (HLAT-8), the Newest Vital Sign (NVS), and the 47-item Health Literacy Survey (HLS-47).

RESULTS

A total of 120 students (age 12-15 years) were finally recruited from one school, whereas the other three schools declined due to busy educational commitment or no interest in research. Learnings and reflections on data collection included: a shared perspective of health literacy evaluation between school and researchers; the feasibility of online data collection; and the possibility of obtaining passive, opt-out consent. About one-quarter (23.7%-32.2%) of students were likely to have poor health literacy.

CONCLUSIONS

Although the recruitment was challenging, this pilot study indicates the feasibility of large-scale online health literacy survey in future school-based research. SO WHAT?: Measuring and monitoring adolescent health literacy is essential to achieve the aim of the Australian Curriculum of Health and Physical Education. More implementation research is needed with representative samples to validate health literacy instruments and examine the impact of health literacy on health promotion outcomes in Australian adolescents.