Evaluating the effect of an adapted mental health literacy intervention on mental health related stigma among secondary students in Germany: results of a pre-post evaluation study.

BACKGROUND: Most mental health problems develop during youth, with about three quarter emerging before age 25. In adolescence, stigmatizing attitudes related to mental illness become more nuanced and consolidate into one's belief system. As the stigma of mental illness is still one of the leading barriers to help-seeking, intervention measures should explicitly address it before it becomes entrenched over time. Preventive measures, for example, based on promoting mental health literacy (MHL), can be used to address and tackle stigmatizing attitudes. The Canadian MHL-based intervention "the Guide" was translated and adapted for the use in German schools. The present study evaluates the effect of the German version of the Guide on attitudes towards mental illness among students in Germany. METHODS: The first-time application of the Guide (German version) was evaluated with a pre-post-evaluation study with an intervention and a control group. The evaluation data of 188 students (intervention group n = 106, control group n = 82) were statistically analyzed focusing on the outcomes social stigma, social distance, and self-stigma. RESULTS: The analysis showed that participants do not tend to hold stigmatizing attitudes even before the intervention. Nevertheless, the intervention was effective in reducing social stigma, but not in reducing social distance and self-stigma. Neither gender, pre-existing experience with mental illness, nor the delivery modality of the contact element within the intervention (speaker vs. video) seemed to influence the outcomes. CONCLUSIONS: The German version of the MHL-based intervention, the Guide, seems to be a suitable intervention to improve attitudes towards mental illness among students in Germany. More extensive research is necessary to confirm the findings and further explore factors that influence the program's effects on attitudes short- and long-term.

[Perspective Paper "Future Prevention Research" - Current and Future Coordinated Research on Prevention and Health Promotion]. / Perspektivpapier "Zukunft Präventionsforschung": Koordinierte Forschung zu Prävention und Gesundheitsförderung ­ aktuell und in der Zukunft.

From 2014 to 2022, the BMBF has funded five research networks in prevention research and health promotion that are also jointly coordinated (Research Network Primary Prevention and Health Promotion, www.fp2g.net). The researchers have produced a large number of relevant research outputs with insights gained into essential aspects of prevention research and health promotion. The networks research focused on basic principles, application-relevant findings, and implementation conditions of long-term prevention and health promotion for non-communicable diseases (NCDs). The constraints imposed by the pandemic from 2020 onwards were partly addressed by integrating Corona-related research and transfer activities. The importance of resilience for dealing with multiple health and social challenges got increased attention and was analyzed and discussed during the pandemic. For prevention research, research questions such as how to better implement prevention measures through digital tools are gaining additional importance. Together, the research networks have presented achievements and desiderata for future research. This perspective paper with its nine theses formulated in conclusion is intended as a stimulus for discussion among funders as well as the communty of researchers on the subject of successful prevention and health promotion. It is explicitly part of the continuity of the memoranda on prevention research developed in 2012.

[DNVF Memorandum Health Literacy (Part 2) - Operationalisation and Measuring of Health Literacy from a Health Services Research Perspective]. / DNVF Memorandum Gesundheitskompetenz (Teil II) ­ Operationalisierung und Messung von Gesundheitskompetenz aus Sicht der Versorgungsforschung.

The "DNVF Memorandum Health Literacy (Part 2): Operationalization and Measurement of Health Literacy from the Perspective of Health Services Research" of the German Network for Health Services Research represents the continuation of the memorandum "DNVF Memorandum Health Literacy (Part 1): Background, Subject and Issues in Health Services Research". In addition to the general requirements for the measurement of health literacy, this memorandum also deals with the specific requirements, such as the differentiation of health literacy from related constructs, the differences between performance-based and self-assessment methods, the differences between generic and specific instruments, the use of screening instruments, and the measurement of health literacy in special populations. Furthermore, special considerations about the measurement of digital health literacy, potentials of qualitative and participatory research approaches as well as research ethics in the measurement of health literacy will be elaborated on. A special emphasis is placed on practical relevance for health services researchers. Finally, the authors will give an outlook on challenges and research desiderata in connection with the measurement of health literacy in the context of health services research.

Advancing perspectives on health literacy in childhood and youth.

Children and young people's importance as core target population for health literacy has been highlighted throughout the literature due to the relevance of the early life phases for maintaining, restoring and promoting health during the life course. Transferring health literacy concepts to the target population, however, requires proper testing of their applicability and their fit to the developmental phases as well as the target populations' realities and needs. This article aims to discuss children's and young people's health literacy by elaborating and exploring childhood and youth as life phases with unique characteristics from multidisciplinary perspectives. Drawing on theories and findings from developmental studies, sociology and socialization research, health literacy in childhood and youth is discussed along five 'D' dimensions: (i) disease patterns and health perspectives, (ii) demographic patterns, (iii) developmental change, (iv) dependency and (v) democracy. The unique particularities of children and young people relevant for health literacy include their disease and health-risk profiles, their vulnerability to demographic factors, their social role and status, and their right to participation. Inter- and intra-generational relationships and an unequal distribution of power can either promote or hinder children and young people's health literacy development and their opportunities for participating in health-related decision making. Specifying what is called the 'contextual' and 'relational' dimension of health literacy for the target group requires considering their personal attributes and agency as contextually embedded and interrelated. Taking these considerations into account can help to move towards a more tailored and holistic approach to health literacy of children and young people.

[DNVF Memorandum Health Literacy (Part 1) - Background, Relevance, Research Topics and Questions in Health Services Research]. / DNVF Memorandum Gesundheitskompetenz (Teil 1) ­ Hintergrund, Relevanz, Gegenstand und Fragestellungen in der Versorgungsforschung.

More than half of the German population has difficulties in dealing with health information. It is an important task of health services research to examine how healthcare professionals and health care organizations can meet this challenge. The DNVF Memorandum Health Literacy (Part 1) defines the terms of individual and organizational health literacy, presents the national and international state of research and ethical aspects of health literacy research in health care settings. The relevance of health literacy research is worked out in different phases of life, for different target groups and in different healthcare contexts. Central research topics and future research desiderata are derived.

[DNVF Memorandum Health Literacy (Part 1) - Background, Relevance, Research Topics and Questions in Health Services Research: Short Version]. / DNVF Memorandum Gesundheitskompetenz (Teil 1) ­ Hintergrund, Relevanz, Gegenstand und Fragestellungen in der Versorgungsforschung: Kurzfassung.

More than half of the German population has difficulties in dealing with health information. It is an important task of health services research to examine how healthcare professionals and health care organizations can meet this challenge. This short version of the DNVF Memorandum Health Literacy (Part 1) defines the terms of individual and organizational health literacy, presents the national and international state of research and ethical aspects of health literacy research in health care settings. Central research topics and future research desiderata are derived.

[National Action Plan Health Literacy: Need, Objective and Content]. / Der Nationale Aktionsplan Gesundheitskompetenz ­ Notwendigkeit, Ziel und Inhalt.

In recent years, studies on health literacy of the population have been conducted in many countries. Most of them show that health literacy levels are worse than expected and that large parts of the population have low health literacy levels. National strategies and action plans to promote health literacy have been developed in many countries to address these results. Following these examples, a National Action Plan on Health Literacy was also developed for Germany. A panel of 15 experts was involved in the 2-year development process. Based on an analysis of available literature on health literacy and existing action plans, the concept, objectives and priorities of the action plan were defined, and recommendations were developed. The National Action Plan on Health Literacy formulates recommendations in the fields of living environments, the healthcare system, chronic illness, and research.

Generic health literacy measurement instruments for children and adolescents: a systematic review of the literature.

BACKGROUND: Health literacy is an important health promotion concern and recently children and adolescents have been the focus of increased academic attention. To assess the health literacy of this population, researchers have been focussing on developing instruments to measure their health literacy. Compared to the wider availability of instruments for adults, only a few tools are known for younger age groups. The objective of this study is to systematically review the field of generic child and adolescent health literacy measurement instruments that are currently available. METHOD: A systematic literature search was undertaken in five databases (PubMed, CINAHL, PsycNET, ERIC, and FIS) on articles published between January 1990 and July 2015, addressing children and adolescents ≤18 years old. Eligible articles were analysed, data was extracted, and synthesised according to review objectives. RESULTS: Fifteen generic health literacy measurement instruments for children and adolescents were identified. All, except two, are self-administered instruments. Seven are objective measures (performance-based tests), seven are subjective measures (self-reporting), and one uses a mixed-method measurement. Most instruments applied a broad and multidimensional understanding of health literacy. The instruments were developed in eight different countries, with most tools originating in the United States (n = 6). Among the instruments, 31 different components related to health literacy were identified. Accordingly, the studies exhibit a variety of implicit or explicit conceptual and operational definitions, and most instruments have been used in schools and other educational contexts. While the youngest age group studied was 7-year-old children within a parent-child study, there is only one instrument specifically designed for primary school children and none for early years. CONCLUSIONS: Despite the reported paucity of health literacy research involving children and adolescents, an unexpected number of health literacy measurement studies in children's populations was found. Most instruments tend to measure their own specific understanding of health literacy and not all provide sufficient conceptual information. To advance health literacy instruments, a much more standardised approach is necessary including improved reporting on the development and validation processes. Further research is required to improve health literacy instruments for children and adolescents and to provide knowledge to inform effective interventions.

Health literacy in childhood and youth: a systematic review of definitions and models.

BACKGROUND: Children and young people constitute a core target group for health literacy research and practice: during childhood and youth, fundamental cognitive, physical and emotional development processes take place and health-related behaviours and skills develop. However, there is limited knowledge and academic consensus regarding the abilities and knowledge a child or young person should possess for making sound health decisions. The research presented in this review addresses this gap by providing an overview and synthesis of current understandings of health literacy in childhood and youth. Furthermore, the authors aim to understand to what extent available models capture the unique needs and characteristics of children and young people. METHOD: Six databases were systematically searched with relevant search terms in English and German. Of the n = 1492 publications identified, N = 1021 entered the abstract screening and N = 340 full-texts were screened for eligibility. A total of 30 articles, which defined or conceptualized generic health literacy for a target population of 18 years or younger, were selected for a four-step inductive content analysis. RESULTS: The systematic review of the literature identified 12 definitions and 21 models that have been specifically developed for children and young people. In the literature, health literacy in children and young people is described as comprising variable sets of key dimensions, each appearing as a cluster of related abilities, skills, commitments, and knowledge that enable a person to approach health information competently and effectively and to derive at health-promoting decisions and actions. DISCUSSION: Identified definitions and models are very heterogeneous, depicting health literacy as multidimensional, complex construct. Moreover, health literacy is conceptualized as an action competence, with a strong focus on personal attributes, while also recognising its interrelatedness with social and contextual determinants. Life phase specificities are mainly considered from a cognitive and developmental perspective, leaving children's and young people's specific needs, vulnerabilities, and social structures poorly incorporated within most models. While a critical number of definitions and models were identified for youth or secondary school students, similar findings are lacking for children under the age of ten or within a primary school context.

[Students Having Parents with Mental Health Issues and Teachers' Mental Health Literacy]. / Schüler mit einem psychisch erkrankten Elternteil und die Mental Health Literacy von Lehrkräften.

Students Having Parents with Mental Health Issues and Teachers' Mental Health Literacy Mental health issues of parents of school children often negatively affects the children as well, including their school performance and social behavior in the school setting. Teachers are then required to take actions with regards to supporting children in their coping with and mastering of their home situation and their responds to educational demands. As such, schools' and teachers' actions can either support affected children and fulfill a protective function or respond inappropriately, with negative impact on the affected children. Although the societal discussion about and acceptance of mental illnesses have increased in recent years, scientific knowledge on how well teachers are prepared for meeting the needs of affected students remains insufficient. Therefore, this research study examines teachers' attitudes towards, knowledge about, and competencies regarding children affected by a mentally ill parent. 15 in-depth interviews and 3 focus groups (n = 11) with teachers from primary and secondary schools were conducted and systematically analyzed. Although burdens in the family are perceived as major influences on children's school day and performance, teachers report to not feel sufficiently prepared for and uncertain about supporting and coping with the special needs of affected students. Instead they report to "learn from a case to case" basis. Recognizing the family situation of children with mentally ill parents is reported to be especially difficult for teachers. Responding inadequately and insensitive to the needs of affected children was perceived as a serious burden for teachers themselves. While schools can function as entry points to professional social help systems, teachers frequently reported barriers and challenges in accessing, communicating, and collaborating with these systems. The practical implications of these results regarding the "Mental Health Literacy" of teachers are being discussed.

The effects of an adapted mental health literacy curriculum for secondary school students in Germany on mental health knowledge and help-seeking efficacy: results of a quasi-experimental pre-post evaluation study.

Background: Because the majority of mental illnesses develop early in life, effective preventative public mental health interventions are needed. Interventions fostering mental health literacy can be used to enhance personal resources and capacities to facilitate mental health care and thus, address help-seeking barriers. A Canadian mental health literacy school curriculum was adapted, piloted, and evaluated for the use in German schools. The study presents the intervention's effects on mental health knowledge and help-seeking efficacy among 10th grade students in Germany. Methods: 10th grade students (aged 14-17 years old) from one secondary school participated in a pre- and post-intervention control group study. Both groups completed a questionnaire at two time points assessing mental health knowledge and help-seeking efficacy. Repeated measure analysis of variance (ANOVA) was employed to evaluate the intervention's effects. Results: Data from 188 students was eligible for analysis. The analysis of the baseline data reveals a high comparability of the two groups in terms of demographics, and initial mental health knowledge and help-seeking efficacy scores. ANOVA results showed significant improvements for the intervention group having a large effect size for mental health knowledge (f = 0.574, p < 0.001, partial η2 = 0.25) and a medium effect size for help-seeking efficacy (f = 0.311, p < 0.001, partial η2 = 0.09). Conclusion: The first-time application and evaluation of an adapted mental health literacy school curriculum shows significant increases in mental health knowledge and help-seeking efficacy, two core dimensions of mental health literacy, among 10th grade students in Germany. Further studies are needed to confirm these results as well as have a more in-depth analysis on the interrelations of the different dimensions of mental health knowledge and help-seeking practices.

The Long-Term Effectiveness of Interventions Addressing Mental Health Literacy and Stigma of Mental Illness in Children and Adolescents: Systematic Review and Meta-Analysis.

Objectives: This study aims to provide a systematic review and meta-analysis of the literature on the long-term effects of interventions addressing children's and adolescents' mental health literacy and/or stigmatizing attitudes. Methods: Articles in English or German published between January 1997 and May 2020 were retrieved from five databases, leading to a total of 4,375 original articles identified. Results: 25 studies were included after applying exclusion criteria, 13 of which were eligible for meta-analysis. The overall average of the follow-up period was about 5 months. Long-term improvements were sustained for mental health literacy, d = 0.48, 95% CI = (0.34, 0.62), as well as for stigmatizing attitudes, d = 0.30, 95% CI = (0.24, 0.36), and social distance, d = 0.16, 95% CI = (0.03, 0.29). The combination of educational and contact components within interventions led to worse results for mental health literacy, but not stigmatizing attitudes or social distance. Conclusion: Interventions targeting children and adolescents generally have a brief follow-up period of an average of 5 months. They show a stable improvement in mental health literacy, but are to a lesser degree able to destigmatize mental illness or improve social distance.

Coronavirus-Related Health Literacy: A Cross-Sectional Study in Adults during the COVID-19 Infodemic in Germany.

There is an "infodemic" associated with the COVID-19 pandemic-an overabundance of valid and invalid information. Health literacy is the ability to access, understand, appraise, and apply health information, making it crucial for navigating coronavirus and COVID-19 information environments. A cross-sectional representative study of participants ≥ 16 years in Germany was conducted using an online survey. A coronavirus-related health literacy measure was developed (HLS-COVID-Q22). Internal consistency was very high (α = 0.940; ρ = 0.891) and construct validity suggests a sufficient model fit, making HLS-COVID-Q22 a feasible tool for assessing coronavirus-related health literacy in population surveys. While 49.9% of our sample had sufficient levels of coronavirus-related health literacy, 50.1% had "problematic" (15.2%) or "inadequate" (34.9%) levels. Although the overall level of health literacy is high, a vast number of participants report difficulties dealing with coronavirus and COVID-19 information. The participants felt well informed about coronavirus, but 47.8% reported having difficulties judging whether they could trust media information on COVID-19. Confusion about coronavirus information was significantly higher among those who had lower health literacy. This calls for targeted public information campaigns and promotion of population-based health literacy for better navigation of information environments during the infodemic, identification of disinformation, and decision-making based on reliable and trustworthy information.

Exploring Associated Factors of Subjective Health Literacy in School-Aged Children.

Low health literacy is considered to lead to worse health-related outcomes and behaviors and has therefore been recognized as a social determinant of health. While health literacy and its potential determinants have been studied in adults, little research has been conducted with children. This study aims to address this research gap by investigating factors associated with children's subjective health literacy. Cross-sectional data was collected from fourth graders at German schools with a self-report questionnaire. Sociodemographic characteristics, health-related attitudes, and motivation were analyzed. We used hierarchical multivariate linear regression to explain variance in the dependent variable "subjective health literacy". A total of n = 907 fourth graders were surveyed. Regarding health literacy, eight out of ten participants (82.2%) reported that it was "rather easy" or "very easy" to deal with health-related information. Family affluence, but not language spoken at home, was significantly related to subjective health literacy, after controlling for confounding. Moreover, parental health orientation, self-efficacy, and motivation are factors significantly associated with health literacy. Based on the results of this study, it is hypothesized that a general motivation to learn new things about health, as well as an environment promoting health-positive behavior, might foster children's health literacy.

Adapting the European Health Literacy Survey Questionnaire for Fourth-Grade Students in Germany: Validation and Psychometric Analysis.

BACKGROUND: Until now, children younger than age 13 years have received little attention in research on health literacy. Although some tools assess children's health literacy, no validated tool is available that assesses self-reported health literacy in a systematic and comparable way. The European Health Literacy Survey Questionnaire (HLS-EU-Q) is a valid and reliable measure of adults' self-reported health literacy. It has also been used among adolescents, but it has never been adapted for use with children. We believe it would be worth adapting for younger age groups so that self-reported health literacy could be assessed continuously. OBJECTIVE: This study aimed to quantitatively test an adapted scale based on the HLS-EU-Q developed for German-speaking children age 9 and 10 years. METHODS: An adapted 26-item HLS-EU-Q scale was given in a paper-and-pencil survey to 907 fourth-grade students in North Rhine-Westphalia, Germany. The psychometric properties of the scale were investigated with item analysis and factor analyses, and both convergent and discriminant validity were assessed. KEY RESULTS: Of the 26 tested items, 9 were discarded due to poor performance in terms of missing values, item difficulty, and factor structure. This left a 15-item scale with a high internal consistency (α = .791) that takes only a short time to administer. The scale, called the HLS-Child-Q15, had a low correlation with functional health literacy (r = .107, p < .001), and a moderate correlation with indicators of self-efficacy (ρ = .280 to .306, p < .001). The latter indicates adequate discriminant validity, whereas the former points to a need to further investigate convergent validity. CONCLUSIONS: This is the first study to apply an age-adapted version of the HLS-EU-Q to children. Statistical analyses indicated the successful development of a promising instrument, but further research is needed on its factor structure and validity. This study contributes significantly to the comparative assessment of health literacy across the life course by providing a measurement tool for children age 9 and 10 years. [HLRP: Health Literacy Research and Practice. 2020;4(3):e144-e159.] PLAIN LANGUAGE SUMMARY: The European Health Literacy Survey Questionnaire was adapted for German-speaking 9- and 10-year-old children, and 26 adapted items were tested in a written survey of 907 children. Item analysis resulted in a 15-item scale with satisfactory psychometric properties. This scale, the HLS-Child-Q15, shows high internal consistency and can be used to assess self-reported health literacy in German-speaking 9- and 10-year-old children. Nonetheless, further studies are needed to validate these results.

Adapting the European Health Literacy Survey for Fourth-Grade Students in Germany: Questionnaire Development and Qualitative Pretest.

BACKGROUND: Promoting health literacy in early life is regarded as an important means of sustaining health literacy and health over the life course. However, little evidence is available on children's health literacy, partly due to a scarcity of suitable measurement tools. Although there are 18 tools to measure specific items of health literacy for people younger than age 13 years, there is a lack of comparable, valid, and age-appropriate measures of generic health literacy. OBJECTIVE: This study aimed to develop and qualitatively test an age-adapted version of the European Health Literacy Survey Questionnaire (HLS-EU-Q) for German-speaking children age 9 and 10 years. Although validated for adults and adolescents, the HLS-EU-Q has never been age-adapted or used with children. METHODS: The content and language of HLS-EU-Q items were adapted for this age range. The literature was consulted to inform this process, and adaptations were developed and selected based on consensus among authors. From an item pool of 102 adapted items, 37 were given to 30 fourth-grade students in a cognitive pretest, which is a standard procedure in questionnaire development aiming to explore how items are interpreted. Participants (18 girls, 12 boys) were mostly age 9 or 10 years (range, 9-11 years). KEY RESULTS: Problems with misinterpretation were identified for some items and participants (e.g., items designed to assess participants' perceived difficulty in accessing and appraising health information were partly answered on the basis of knowledge and experience). A final selection of 26 well-performing items corresponded to the underlying HLS-EU-Q framework. CONCLUSIONS: This is the first age-adapted version of the HLS-EU-Q. A preliminary 26-item questionnaire was successfully developed that performed well in a cognitive pretest. However, further research needs to verify its validity and reliability. The present findings help to advance the measurement of generic self-reported health literacy in children and highlight the need for cognitive pretesting as an essential part of questionnaire development. [HLRP: Health Literacy Research and Practice. 2020;4(2):e119-e128.] PLAIN LANGUAGE SUMMARY: The European Health Literacy Survey Questionnaire is used for testing adults' health literacy. It was adapted for German-speaking children age 9 and 10 years. Based on a review of the original items and the literature, 26 questionnaire items were developed and tested in interviews with 30 children. Although problems with understanding could be identified, the questionnaire was mostly well understood.

Child and Youth Health Literacy: A Conceptual Analysis and Proposed Target-Group-Centred Definition.

(1) Background: This article adopts an interdisciplinary perspective to analyse, examine, and reflect upon prominent health literacy (HL) understandings in childhood and youth. (2) Method: The conceptual analysis combined Rodgers' and Jabareen's approaches to conceptual analysis in eight phases. (3) Results: First, we present exploratory entry points for developing a child-specific HL understanding based on the six dimensions of a 'health-literacy 6D model'. Second, we describe and reflect upon five meta-level dimensions covering the HL definitions and models for children and youth found in the conceptual analysis. Third, we integrate our findings into a target-group-centred HL definition for children and youth. (4) Discussion/Conclusion: This article raises awareness for the heterogeneity of the current conceptual HL debate. It offers a multidisciplinary approach for advancing the existing understanding of HL. Four recommendations for future actions are deduced from the following four principles, which are inherent to the proposed target-group-centred HL definition: (a) to characterize HL from an asset-based perspective, (b) to consider HL as socially embedded and distributed, (c) to recognize that HL develops both in phases and in flexible ways, and (d) to consider the multimodal nature of health-related information. Further research is necessary to test the feasibility and applicability of the proposed definition and conceptual understanding in both research and practice.

What are the family needs when a parent has mental health problems? Evidence from a systematic literature review.

PROBLEM: Little evidence exists showing how a given high-risk group of children born to parents with poor mental health seek help and how care may be improved in order to better reach and support their families. METHODS: A systematic literature review was undertaken to identify the needs and help-seeking behaviors of children and their parents. Through an analysis of both quantitative and qualitative studies, published in German- and English-speaking research literature, the needs of children and parents were identified and categorized. Findings concerning their help-seeking behavior and the influence of demographic variables on needs and help-seeking behaviors were also described. FINDINGS: In the primary studies, the most identified parental needs were "the need for being a good parent"; "worries about the child's well-being"; and "the need for practical help." For children, the categories identified included "the need for knowledge"; "worries about parent's well-being"; and "the need for normality." However, information about help-seeking behaviors and influences of demographic factors was fairly limited in the literature. CONCLUSIONS: In families with parental mental health problems, it seems especially important to take a family-focused approach. The individual needs of children (and their families) should shape the planning of treatment and nursing care.