The level of active DNA demethylation compounds in leukocytes and urine samples as potential epigenetic biomarkers in breast cancer patients.

The active DNA demethylation process, which involves TET proteins, can affect DNA methylation pattern. TET dependent demethylation results in DNA hypomethylation by oxidation 5-methylcytosine (5-mC) to 5-hydroxymethylcytosine (5-hmC) and its derivatives. Moreover, TETs' activity may be upregulated by ascorbate. Given that aberrant DNA methylation of genes implicated in breast carcinogenesis may be involved in tumor progression, we wanted to determine whether breast cancer patients exert changes in the active DNA demethylation process. The study included blood samples from breast cancer patients (n = 74) and healthy subjects (n = 71). We analyzed the expression of genes involved in the active demethylation process (qRT-PCR), and 5-mC and its derivatives level (2D-UPLC MS/MS). The ascorbate level was determined using UPLC-MS. Breast cancer patients had significantly higher TET3 expression level, lower 5-mC and 5-hmC DNA levels. TET3 was significantly increased in luminal B breast cancer patients with expression of hormone receptors. Moreover, the ascorbate level in the plasma of breast cancer patients was decreased with the accompanying increase of sodium-dependent vitamin C transporters (SLC23A1 and SLC23A2). The presented study indicates the role of TET3 in DNA demethylation in breast carcinogenesis.

Physical activity promotion in daycare centres in Germany: study protocol for a cross-sectional survey within the BeweKi study.

INTRODUCTION: In Germany, a total of 92.2% of children between the age of 3 and school entry age attend daycare centres. Therefore, daycare centres are a suitable setting to promote physical activity among children. Yet, there is a lack of knowledge on the promotion of physical activity in daycare centres with regards to different structures and concepts, culture/policies/practices and the characteristics of directors and pedagogical staff of daycare centres in Germany. The aim of this study is to investigate (a) the status quo, as well as (b) the fostering and hindering conditions (barriers and facilitators) of physical activity promotion in daycare centres in Germany. METHODS AND ANALYSIS: The cross-sectional study will collect data from November 2022 to February 2023. For the sample, about 5500 daycare centres will be drawn from an address database available through the German Youth Institute (DJI) and invited to the survey. From each daycare centre a director and a pedagogical staff member will be asked to fill in a standardised self-administered questionnaire. The survey explores characteristics of the daycare centre and the implementation of physical activity promotion, for example, the extent and form of physical activity promotion, the use and size of indoor and outdoor area, structural conditions such as personal and financial resources, personal attitudes towards physical activity promotion, demographic characteristics of pedagogical staff, structural daycare centre's characteristics such as proportion of children from socioeconomic disadvantaged groups. In addition, micro-geographical data on socioeconomic and infrastructural environment of the daycare centres will be included in the data set. ETHICS AND DISSEMINATION: The study has been received and approved by the Commissioner for Data Protection of the Robert Koch Institute and by the Ethics Committee of Alice Salomon Hochschule Berlin, University of Applied Sciences. Results will be disseminated through publications and presentations to scientific community and stakeholders.

Motivational readiness for physical activity and health literacy: results of a cross-sectional survey of the adult population in Germany.

BACKGROUND: Health literacy, defined as the knowledge, motivation, and competences to use health information to improve health and well-being, is associated with regular physical activity. However, there is limited evidence on whether health literacy is also related to the motivational readiness for physical activity in a general population. The aim of this study was to investigate whether motivational readiness for leisure-time physical activity is associated with health literacy. METHODS: Analyses were based on data of 21,895 adults from the cross-sectional German Health Update and European Health Interview Survey 2014/2015 (GEDA 2014/2015-EHIS). Motivational readiness for leisure-time physical activity was assessed with stages of change for physical activity with a set of validated items. It was then classified, according to an established algorithm, into five stages: precontemplation, contemplation, preparation, action, and maintenance. Health literacy was measured with the short form of the European Health Literacy Survey Questionnaire (HLS-EU-Q16) and categorised as low, medium, and high. For bivariate and multinomial logistic regression analyses, the stages were categorised in three phases as: (1) no intention (precontemplation), (2) planning (contemplation or preparation), and (3) in activity (action or maintenance). The models were adjusted for sex, age, education, health consciousness, self-efficacy, and self-perceived general health status. RESULTS: High compared to low health literacy was associated with a 1.65-times (95% CI = 1.39-1.96) greater probability of being in activity than planning. High compared to low health literacy was associated with a reduced risk of having no intention to change physical activity behaviour (relative risk ratio, RRR = 0.84, 95% CI = 0.75-0.95). The associations persisted after adjusting for covariates. CONCLUSION: High health literacy was positively associated with more advanced phases of motivational readiness for leisure-time physical activity. Therefore, taking health literacy into account in interventions to promote motivational readiness for leisure-time physical activity could be a useful approach.

How much do adults sit? Results from the German Health Update (GEDA 2019/2020-EHIS).

Background: Sedentary behaviour is increasingly perceived as a risk factor for the development of diseases and for increased mortality. In particular, increased time spent sitting in combination with low physical activity seems to have negative health consequences. Methods: In the nationwide cross-sectional study German Health Update (GEDA 2019/2020-EHIS), the indicator 'sitting' was captured by the self-report of the participants. Results: For at least eight hours a day, 16.7% of women and 22.3% of men sit: Men more often than women, younger persons more often than older persons and the proportion increases significantly from the low to the high education group. Similarly, about one fifth of adults in Germany sit for at least four hours a day and do not engage in physical activity in their leisure time. Conclusion: The results indicate that preventive measures are needed to reduce time spent sitting and increase physical activity.

Exploring pandemic-related health literacy among adolescents in Germany: a focus group study.

BACKGROUND: Health literacy enables people to cope efficiently with health threats, such as the COVID-19 pandemic. However, little is known about health literacy among adolescents in general and especially in the context of pandemics. This study aimed to explore pandemic-related health literacy among adolescents by addressing cognitive, behavioral, conative, and affective components of the multidimensional health literacy construct. METHODS: Four online focus groups with 24 adolescents aged 13-17 years from four German federal states were conducted during the COVID-19 pandemic in May and June 2021. Data were analyzed using qualitative content analysis. RESULTS: Regarding the cognitive and behavioral components of pandemic-related health literacy, adolescents reported to use a broad range of traditional and digital media and personal information sources. The adolescents considered pandemic-related information to be good and easy to understand, when the information is presented in a concise and structured manner. The participants stated difficulties in finding, understanding, and evaluating pandemic-related information regarding particular protective measures. The adolescents described themselves to be critical when evaluating pandemic-related information and reported a high level of adherence to protective measures. Regarding the conative and affective components of health literacy, the adolescents explained that their wish to protect their loved ones from getting infected was the predominant motive for adherence to protective measures. They were convinced that people of their age play a role in pandemic containment. The adolescents reported sometimes making exceptions from adhering to protective measures to cope with negative feelings they experienced during the pandemic. CONCLUSIONS: This study provides insights on how measures to improve pandemic-related health literacy among adolescents may be tailored to their needs. Prompt, concise, structured, and comprehensible preparation and communication of pandemic-related information in addition to educational efforts to strengthen health-related cognitive skills and critical health literacy may be supportive to reduce barriers in finding, understanding, and evaluating pandemic-related content.

Correction: Loer et al. Subjective Generic Health Literacy and Its Associated Factors among Adolescents: Results of a Population-Based Online Survey in Germany. Int. J. Environ. Res. Public Health 2020, 17, 8682.

In the discussion chapter (page 15 ff.) of the original paper [...].

Differences in risk perception, knowledge and protective behaviour regarding COVID-19 by education level among women and men in Germany. Results from the COVID-19 Snapshot Monitoring (COSMO) study.

The main strategy for combatting SARS-CoV-2 infections in 2020 consisted of behavioural regulations including contact reduction, maintaining distance, hand hygiene, and mask wearing. COVID-19-related risk perception and knowledge may influence protective behaviour, and education could be an important determinant. The current study investigated differences by education level in risk perception, knowledge and protective behaviour regarding COVID-19 in Germany, exploring the development of the pandemic over time. The COVID-19 Snapshot Monitoring study is a repeated cross-sectional online survey conducted during the pandemic in Germany from 3 March 2020 (waves 1-28: 27,957 participants aged 18-74). Differences in risk perception, knowledge and protective behaviour according to education level (high versus low) were analysed using linear and logistic regression. Time trends were accounted for by interaction terms for education level and calendar week. Regarding protective behaviour, interaction terms were tested for all risk perception and knowledge variables with education level. The strongest associations with education level were evident for perceived and factual knowledge regarding COVID-19. Moreover, associations were found between low education level and higher perceived severity, and between low education level and lower perceived probability. Highly educated men were more worried about COVID-19 than those with low levels of education. No educational differences were observed for perceived susceptibility or fear. Higher compliance with hand washing was found in highly educated women, and higher compliance with maintaining distance was found in highly educated men. Regarding maintaining distance, the impact of perceived severity differed between education groups. In men, significant moderation effects of education level on the association between factual knowledge and all three protective behaviours were found. During the pandemic, risk perception and protective behaviour varied greatly over time. Overall, differences by education level were relatively small. For risk communication, reaching all population groups irrespective of education level is critical.

Health-promoting behaviour among adults in Germany - Results from GEDA 2019/2020-EHIS.

Health-promoting behaviours are important at any age to prevent diseases and to promote well-being. Using data from GEDA 2019/2020-EHIS, a Germany-wide, representative survey, this article describes how often the adult population in Germany reports certain types of health-promoting behaviour in their everyday lives. The behaviours considered are nonsmoking, low-risk alcohol consumption, achievement of the World Health Organization's (WHO) recommendations on aerobic physical activity, at least daily fruit and vegetable consumption, and maintaining a body weight within the normal range. This article describes the proportion of people who report these behaviours in their everyday lives by gender, age and education level, the number of health-promoting behaviours each person reports and the most common combinations in which they occur. Young adults between 18 and 29 years are most likely to achieve a health-promoting lifestyle. The proportion of people who report at least 150 minutes of physical activity per week and a normal body weight is lower in later adulthood than among 18- to 29-year-olds. The recommendation to eat fruit and vegetables daily is implemented least often of all five aspects of health behaviour under study. Finally, women are more likely to lead a health-promoting lifestyle than men.

Subjective Generic Health Literacy and Its Associated Factors among Adolescents: Results of a Population-Based Online Survey in Germany.

Profound data on adolescent health literacy are needed as a requirement for the development of health literacy promoting interventions. This paper aims to study the level of generic health literacy among adolescents and to explore associations between health literacy and socio-demographic (age, sex, family affluence, migration background), social (social support by family and friends) and personal (self-efficacy) factors. We conducted a representative cross-sectional online survey. Four health literacy dimensions were captured among 14-17 years old adolescents living in Germany (n = 1235) with the "Measurement of Health Literacy Among Adolescents-Questionnaire" (MOHLAA-Q). Descriptive, bivariate and multiple logistic regression analyses were used to analyse the data (n = 1202). We found poor health literacy levels-to varying degrees-in all examined health literacy dimensions: dealing with health-related information (8.41% with many difficulties), health-related communication skills (28.13% with low skills), attitudes toward one's own health and health information (8.81% with passive attitudes) and health-related knowledge (22.73% with low levels). We identified significant associations between poor health literacy levels and all factors studied except for age. Our results indicate a need for the implementation of evidence-based health literacy-related promoting interventions, preferentially in education and training institutions.

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.

Development and Psychometric Properties of a Questionnaire Assessing Self-Reported Generic Health Literacy in Adolescence.

Health literacy is a promising approach to promoting health and preventing disease among children and adolescents. Promoting health literacy in early stages of life could contribute to reducing health inequalities. However, it is difficult to identify concrete needs for action as there are few age-adjusted measures to assess generic health literacy in young people. Our aim was to develop a multidimensional measure of health literacy in German to assess generic health literacy among 14- to 17-year-old adolescents, namely, the "Measurement of Health Literacy Among Adolescents Questionnaire" (MOHLAA-Q). The development process included two stages. Stage 1 comprised the development and validation using a literature review, two rounds of cognitive interviews, two focus groups and two rounds of expert assessments by health literacy experts. Stage 2 included a standard pretest (n = 625) of the questionnaire draft to examine the psychometric properties, reliability and different validity aspects. The MOHLAA-Q consists of 29 items in four scales: (A) "Dealing with health-related information (HLS-EU-Q12-adolescents-DE)"; (B) "Communication and interaction skills", (C) "Attitudes toward one's own health and health information", and (D) "Health-related knowledge". The confirmatory factor analysis indicated a multidimensional structure of the MOHLAA-Q. The internal consistency coefficients (Cronbach's α) of the scales varied from 0.54 to 0.77. The development of the MOHLAA-Q constitutes a significant step towards the comprehensive measurement of adolescents' health literacy. However, further research is necessary to re-examine its structural validity and to improve the internal consistency of two scales.

Online Survey for the Assessment of Generic Health Literacy among Adolescents in Germany (GeKoJu): Study Protocol.

The promotion of health literacy at a young age can protect, maintain and improve health across the life course. Yet to date, a sound data basis on adolescent health literacy as a requirement for the development of strategies to promote health literacy has not been given. This paper presents a study protocol for the online survey "Health Literacy Among Adolescents" (GeKoJu) that collects the first nation-wide representative data on self-reported generic health among adolescents aged 14-17 years in Germany. The objectives of the survey are (1) to assess the distribution of generic health literacy among adolescents in Germany, (2) to identify socio-demographic and social factors in regard to health literacy and (3) to assess the association of health literacy and health-related outcomes. The cross-sectional survey was conducted from September 2019 through December 2019. A two-stage stratified cluster sampling strategy was applied. Individuals invited to participate in the survey (N = 6608) were randomly selected among German-speaking adolescents aged 14-17 years, with permanent residence in Germany. Generic health literacy is measured with the "Measurement of Health Literacy Among Adolescents-Questionnaire" (MOHLAA-Q). Data collection also covers questions on health behavior, subjective health status, personal and social resources, socio-demographic and social factors and health services use. Results of the GeKoJu survey will provide data for the development of strategies to promote generic health literacy among families, in schools, communities and health care.

The potential influence of breast cancer estrogen receptors' distribution on active DNA demethylation.

Alterations in DNA methylation may cause disturbances in regulation of gene expression, including drug metabolism and distribution. Moreover, many cancers, including breast cancer, are characterized by DNA hypomethylation and a decreased 5-hydroxymethylcytosine level. The abnormal cell growth found in breast carcinoma might be the result of impaired up-regulation of breast cancer receptors. Receptors' expression in breast cancer determines clinical outcome, and it is possible that they lead to different DNA methylation patterns. Excessive steroid exposure can affect DNA methylation by promoting demethylation of CpG islands in promoter regions of genes, and hence may have an impact on promotion and progression of breast cancer cells. Tamoxifen, as a leading drug in breast cancer hormone therapy, has an ability to act like estrogen or antiestrogen depending on the type and localization of the breast cancer receptor. Further studies are needed to determine whether tamoxifen, similarly to steroids, may evoke changes in methylation pattern.

Health literacy in men and women with cardiovascular diseases and its association with the use of health care services - Results from the population-based GEDA2014/2015-EHIS survey in Germany.

BACKGROUND: Health literacy (HL), defined as the ability to access, understand, appraise and apply health information, offers a promising approach to reduce the development of cardiovascular diseases (CVD) and to improve the management of CVD in populations. DESIGN: We used data from nationwide cross-sectional German Health Update (GEDA2014/2015-EHIS) survey. 13,577 adults ≥ 40 years completed a comprehensive standardized paper or online questionnaire including the short form of the European Health Literacy Survey Questionnaire (HLS-EU-Q16). METHODS: We compared participants with and without CVD with regard to their HL. We also analyzed the association between HL level and health care outcomes among individuals with CVD, i.e. frequency of general practitioner or specialist consultations, hospitalization and treatment delay. RESULTS: The percentage of "problematic" or "inadequate" HL, defined as "not sufficient" HL, was significantly higher in individuals with CVD compared to without CVD (men 41.8% vs. 33.6%, women 46.7% vs. 33.4%). Having CVD was independently associated with "not sufficient" HL after adjusting for age, education, income, health consciousness and social support (adjusted OR: men 1.36, women 1.64). Among participants with CVD, individuals with "inadequate" HL were more likely to have more than 6 general practitioner consultations (49.3% vs. 28.7%), hospitalization (46.6% vs. 36.0%) in the last 12 months and to experience delay in getting health care because of long waiting lists for an appointment (30.7% vs. 18.5%) compared to participants with "sufficient" HL. CONCLUSION: "Problematic" or "inadequate" HL is independently associated with CVD and health care use. This is a challenge and an opportunity for both CVD prevention and treatment.

Do adolescents understand the items of the European Health Literacy Survey Questionnaire (HLS-EU-Q47) - German version? Findings from cognitive interviews of the project "Measurement of Health Literacy Among Adolescents" (MOHLAA) in Germany.

BACKGROUND: In Germany, there are no measurement tools to assess the general health literacy of adolescents. The aim of the study "Measurement of Health Literacy Among Adolescents" (MOHLAA) is to develop such a tool for use among adolescents aged 14-17. The German version of the European Health Literacy Survey Questionnaire (HLS-EU-Q47-GER) served as a blueprint for the development of the tool. The present study examined the extent to which the HLS-EU-Q47-GER can be applied to the measurement of general health literacy in adolescents. METHODS: The applicability of the HLS-EU-Q47-GER for adolescents was tested qualitatively using cognitive interviewing (CI). Purposive sampling was used to achieve an equal distribution of participants regarding age groups, educational backgrounds and gender. CI was standardized on the basis of an interview guide. Verbal probing and the retrospective think-aloud technique were applied. The interviews were audio-recorded, transcribed and analyzed using the criteria of theory-based analysis, which were derived from the model of cognitive processes. The analysis focused on identifying terms and questions that were difficult to understand and on scrutinizing the extent to which the content of the items is appropriate for assessing adolescents' health literacy. RESULTS: Adolescent respondents were unfamiliar with some terms of the HLS-EU-Q47-GER or provided heterogeneous interpretations of the terms. They had limited or no experience regarding some health-related tasks in health care and disease prevention that are addressed by HLS-EU-Q-items. A few items seemed to be too "difficult" to answer due to a high abstraction level or because they lacked any reference to the everyday lives of youth. Despite comprehension problems with some of the HLS-EU items, the respondents assessed the covered health-related tasks as "very easy" or "fairly easy". CI stressed the importance of interpersonal agents, especially parents, in helping adolescents understand and judge the reliability of health information. CONCLUSIONS: The results of CI indicated that the applicability of the HLS-EU-Q47-GER to the measurement of general health literacy among adolescents aged 14-17 is limited. In order to prevent biased data, some items of the questionnaire should be adjusted to adolescents' state of development and experiences with health care and disease prevention.

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.

The Frankfurt Patient Safety Climate Questionnaire for General Practices (FraSiK): analysis of psychometric properties.

BACKGROUND Safety culture has been identified as having a major impact on how safety is managed in healthcare. However, it has not received much attention in general practices. Hence, no instrument yet exists to assess safety climate-the measurable artefact of safety culture-in this setting. This study aims to evaluate psychometric properties of a newly developed safety climate questionnaire for use in German general practices. METHODS The existing Safety Attitudes Questionnaire, Ambulatory Version, was considerably modified and enhanced in order to be applicable in general practice. After pilot tests and its application in a random sample of 400 German practices, a first psychometric analysis led to modifications in several items. A further psychometric analysis was conducted with an additional sample of 60 practices and a response rate of 97.08%. Exploratory factor analysis with orthogonal varimax rotation was carried out and the internal consistency of the identified factors was calculated. RESULTS Nine factors emerged, representing a wide range of dimensions associated with safety culture: teamwork climate, error management, safety of clinical processes, perception of causes of errors, job satisfaction, safety of office structure, receptiveness to healthcare assistants and patients, staff perception of management, and quality and safety of medical care. Internal consistency of factors is moderate to good. CONCLUSIONS This study demonstrates the development of a patient safety climate instrument. The questionnaire displays established features of safety climate and additionally contains features that might be specific to small-scale general practices.