An Iterative, Participatory Approach to Developing a Neighborhood-Level Indicator System of Health and Wellbeing.

Despite increased awareness of the essential role of neighborhood characteristics for residents' health and wellbeing, the development of neighborhood-level indicator systems has received relatively little attention to date. To address this gap, we describe the participatory development process of a small-area indicator system that includes information on local health needs in a pilot neighborhood in the German city of Mannheim. To identify relevant indicators, we partnered with representatives of the city's public health department and used an iterative approach that included multiple Plan-Do-Check-Act cycles with ongoing feedback from local key stakeholders. The described process resulted in a web-based indicator system with a total of 86 indicators. Additionally, 123 indicators were perceived as relevant by stakeholders but could not be included due to data unavailability. Overall, stakeholders evaluated the participatory approach as useful. Even though the onset of the COVID-19 pandemic and the lack of some data elements hindered instrument development, close collaboration with public health partners facilitated the process. To identify and target sub-national health inequalities, we encourage local public health stakeholders to develop meaningful and useful neighborhood-level indicator systems, building on our experiences from the applied development process and considering identified barriers and facilitators.

University Fairness Questionnaire (UFair): Development and Validation of a German Questionnaire to Assess University Justice-A Study Protocol of a Mixed Methods Study.

Distress is a widespread phenomenon in the general population, but also among university students, associated with poorer learning success and negative health consequences. A source of distress might be the experience of injustice. Theoretical and empirical work in the area of perceived fairness in the workplace ("organizational justice") has shown that perceived unfairness is related to various stress indicators and health outcomes. Preliminary evidence indicates that unfairness matters not only in the work context but also in the university context. However, an adapted and validated tool to assess perceived unfairness in the university context is hitherto missing. The goal of the proposed project is therefore to adapt the construct of organizational justice to the university context and to develop a corresponding questionnaire by means of established scientific procedures. An exploratory sequential mixed-methods design is applied in which qualitative and quantitative methods are combined. A valid and practicable measurement instrument ("UFair" University Fairness Questionnaire) will be developed and tested, and the relationship with various health outcomes will be examined. The UFair questionnaire will be made available free of charge to other researchers.

Role of contextual and compositional characteristics of schools for health inequalities in childhood and adolescence: a scoping review.

OBJECTIVES: To synthesise the evidence on the role of compositional or contextual characteristics of schools in the association between students' socioeconomic position and their health in primary and secondary education in developed economies. DESIGN: Scoping review. We included studies examining the role of at least one school or class characteristic on students' health inequalities and was published since 1 January 2000, in English or German. We searched PubMed/Medline, Web of Science and Education Resources Information Center. We provided a narrative synthesis and an overview of findings. School characteristics were grouped into five broad categories: school composition, school climate, school policies and organisation, food environment and facilities. RESULTS: Of 8520 records identified, 26 studies were included. Twelve studies found a moderating and 3 a mediating effect. The strongest evidence came from studies examining the moderating effect of school composition, that is, the negative impact of a low individual socioeconomic position on mental health and well-being was aggravated by a low average socioeconomic position of schools. Evidence concerning the role of school climate, school stratification (eg, performance base tracking) and sponsorship, food environment and sport facilities and equipment was generally weak or very weak and mostly based on singular findings. Overall, favourable meso-level characteristics mitigated the negative impact of low individual socioeconomic position on health outcomes. CONCLUSIONS: School characteristics affect health inequalities in children and adolescents to some degree, but future research is necessary to strengthen the existing evidence and address under-represented aspects in school characteristics and health outcomes.

Which Meso-Level Characteristics of Early Childhood Education and Care Centers Are Associated with Health, Health Behavior, and Well-Being of Young Children? Findings of a Scoping Review.

Characteristics of early childhood education and care (ECEC) centers might be relevant for children's health. This scoping review aims to provide an overview of the association between meso-level characteristics (MLCs) of ECEC centers with children's health, health behavior, and wellbeing. Five databases were searched for quantitative and qualitative research articles published in English or German since 1 January 2000 on health, health behavior, and wellbeing of children aged 0 to 6 years considering MLCs of ECEC centers. Two authors screened 10,396 potentially eligible manuscripts and identified 117 papers, including 3077 examinations of the association between MLCs and children's health indicators (Kappas > 0.91). Five categories of MLCs were identified: (1) structural characteristics, (2) equipment/furnishings, (3) location, (4) facilities/environment, (5) culture/activities/policies/practices, and 6) staff. Only very few studies found an association of MLCs with body weight/obesity, and general health and wellbeing. Especially physical activity and mental health were related to MLCs. In general, the location (rural vs. urban, neighborhood status) seemed to be a relevant health aspect. MLCs of ECEC centers appeared relevant for child health indicators to different degrees. Future research should focus on these associations, in detail, to identify concrete ECEC indicators that can support health promotion in early childhood.

Comparative physical activity as a global question to assess physical activity among university students.

BACKGROUND: To assess physical activity (PA), a comparative measurement - evaluating one's own PA compared to others - may be an appropriate method. In previous studies, the use of comparative measurements led to an effect known as unrealistic comparative optimism (UCO) - people being unrealistically optimistic about their behavior. Our aim was to use this comparative measurement in university students to quantify the prevalence of UCO at the group level and to draw conclusions on its validity. METHODS: We used data from the Nutrition and Physical Activity in Adolescence Study (NuPhA), a cross-sectional online survey that included only self-reports (n = 689). To assess PA among students, they were asked to rate their PA level compared to that of their same-aged fellow students. In addition, we used the Godin-Shephard leisure-time PA questionnaire and other questions on PA for comparisons. We used bivariate and cluster-based analyses to identify potential UCO. RESULTS: We found that UCO at the group level led to an uneven distribution, with a higher proportion of students who rated themselves as being more physically active than average. However, the individual assessment of PA with a single and simple comparative question seemed to be valid. DISCUSSION: A global single comparative question seems useful for studies where PA is measured as a covariate in university students.

[Social Inequalities in Health and Health Behaviors among University Students]. / Sozialbedingte Ungleichheiten von Gesundheit und Gesundheitsverhalten bei Studierenden.

AIM OF THE STUDY: Disease prevention and health science research have focused increasingly on students in recent years. However, students are usually perceived as a homogeneous group. The aim of this article was to examine if there exist health inequalities among students. METHODS: A nationwide student survey, the so-called NuPhA study, was used to answer this question (n=689, 69.5% female, average age: 22.69 years). RESULTS AND CONCLUSIONS: We found that socio-economic indicators were associated with health and health behavior. For instance, being a scholarship holder was associated with a better general, mental, and physical health. In particular, subjective social status was positively associated with better general, mental, and physical health as well as higher physical activity. The results indicate that while students initially appeared to form a homogenous group, health inequalities exist among them. This suggests the need for a differentiated view on the student group and the importance of examining and explaining health inequalities among students in depth and to finally reduce them.

Role of contextual and compositional characteristics of schools for health inequalities in childhood and adolescence: protocol for a scoping review.

INTRODUCTION: Childhood and adolescence are crucial life stages for health trajectories and the development of health inequalities in later life. The relevance of schools for health and well-being of children and adolescents has long been recognised, and there is some research regarding the association of contextual and compositional characteristics of schools and classes with health, health behaviour and well-being in this population. Little is known about the role of meso-level characteristics in relation to health inequalities. The aim of this scoping review is to retrieve and synthesise evidence about the mediating or moderating role of compositional or contextual characteristics of schools for the association between students' socioeconomic position and health in primary and secondary education. METHODS AND ANALYSIS: We will conduct a systematic search of electronic databases in PubMed/Medline, Web of Science and Education Resources Information Center. Studies must meet the following inclusion criteria: (1) The population must be students attending primary or secondary schools in developed economies. (2) The outcomes must include at least one indicator for individual health, health behaviour or well-being. (3) The study must include at least one contextual or compositional characteristic of the school context and one individual determinant of socioeconomic position. (4) The study must also examine the mediating or moderating role of the contextual or compositional characteristic of the school context for the associations between socioeconomic position and health, health behaviour or well-being. (5) The study must be published since 1 January 2000 in English or German language. We will provide a narrative synthesis of findings. ETHICS AND DISSEMINATION: We will not collect primary data and only include secondary data derived from previously published studies. Therefore, ethical approval is not required. We intend to publish our findings in an international peer-reviewed journal and to present them at national and international conferences.

Associations between contextual and compositional characteristics of early childcare facilities with health, health behaviours and well-being among young children aged 06 years: protocol for a scoping review.

INTRODUCTION: Early childhood is an important life stage which is crucial for determining health and health inequalities in later life. At the meso-level (institutional-level), early childcare facilities (eg, kindergartens, preschools) are the most important agent of socialisation next to families in young children aged 06 years. In recent years, an increasing amount of studies has focused on contextual and compositional characteristics of early childcare facilities and their association with health (eg, self-rated health), health behaviour (eg, physical activity) and well-being (eg, emotional well-being) in this age group. However, as currently no overview of the available literature on this topic exists, we will conduct a scoping review including various study designs (eg, cross-sectional studies, prospective studies, qualitative studies). METHODS AND ANALYSIS: We will follow the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews. A systematic search of the following scientific databases will be conducted: PubMed/Medline, PsycInfo, Sociological Abstracts, Education Resources Information Center and The Cochrane Library. During the selection process, we will follow a two-step process. First, two reviewers will independently screen titles/abstracts of all potentially eligible articles by applying a set of previously defined inclusion and exclusion criteria. After the completion of the title/abstract screening, full texts of the remaining articles will be screened following the same procedure. To determine inter-rater agreement between reviewers, we will calculate Cohen's Kappa after both steps. Key characteristics (eg, country of origin, sample size, study design) of included articles will be extracted. We will map the evidence available by providing a summary table on the key characteristics extracted and by presenting the associations using various types of illustrations. ETHICS AND DISSEMINATION: Since no primary data will be collected for this review, ethical approval is not required. Our findings will be published in an international peer-reviewed journal and presented at national and international conferences.

'When I have time pressure, sport is the first thing that is cancelled': A mixed-methods study on barriers to physical activity among university students in Germany.

The transition from school to university has been found to be associated with a decline in physical activity (PA). As regular engagement in PA plays an important role in preventing obesity and various chronic diseases such as type 2 diabetes and cardiovascular diseases, a deeper understanding on barriers that hinder university students from being physically active is necessary. We therefore conducted a mixed-methods study which built, first, on conducting a quantitative online survey across Germany (n = 689; 69.5% female) to examine barriers among university students. Afterwards, we explored these barriers in more detail by conducting 20 in-depth qualitative interviews (65.0% female). While we identified in our quantitative survey that especially time-related and motivational barriers hindered university students to engage in PA, our qualitative interviews indicate that connections between these barriers seem to exist. Moreover, the qualitative interviews enabled us to identify additional transition-related barriers (e.g., missing routines in everyday life, difficulties in finding a new sports club) that were not included in the quantitative questionnaire. Thus, such barriers should be incorporated into quantitative instruments to assess these barriers in larger samples of university students in the future. Moreover, our findings provide potential starting points for promoting PA in German university settings.

Desert on the menu? What children are served in German full-service restaurants.

OBJECTIVES: Prevalence of obesity and overweight among children is rising worldwide. Thus, the importance of restaurants as food environments is also growing. Considering these developments, the present study describes and evaluates menus and meals offered to children in German full-service restaurants. METHODS: Using quota sampling procedure, a representative sample of German full-service restaurants was identified. The individual meals were then assessed, using the Children's Menu Assessment tool (CMA). A total of 500 restaurants and 1,877 individual meals were analyzed. RESULTS: On average, every menu included 3.76 ± 1.31 meals for children. The arithmetic mean of the CMA score was 0.73 ± 0.85. Around 80% of all offered meals were limited to eight typical dishes and over 50% included French fries or another form of fried potatoes. Not one of the meals included any nutritional information. Healthy entrees were never marked (e.g. by an optional qualitative information such as healthy food symbol or a healthier choice tag). Eighty-one percent of all the main components in the meals were rated as unhealthy and none of the meals used wholegrain products. The automatic inclusion of a drink and free refill options are both rather unusual in Germany, as well as the use of cartoon characters and product logos or giving away promotional toys. A positive correlation was found between the price of the food and its quality. The majority of dishes feature a high energy density while simultaneously having a low nutrient density. CONCLUSIONS: Overall, the range of food on offer for children in German restaurants is unhealthy and lacking in variety. There is an urgent need for improvement of both the menus themselves as well as the offered meals. Our study is not only by far the most comprehensive study, but also the study with the worst CMA score values worldwide.

Obesity à la carte? Children's meal options in German full-service restaurants.

OBJECTIVE: In light of the increasing prevalence of juvenile obesity seen around the world, obesogenic environments in general and the food environment in particular are receiving increasing attention in current public health research. Restaurants play a significant role in the food environment. The present study aimed to quantitatively describe and qualitatively evaluate the range of children's meals available in full-service restaurants in Germany. DESIGN: Five hundred restaurants were identified using a systematic quota sampling technique. The individual meals were evaluated using quality standards stipulated by the German Nutrition Society (DGE). SETTING: Nationwide sample of menus from full-service restaurants. PARTICIPANTS: Meals (n 1877) from 500 menus were analysed. RESULTS: Menus included 3·76 (sd 1·31) meals for children. About 70 % of the meals were limited to six typical dishes of low nutritional quality. In total, 54 % of meals included French fries or another form of fried potatoes. Of all meals, 23 % did not fulfil any of the eleven quality criteria set by the DGE and 38 % satisfied only one criterion. The majority of dishes on offer featured high energy density while simultaneously having low nutrient density. Healthy dishes were not highlighted visually in any menu. CONCLUSIONS: The range of dishes on offer for children in German restaurants is severely lacking in variety and in need of improvement from a nutritional point of view. Considering the growing importance of restaurants as food environments, there is a need to improve the presentation of menus and the meals offered.

'Oh God, I Have to Eat Something, But Where Can I Get Something Quickly?'-A Qualitative Interview Study on Barriers to Healthy Eating among University Students in Germany.

Healthy eating can prevent individuals across all age groups from developing overweight/obesity and non-communicable diseases such as type 2 diabetes and cardiovascular disease. However, unhealthy eating habits (e.g., a high level of fast food consumption) have been found to be widespread among university students. Thus, it seems necessary to develop prevention strategies to improve students' eating habits. However, to ensure that such strategies are successful, it is important that they fit the needs of the target population. By conducting qualitative interviews with students (n = 20), we aimed to get a deeper understanding of barriers to healthy eating. Students were asked about barriers to healthy eating and to suggest possible ideas that could improve their eating behavior in the future. Our findings revealed that students are especially affected by time-related barriers (e.g., a lack of time due to university commitment) and environmental barriers (e.g., a lack of cheap, tasty, and healthy meal options at the university canteen). Time-related barriers were also related to motivational barriers (e.g., being too lazy to cook after a busy day at university). In addition, knowledge/information-related barriers, social-support-related barriers, and transition-related barriers emerged from our interviews. The variety of barriers addressed and the different views on some of these, indicate that various strategies seem to be needed to improve the eating behavior among university students and to prevent them from gaining weight and developing non-communicable diseases in the future.

Identification of starting points to promote health and wellbeing at the community level - a qualitative study.

BACKGROUND: As health is influenced by the social, economic and environmental conditions in which individuals live, local communities are an ideal setting to promote health and wellbeing. However, up to now various health promotion interventions at the community level have had limited success, perhaps related to an incomplete understanding of local contexts and priorities. We therefore aimed to develop a broader and deeper understanding of topics or issues that were most salient to residents of a South-West German community by exploring their perceptions of needs, challenges, barriers and existing resources related to health and well-being. METHODS: As an initial step of a multi-year community-based participatory research project, we conducted semi-structured interviews with key informants (n = 30) from various community settings (e.g., child care, elderly care, businesses, non-profit organizations, village councils, and local government). The terms "health" and "wellbeing" were included in the stem of each question in the semi-structured interview guide to enable a focus on related perceived needs, challenges, barriers and existing resources. Interviews were audiotaped, transcribed verbatim and analyzed using qualitative content analysis techniques. RESULTS: Themes emerging from our interviews appeared to center primarily in three distinct areas: natural resources and built environment, access to services, and social cohesion including subthemes on the importance of social engagement and volunteerism, sense of community, and shared identity. CONCLUSIONS: That health and wellbeing were not identified explicitly as a priority by key informants suggests that these should not be presented as the primary focus of a community-wide initiative. Instead themes with a higher priority should be addressed in ways that can lead to better health and wellbeing as a secondary goal.

Loneliness at Universities: Determinants of Emotional and Social Loneliness among Students.

The transition from school to university is associated with social, structural, and behavioral changes. These changes may be related to feelings of loneliness, which are in turn related to morbidity. The authors' aim was to quantify loneliness among students and to identify its determinants and its relation to transition-related variables (e.g., changes in weight, diet, or physical activity since the transition from high school to university). Coming from across Germany, 689 students participated in the Nutrition and Physical Activity in Adolescence (NuPhA) survey (16⁻29 years; 69.5% female). Associations of loneliness with the above-mentioned aspects were analyzed using descriptive statistics and linear regressions. Altogether, 32.4% felt moderately lonely and 3.2%, severely lonely. Emotional loneliness was more common than social loneliness (severe loneliness: 7.7% vs. 3.2%). Both were positively associated with feelings of depression and anxiety. Being married or in a committed relationship seemed to be protective factors for emotional loneliness. Physical inactivity, an immigrant background, and studying social sciences were related to higher social loneliness. Transition-related variables produced mixed results. In conclusion, this study's findings indicated that loneliness seemed to be prevalent in university students. The authors identified important starting points for interventions to prevent loneliness. Such interventions may help reduce the disease burden in the students' future professional life.

Effort-reward imbalance among students at German universities: associations with self-rated health and mental health.

PURPOSE: Although psychosocial stress has been associated with adverse health parameters, little is known about this topic among the variety of university students. We thus examined associations of psychosocial stress due to academic education with self-rated health, and symptoms of depression and anxiety among students from various study disciplines. METHODS: We used data from the Nutrition and Physical Activity (NuPhA) Study, a cross-sectional online survey among students enrolled across German universities (n = 698). Academic stress was assessed by a newly developed and validated student version of the Effort-Reward Imbalance (ERI-Student) Questionnaire. Depressive and anxiety symptoms were measured by applying the Patient Health Questionnaire-4 (PHQ-4) and using validated cut-offs. RESULTS: Separate multivariate logistic regression analyses run for the different ERI components, the ERI-ratio revealed that high effort, low reward, high over-commitment, and a high ERI-ratio were associated with poor self-rated health, and depressive and anxiety symptoms (odds ratios ≥ 2.43). Separate analyses for medical students and non-medical students largely confirmed these findings for both groups. Associations between all ERI components, the ERI ratio, and both mental health measures were, however, more pronounced among medical students. CONCLUSIONS: We were able to show consistent associations between the ERI-Student Questionnaire and self-rated health and mental health across students from different study disciplines. Further research on associations between academic stress and health parameters is necessary to develop effective strategies that prevent students from adverse health outcomes during their academic education.

Students' Motivation for Sport Activity and Participation in University Sports: A Mixed-Methods Study.

BACKGROUND: Physical activity among students is essential for complimenting sedentary behavior and for individuals' future health. This study investigates reasons for sport engagement among students and addresses the utilization of university sports programs (USP) by employing a mixed-methods approach. METHODS: The NuPhA-Study consists of a quantitative online survey (n=689) followed by qualitative interviews (n=20). In the survey, we assessed reasons for sport activity using a 24-item battery and USP utilization. Quantitative results were further explored using qualitative data to check for completeness of the predefined items (content validity) and to identify opportunities to improve participating in USP. RESULTS: A factor analysis grouped the 24 items into five factors (life balance/fitness/body image/contact with others/fun). Our qualitative study explained these in more detail and revealed missing aspects. 47.6% of students participated in USP. Potential improvements for USP include program maintenance during the semester break and temporal harmonization with the classes. DISCUSSION: The qualitative component identified additional reasons for sport activity that were not addressed by the item battery, which provides critical implications for developing item batteries for future research. Our results may help to generate a more target-group-oriented approach to increase physical activity among students, which will reduce sedentary behavior and future disease burden.

Associations between dietary factors and obesity-related biomarkers in healthy children and adolescents - a systematic review.

BACKGROUND: The obesity prevalence in children and adolescents has increased worldwide during the past 30 years. Although diet has been identified as one risk factor for developing obesity in this age group, the role of specific dietary factors is still unclear. One way to gain insight into the role of these factors might be to detect biomarkers that reflect metabolic health and to identify the associations between dietary factors and these biomarkers. This would enable nutrition-related metabolic changes to be detected early in life, which might be a promising strategy to prevent childhood obesity. However, existing literature offers only inconclusive evidence for diet and some of these obesity-related biomarkers (e.g., blood lipids). We thus conducted a systematic literature review to further examine eligible studies that investigate associations between dietary factors and 12 obesity-related biomarkers in healthy children and adolescents aged 3-18 years. METHODS: We searched the scientific databases PubMed/Medline and Web of Science Core Collection for potentially eligible articles. Our final literature search resulted in 2727 hits. After the selection process, we included 81 articles that reported on 1111 single observations on dietary factors and any of the obesity-related biomarkers. RESULTS: Around 81% of the total observations showed nonsignificant results. For many biomarkers we did not find enough observations to draw clear conclusions on possible associations between a dietary factor and the respective biomarker. In cases where we identified enough observations, the results were contradictory. Since these nonsignificant and inconclusive findings may impede the development of effective strategies against childhood obesity, this article takes a closer look at possible reasons for such findings. In addition, it provides action points for future research efforts. CONCLUSIONS: In conclusion, current evidence on associations between dietary factors and obesity-related biomarkers is inconclusive. We thus provided an overview on which specific limitations may impede current research. Such knowledge is necessary to enable future research efforts to better elucidate the role of diet in the early stages of obesity development.