Three years into the pandemic: results of the longitudinal German COPSY study on youth mental health and health-related quality of life.

Purpose: For the past three years, the German longitudinal COPSY (COVID-19 and PSYchological Health) study has monitored changes in health-related quality of life (HRQoL) and the mental health of children and adolescents during the COVID-19 pandemic. Methods: A nationwide, population-based survey was conducted in May-June 2020 (W1), December 2020-January 2021 (W2), September-October 2021 (W3), February 2022 (W4), and September-October 2022 (W5). In total, n = 2,471 children and adolescents aged 7-17 years (n = 1,673 aged 11-17 years with self-reports) were assessed using internationally established and validated measures of HRQoL (KIDSCREEN-10), mental health problems (SDQ), anxiety (SCARED), depressive symptoms (CES-DC, PHQ-2), psychosomatic complaints (HBSC-SCL), and fear about the future (DFS-K). Findings were compared to prepandemic population-based data. Results: While the prevalence of low HRQoL increased from 15% prepandemic to 48% at W2, it improved to 27% at W5. Similarly, overall mental health problems rose from 18% prepandemic to W1 through W2 (30-31%), and since then slowly declined (W3: 27%, W4: 29%, W5: 23%). Anxiety doubled from 15% prepandemic to 30% in W2 and declined to 25% (W5) since then. Depressive symptoms increased from 15%/10% (CES-DC/PHQ-2) prepandemic to 24%/15% in W2, and slowly decreased to 14%/9% in W5. Psychosomatic complaints are across all waves still on the rise. 32-44% of the youth expressed fears related to other current crises. Conclusion: Mental health of the youth improved in year 3 of the pandemic, but is still lower than before the pandemic.

Quality of life and mental health in children and adolescents during the first year of the COVID-19 pandemic: results of a two-wave nationwide population-based study.

BACKGROUND: The COVID-19 pandemic has disrupted the lives of children and adolescents worldwide. The German COPSY study is among the first population-based longitudinal studies to examine the mental health impact of the pandemic. The objective of the study was to assess changes in health-related quality of life (HRQoL) and mental health in children and adolescents and to identify the associated risk and resource factors during the pandemic. METHODS: A nationwide longitudinal survey was conducted with two waves during the pandemic (May/June 2020 and December 2020/January 2021). In total, n = 1923 children and adolescents aged 7 to 17 years and their parents participated (retention rate from wave 1 to wave 2: 85%). The self-report and parent-proxy surveys assessed HRQoL (KIDSCREEN-10), mental health problems (SDQ with the subscales emotional problems, conduct problems, hyperactivity, and peer problems), anxiety (SCARED), depressive symptoms (CES-DC, PHQ-2) and psychosomatic complaints (HBSC-SCL). Mixed model panel regression analyses were conducted to examine longitudinal changes in mental health and to identify risk and resource factors. RESULTS: The HRQoL of children and adolescents decreased during the pandemic, and emotional problems, peer-related mental health problems, anxiety, depressive and psychosomatic symptoms increased over time, however the change in global mental health problems from wave 1 to wave 2 was not significant, and some changes were negligible. Socially disadvantaged children and children of mentally burdened parents were at particular risk of impaired mental health, while female gender and older age were associated with fewer mental health problems. A positive family climate and social support supported the mental health of children and adolescents during the pandemic. DISCUSSION: Health promotion, prevention and intervention strategies could support children and adolescents in coping with the pandemic and protect and maintain their mental health.

[Digital Health Literacy of the Population in Germany: Results of the HLS-GER 2]. / Digitale Gesundheitskompetenz der Bevölkerung in Deutschland: Ergebnisse des HLS-GER 2.

AIM: While the availability and variety of digital information on health offers a range of opportunities, they also pose a number of challenges, because the need for digital health literacy (DHL) is increasing along with the growing range of information possibilities. The aim of this study was to analyze the extent of DHL in the German population, key determinants, and consequences for the use of digital health information resources. METHODOLOGY: The analysis was based on data from the Second Health Literacy Survey Germany (HLS-GER 2), consisting of a representative sample of n=2,151. A questionnaire developed as part of the international comparative study HLS19 was used to measure DHL, its determinants, and the use of digital health information resources. Bivariate and multivariate analyses were conducted. RESULTS: Overall, 75.8% of the population had low DHL. In particular, low literacy skills, older age, a lower level of education and social status were associated with low DHL. Multivariate analysis also indicated a strong association between DHL and general health literacy (HL). Low DHL led to lower use of digital health information resources. CONCLUSION: The results underscore the importance of promoting DHL in the general population and especially among groups with low DHL. Efforts in this area should include general HL, as it is closely related to DHL. Strengthening DHL is also a socially important task in order to increase the still low use of digital health information resources in Germany and, in general, to meet the increasing digitalization of the health care system.

[Comparison of Health Literacy of the Population in Germany between 2014 and 2020]. / Gesundheitskompetenz der Bevölkerung in Deutschland im Zeitvergleich der Jahre 2014 und 2020.

AIM: This article compares the results of two health literacy (HL) surveys of the population in Germany over time. The first survey was conducted in 2014, the second in 2020. The changes in GK, measured by the degree of subjectively assessed difficulties in individual information tasks in the three areas of health care, prevention, health promotion, in the total population and in subgroups are examined. METHODOLOGY: The analyses were based on population-representative cross-sectional data collected in 2014 and 2020. An internationally coordinated questionnaire (HLS-EU-Q47) was used to measure GK. Changes in the population groups were analysed uni- and bivariately as well as multivariately in a trend analysis. RESULTS: The HL of the German population has worsened statistically significantly within six years. This can be observed in all three overall domains. This effect was particularly evident among people with low social status and financial deprivation. CONCLUSION: Over time, dealing with health and disease-related information has become more difficult. As this development is mainly driven by socioeconomically disadvantaged population groups, it has apparently increased social inequality in the health sector. Promoting HL - as this and other studies show - is more important for the society than ever and should be given special attention in relation to the above-mentioned population groups.

Child and Adolescent Mental Health During the COVID-19 Pandemic: Results of the Three-Wave Longitudinal COPSY Study.

PURPOSE: The German population-based longitudinal COVID-19 andPsychological Health study monitors changes in health-related quality of life (HRQoL) and mental health of children and adolescents during the COVID-19 pandemic and identifies vulnerable groups. METHODS: A nationwide, population-based survey was conducted in May 2020 to June 2020 (Wave 1), December 2020 to January 2021 (Wave 2), and September 2021 to October 2021 (Wave 3). In total, n = 2,097 children and adolescents aged 7-17 years were investigated using measures to assess HRQoL (KIDSCREEN-10), mental health problems (SDQ), anxiety (SCARED), depressive symptoms(PHQ-2), and psychosomatic complaints(HBSC-SCL). RESULTS: The prevalence of low HRQoL increased from 15% prepandemic to 40% and 48% in Waves 1 and 2 and improved slightly to 35% in Wave 3 (all differences significant). Similarly, overall mental health problems increased from 18% prepandemic to 29% in Wave 1 and 31% in Wave 2 to 28% in Wave 3 (all differences significant, except Wave 3 vs. 2), anxiety increased from 15% prepandemic to 24% and 30% in Waves 1 and 2 and was still 27% in Wave 3. Depressive symptoms increased from 10% prepandemic to 11% and 15% in Waves 1 and 2 and were 11% in Wave 3. A group with low parental education, restricted living conditions, migration background, and parental mental health problems was at significantly increased risk of HRQoL and mental health impairments. DISCUSSION: The prevalence of low HRQoL, mental health problems, and anxiety has been elevated throughout the pandemic. Thus, mental health promotion, prevention, and intervention strategies need to be implemented to support adolescents-particularly those at risk.

[Health Literacy in Germany before and during the COVID-19 Pandemic]. / Gesundheitskompetenz in Deutschland vor und während der Corona-Pandemie.

AIM: The aim of this study was to compare the general and digital health literacy (HL) of the German population before the outbreak of the COVID-19 pandemic and during its persistence and to investigate different changes in population groups. METHODOLOGY: The analyses are based on population representative cross-sectional data collected in 2019/2020 before and 2020 during the pandemic. An internationally coordinated questionnaire (HLS19) was used. Changes in groups were analyzed bivariate. RESULTS: The results showed that the HL of the population in Germany tended to improve during the pandemic. This effect was especially evident with regard to the evaluation of health information and in the area of digital HL. Women, people with low or medium education, younger people and those with a migration background appeared to have benefited to a more than average extent. For older people, there was no change, and for those with multiple chronic conditions, the results even indicated a worsening. CONCLUSION: The systematic exposure to clearly structured and continuously repeated health information during the COVID-19 pandemic seems to have improved the ability to process health-related information in the German population. In particular, there has been an increase in competence in dealing with digital information media, which are being increasingly used to communicate health information. However, there are some large differences between different population groups.

Health Literacy in Germany - Findings of a Representative Follow-up Survey.

BACKGROUND: Studies have shown that the health literacy of the German population is low. The aim of this article is to analyze current developments in health literacy on the basis of recent data. METHODS: The Health Literacy Survey Germany 2 (HLS-GER 2) is a representative quantitative survey of the German-speaking resident population of Germany aged 18 and above. It was carried out in December 2019 and January 2020 by paper- assisted personal oral interview (PAPI). Data on health literacy and socio - demographic characteristics were acquired with an internationally coordinated questionnaire. The instrument for measuring general health literacy consisted of 47 questions that reflect an individual's ability to access, understand, appraise, and apply health-related information. The associations between general health literacy and sociodemographic factors were analyzed using bivariate and multivariate statistical tests. RESULTS: 58.8% of the participants had low health literacy, characterized by rating at least one-third of the questions as "difficult" or "very difficult." Many respondents stated that they had difficulties accessing (48.3%), understanding (47.7%), and applying (53.5%) information, and even more of them (74.7%) reported difficulties appraising information. The correlation coefficients reveal that health literacy is weakly associated with the following variables: age, sex, social status, literacy, level of education, financial deprivation, migration background, and the presence of one or more chronic diseases. CONCLUSION: The findings of the HLS-GER 2 highlight the need for action in pro - moting health literacy in the healthcare system. As the explanation of variance is low, there are presumably other important determinants of health literacy that were not taken into account. Further studies should be performed to investigate societal conditions of supplying health information, for example, or social and personal characteristics.

[Mental health and psychological burden of children and adolescents during the first wave of the COVID-19 pandemic-results of the COPSY study]. / Seelische Gesundheit und psychische Belastungen von Kindern und Jugendlichen in der ersten Welle der COVID-19-Pandemie ­ Ergebnisse der COPSY-Studie.

BACKGROUND: The drastic changes during the COVID-19 pandemic may have a negative impact on the psychological wellbeing of children and adolescents. OBJECTIVES: COPSY is the first national, representative German study to examine mental health and quality of life of children and adolescents during the pandemic. Results are compared with data of the representative longitudinal BELLA study conducted before the pandemic. MATERIALS AND METHODS: Internationally established instruments for measuring health-related quality of life and mental health (including anxiety and depressive symptoms) were administered to n = 1586 parents with 7­ to 17-year-old children and adolescents, of whom n = 1040 11- to 17-year-olds also provided self-reports, from 26 May to 10 June 2020. Data were analyzed using descriptive statistics and bivariate tests. RESULTS: Seventy-one percent of the children and adolescents and 75% of the parents felt burdened by the first wave of the COVID-19 pandemic. Compared to the time before the pandemic, the children and adolescents reported a lower health-related quality of life, the percentage of children and adolescents with mental health problems almost doubled, and their health behavior worsened. Socially disadvantaged children felt particularly burdened by the COVID-19 pandemic. Two-thirds of the parents would like to receive support in coping with their child during the pandemic. CONCLUSIONS: The COVID-19 pandemic poses a mental health risk to children and adolescents. Schools, doctors, and society are called to react by providing low-threshold and target-group-specific prevention and mental health promotion programs.

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.

Implementation of the National Action Plan Health Literacy in Germany-Lessons Learned.

The promotion of health literacy (HL) has become an important task in public health. In response, in many countries, strategies and action plans to strengthen HL have been developed. Systematic discussion of implementation strategies of action plans on HL is scarce. This paper presents the implementation strategy and the methodical process of its realization of the National Action Plan HL in Germany which was published in 2018. The implementation strategy was based on considerations of implementation science and research. A process consisting of a continuum of various overlapping methodical and strategic steps of diffusion, dissemination and implementation based on collaboration and co-production was chosen. According to this, the Action Plan was widely diffused via various channels, disseminated through numerous publications and presentations, and implemented in several settings by holding workshops with stakeholders from politics, science and practice, as well as by cooperating with the Alliance for Health Literacy. This three-part collaborative and co-productive implementation strategy has helped to place HL and the National Action Plan on the health policy agenda in Germany. Experience demonstrates that implementation should be also considered, systematically planned, and addressed when developing strategies to strengthen HL.

[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.

Framing health literacy: A comparative analysis of national action plans.

Population and individual deficits in health literacy, and their associated negative health outcomes, have received growing attention in the political arena in recent years. In order to respond to the problem, several governments have adopted national action plans, which outline strategies to improve health literacy. Drawing on the action plans of the USA, Australia, Scotland, and Wales and applying Entman's concept of framing, this paper analyses how health literacy debates are framed within the political arena as well as the factors that influence framing. Analysing data from policy documents and in-depth expert interviews, this paper identifies relevant frames developed to (i) define the problem of limited health literacy, (ii) provide causal explanations, (iii) rationalise why health literacy requires political action, and (iv) present solutions. The findings indicate that the malleability of the concept allows that a diversity of frames and solutions are promoted, yet risks that debates remain vague. Health literacy seems to have been successfully used to instigate political debates about health system reforms, patient empowerment, and shared decision making. The analysis suggests that health literacy might, if applied strategically, help to focus policy debates on key public health problems and the development of systemic solutions.

Class-Level School Performance and Life Satisfaction: Differential Sensitivity for Low- and High-Performing School-Aged Children.

This study investigates whether class-level school performance affects students' life satisfaction and if there are differential effects for high- and low-performing students. Data were derived from the National Educational Panel Study, including n = 5196 students (49.6% girls), nested in 478 classes and 250 secondary schools. School performance in class was measured by aggregating individual grade point average in Mathematics and German. The study could not reveal the "big-fish-little-pond"-effect regarding students' life satisfaction but found differential effects for high- vs. low performing students. There was no significant association for low-performing students attending classes with higher class-level performance However, low-performing students revealed the lowest life satisfaction. High-performing students placed in classes with higher average performance reported lower life satisfaction compared to high-performing students in classes with lower average performance. This study provides evidence for the impact of the learning environment in class on school-aged children's life satisfaction, by highlighting the differential sensitivity of high-performing students when placed in classes with higher or lower average performance.

Is being a "small fish in a big pond" bad for students´ psychosomatic health? A multilevel study on the role of class-level school performance.

BACKGROUND: Features of schools and classes are closely related to students´ health and wellbeing. However, class composition (e.g. in terms of school performance) has rarely been examined in relation to students´ health and wellbeing. This study focuses on the so called Big-Fish-Little-Pond-Effect (BFLPE), by investigating whether the level of high-performing students in classroom is negatively associated with psychosomatic complaints of students who perceive themselves as poor performers. METHODS: Data were derived from the German sample of the WHO-Collaborative "Health Behaviour in School-aged Children (HBSC)" study 2013/2014. The sample included 5226 11-, 13- and 15-year-old students. Individual perceived school performance (PSP) was included (very good/good vs. average/below average PSP) at the individual student-level. At the class-level, school performance in class was generated by aggregating the share (in percentage) of students who report a very good/good PSP to the class-level, indicating the percentage of students with good/very good PSP in classroom. Using multilevel regression models, the association between class-level school performance (in percentage of students with very good/good PSP) and individual psychosomatic complaints were analyzed, stratified by students´ individual PSP. RESULTS: Students who report average/below average PSP showed higher likelihoods of psychosomatic complaints (Odds Ratio: 1.75; 95% Confidence Interval: 1.52-2.03) compared to counterparts with very good/good PSP. The aggregated class-level PSP was not significantly associated with psychosomatic complaints. However, in line with the BFLPE, results further revealed that students with average/below average PSP, who attend classes with a higher percentage of students who report very good/good PSP, had higher likelihoods of psychosomatic complaints (Odds Ratio: 1.91; 95% Confidence Interval: 1.01-4.01) compared to classmates with very good/good PSP. CONCLUSIONS: This study revealed that class composition in terms of PSP was differentially associated with students´ psychosomatic complaints, depending on their individual PSP. Findings highlight the vulnerability of students with poor PSP placed in classes with a higher percentage of students with good PSP. Results of this study therefore indicate a need for initiatives for low performing students from teachers and school staff in class.

Perceived school climate, academic well-being and school-aged children's self-rated health: a mediator analysis.

Background: Schools are crucial settings for young people's development. Rare studies have examined the impact of perceived school-climate and academic well-being on young people's self-rated health in joint analyses. This study focuses on the role of perceived school-climate and academic well-being for young people's self-rated health and examines whether school climate is mediated by indicators of academic well-being. Methods: Data were obtained from the German National Educational Panel Study, including seventh grade students (n = 6838) aged 11-12, nested in 710 classes within 277 schools. Indicators of school climate (teacher control, demands, autonomy, interaction, goal setting and orientation, teaching quality) and academic well-being (satisfaction with school, helplessness in major school subjects) were reported from students. Multilevel modelling was used to analyze the relative importance of perceived school-climate and academic well-being on school-aged children's self-rated health. Results: Results showed that academic well-being is strongly related to self-rated health. The better students perceive their academic well-being, the lower the likelihood of poor self-rated health. In contrast, indicators of perceived school climate are only indirectly related to self-rated health, mediated by academic well-being or are not at all associated with self-rated health. Conclusions: This study suggests that school climate is important for academic well-being but not as important for students' self-rated health as academic well-being. Health promotion initiatives in schools have to ensure that school climate serves to enhance students' academic well-being to avoid health problems in the long-run.