Tool-HLCA: An intervention to promote the health literacy of school-aged children

Background

In the age of ‘infodemic,’ children and young people encounter health-related information in digital environments at an early age. They should therefore learn how to deal with these in a health-competent way while still at school. Above all, it is relevant that they learn how to distinguish good health information from false. This can be achieved by promoting health literacy. The intervention “Toolbox” combines areas of media education in schools and health literacy to be implemented in schools and curricula in the long term.

Methods

The intervention was designed to address existing health topics in the classroom while strengthening digital health literacy in grades 7 to 10. The Toolbox was piloted in three school classes in Germany and the feedback provided by teachers and students was implemented in a new version of the intervention.

Results

The basic understanding of health literacy in the Toolbox is finding, understanding, evaluating and using digital health information. These steps are followed through using quality criteria for good health information. Students learn that they need to find out the type of information, analyze the author, investigate the media provider, and also the sources given. If they are unsure, they can conduct an adapted questionnaire regarding identify misinformation and disinformation. In addition, the students and teachers receive working materials for group work.

Conclusions

Recognizing disinformation is a relevant skill already for children and adolescents. The intervention should make it easier for students to recognize good health information. For teachers it should be made easier to address health literacy in school without additional effort.

Results from a systematic review of interventions promoting mental health literacy in youth

Background

Mental illnesses are amongst the leading causes of ill-health and disability, with most onset of many mental health problems (ca. 75%) emerging before the age of 25 years. Thus, adolescence is an important time period for preventive measures, such as strengthening mental health literacy (MHL). This review aims to give an overview of those interventions which promote MHL on the long run.

Methods

Five databases were searched for English or German articles published between January 1997 and May 2020, leading to a total of 4,375 original articles. Interventions were included only if they had measured MHL and/or stigma on three different time points, had a control group, and delivered an intervention program. Studies reporting means and standard deviations for the outcomes of interest were further included into a meta-analysis using a random effects model. The analysis was carried out with STATA 16.

Results

25 studies were included into the review, and 13 of them were suitable for the meta-analysis. The great majority of studies (76%) were conducted within schools and the addressed topics were general mental health, depression, and schizophrenia. Interventions mostly used psychoeducation or a combination of educational elements and contact as delivery method. The combined use of educational and contact components led to worse results for mental health literacy, but not stigmatizing attitudes or social distance. Generally, interventions led to positive outcomes. The changes were sustained for mental health literacy d = 0.48, as well as for stigmatizing attitudes d = 0.30, and social distance d = 0.16, after an average follow-up of about 5 months.

Conclusions

MHL-interventions targeting adolescents are mostly conducted within schools and generally have a brief follow-up period. They show a stable improvement in mental health literacy and are to a smaller degree able to destigmatize mental illness or improve social distance.

The relationship between health literacy, health status and health outcomes among German 4th-graders

Background

The WHO describes Health literacy (HL) as a critical determinant of health, and a number of studies among adults link low HL to adverse health outcomes. However, little research has been conducted on HL and health outcomes in younger populations. Thus, this study describes the relationship between HL, health behaviors, and health status among children in primary schools.

Methods

A cross-sectional pen-and-paper survey was conducted in a convenience sample of 4th-graders in the federal state of North Rhine-Westphalia, Germany. Self-report measures were used for subjective HL, health behaviors (freq. of brushing teeth, eating fruit, exercising, screen time), and health status (subj. health, chronic condition, freq. of doctor visits, feeling ill). Correlations and binary logistic regression for the outcome “at least one adverse health behavior” (e.g. brushing teeth <2x a day; not eating fruit every day) are reported. Sex, age, family affluence, background of migration, numeracy, literacy, and health knowledge are included in the regression model.

Results

In our sample of n = 899 children (mean age 9,56 years), HL is significantly correlated with subj. health (ρ=.262**) doctor visits (ρ=.086*), feeling ill (ρ=-.078*), brushing teeth (ρ=.116**), eating fruit (ρ=.191**) exercising (ρ=.124**) and screen time (ρ=-.096**). Logistic regression (X2=29.237; p=.001, n = 648) shows that the relative risk for ≥1 adverse health behaviour is higher for boys (OR: 1.4; 95%-CI [1.016-1.927]) and children with lowest family affluence (1.7 [1.097-2.694]). Also, for one unit increase in HL (range 1-4), risk decreases by about 50% (0.472 [.298-.748]).

Conclusions

Already at a young age (9-10 years), HL is linked to a number of health outcomes. Further, HL has been found to be a potential predictor of adverse health behaviors after controlling for confounders.Thus, the promotion of HL might play an important role in mitigating adverse health behaviors early in the life course.

Evaluation of a school-based intervention to promote mental health literacy. Preliminary results

Background

Mental illness is one of the leading causes of ill-health and disability. The current COVID-19 pandemic poses an additional challenge on mental health, e.g., through increased levels of anxiety, depression and fears about the future. As most mental illnesses develop before the age of 25, young people are a critical target group for prevention. Mental health literacy (MHL) is considered to be a key determinant of positive mental health, thus, being crucial for mental health promotion and dealing with the aftermath of the pandemic. This project aims at (i) adapting an evidence-based MHL curriculum for German schools, as school-based interventions are suitable in reaching most young people, and (ii) evaluating its acceptance and effectiveness regarding MHL and stigmatizing attitudes.

Methods

An interdisciplinary team including representatives from self-help groups for mental health translated and adapted the Canadian “TeenMentalHealth” curriculum for German schools. The evaluation design includes a pre, post, follow-up assessment of MHL, stigmatizing attitudes, and help-seeking efficacy.

Results

For better applicability of the curriculum, the original program was shortened, while keeping its core contents such as knowledge and myths around mental health and illness. Written and digital material was developed and distributed to teachers, which were trained to deliver the intervention. Preliminary results show high acceptability, a significant increase in MHL and a decrease in stigmatizing attitudes, while help-seeking efficacy remained unchanged.

Conclusions

An MHL intervention was successfully adapted for the German school setting. While evaluation is ongoing, first results indicate its effectiveness in promoting MHL among students, decreasing stigmatizing attitudes and high acceptability, even during the times of the pandemic. Further evaluation is necessary to confirm the preliminary findings and to gain insight into the missing effect on help-seeking efficacy.

Tool-HLCA: An intervention to promote the health literacy of school-aged children

Background

School-aged children are often exposed to health-related information from digital sources. However, there are no interventions in schools to help them deal with these appropriately. Installing health literacy in schools succeeds more easily if it can be linked to existing curricular requirements. This study aims to implement a toolbox to address (digital) health literacy of school-aged children (grades 7 and 8) in German secondary schools by combining existing media frameworks with health literacy.

Methods

Based on analysing a mandatory curriculum on media literacy in the state of North-Rhine-Westphalia in Germany and elaborating its commonalities with health literacy, we developed the toolbox for strengthening (digital) health literacy in school-aged children. Currently, the toolbox is being piloted in the school-setting in order to gain feedback from children and teachers.

Results

The mandatory media literacy framework for classroom teaching in German schools addresses the health literacy core competencies find, understand, appraise and use information. By using that framework and integrating health as a topic, this toolbox fits to the German core curriculum and will ensure that the toolbox is familiar and can be used with low thresholds by schoolteachers. The toolbox addresses digital health literacy including exercises to evaluate health-related information on different online platforms. It provides topic-specific tasks (e.g. coronavirus, vaccination, nutrition) and evaluation criteria for identifying mis- and disinformation.

Conclusions

The toolbox is an opportunity to enhancing (digital) health literacy in school-aged children by highlighting the intersections of the mandatory curriculum on media literacy and the core competencies of health literacy. In the long term, this kind of curriculum analysis serves as a methodological blueprint for educationalists to integrate health literacy into schools in many ways.

Health Literate Schools (HeLit-Schools): Organizational Health Literacy in the School Setting

Background

Health literacy of schoolchildren has been recognized as an important target for school health promotion. Yet, the environmental and organizational health literacy (OHL) capacities of the school setting has not been addressed so far. The aim of this project is to adapt the “health literate organization-approach” to school settings, including a self-assessment tool to measure the OHL capacity of schools. In terms of sustainability, intersections and links with the health promoting school will be explored.

Methods

The adaption work is carried out by a cooperative and intersectoral approach including different experts from the school setting, the education sector (teachers, principals), and health experts in various circulating phases of commenting, revision and feedback. We jointly developed attributes and indicators of the health literate school, see fit to integrate the concept into the health promoting school framework and consider gender and diversity aspects critical to health literacy. To assess the degree of OHL, school principals will fill out a survey based on a self-assessment tool.

Results

The health literate school concept comprises of eight dimensions, addressing aspects of OHL development including the organisational level (policies and structures enabling health literacy development), the personal level (promoting student health literacy and in school staff), the classroom and education level (materials and principles for classroom learning) as well as networking and cooperating with relevant actors (parents). The assessment of OHL is currently being prepared.

Conclusions

This is the first-time adaption of the OHL concept to schools in Germany, including its assessment. The health literate school shares various intersections with the health promoting school framework, which is partly being implemented in Germany. This systems approach will facilitate both the uptake and promotion of health literacy in students, teachers, and principals.

Teacher Mental Health Literacy: Results from a State-wide Survey in Schools

Background

Teachers have an important role to play in context of mental health literacy (MHL) promotion of school-aged children. Their MHL is seen as the counterpart of student`s health literacy. Especially vulnerable schoolchildren such as those affected by adverse life events (e.g. parental mental health problems) can benefit from programs. In addition, the whole school environment has impact on school mental health promotion. Yet, only little evidence is available on teachers MHL in Europe. The aim is to provide evidence from a state-wide survey on the state of MHL of teachers in Germany.

Methods

Based on semi-structured interviews with school teachers from all school types in one federal state, including primary and secondary schools, a MHL online questionnaire was developed. The survey was conducted in in 2017 in N = 2500 teachers in Germany. Descriptive and regression analyse have been performed.

Results

Teachers feel considerable uncertainties when working with children affected by adversities related to parental mental health problems. Dealing with the social family background seems hard. Teachers state that they don`t feel comfortable when aiming at mental health promotion of affected children or children in general. Data also show that they may tend to make misjudgements, and that they are not sufficiently trained to address mental health issues in the classrooms. Regression models show that the degree and quality of teaching mental health is affected by differences across school forms, satisfaction with and engagement of school principals in mental health action, learned strategies to respond to parents, and experienced stress, burden and exposure during their work.

Conclusions

Increasing teacher MHL and the environmental capacities and responsiveness towards school mental health promotion should be an important capacity building strategy. Policy support for school mental health promotion is a critical means to sustain effective whole-school approaches.

Expert Recommendations for Health Literacy Policies addressing Children and Adolescents

Background

There is an on-going and a well observable uptake of health literacy in the national and international agenda-setting pertaining to the development of new policy strategies to address the issue of promoting health literacy in whole societies. Therefore, the aim of this research is to analyse those policies on how they address children and develop recommendations for future policies.

Methods

Policy documents on national levels, published by February 2019 were retrieved using a two-pronged strategy: (1) systematic review methods (database and online search) and (2) expert consultation. Based on a SWOT analysis of these policies, an interview guide was developed and policy experts (N = 63) from 46 countries across the world were interviewed. Based on the qualitative analysis, a Delphi Study was developed to gather expert comments and validation.

Results

The search has identified 26 policies in 19 countries including case-laws and enacted statues, governmental strategies, polices driven by national key experts, and educational policies. The content of these informed the interview guide. The initial analysis of the interviews led to several recommendations pertaining to schools and the education sector, including principals, teachers and whole-school approaches, characteristics of different settings, such as policy, education and administration, economic perspectives, and the need for research and evidence in order to inform future strategies.

Conclusions

The results will be compiled into a recommendation report and a policy brief. In addition, those will be translated into other languages to share with the countries of the experts who participated in this project. While almost all policies address children somehow, several limitations make it difficult to evaluate the quality of the different policies. To secure and sustain more effective, child-focused policies, current knowledge gaps regarding research on children`s health literacy should be addressed.

Concept and Strategy for Implementing the National Action Plan on Health Literacy in Germany

Background

In Germany, the development of the National Action Plan on Health Literacy (NAP) was triggered by results of the HLS-GER, the first representative study on HL in Germany, showing that more than half of the German population perceive great problems in processing health information. In response to this, a group of 15 experts from academia, practice and policy worked together on a first draft of the NAP, which was refined based on various stakeholder consultations and finally published in 2018. The plan focuses on four areas of action and initially presents 15 specific recommendations to strengthen health literacy in Germany following five key principles. After the delivery to the Federal Minister of Health in 2018, it quickly became clear that the action plan and its recommendations need additional tools for implementation. Therefore, a systematic implementation strategy was developed.

Methods

Core elements of the implementation strategy were a systematic dissemination of the plan as well as workshops with important stakeholders from policy, associations, patient and self-help organisations. The aim of the workshops was it to concretise single recommendations of the NAP and to develop additional tools to implement them in specific fields of actions. The workshops led to policy papers, which were consented by a group of stakeholders and again disseminated broadly.

Results

Through numerous publications and presentations in different contexts the NAP received great attention. Furthermore, seven workshops and one international symposium were conducted focussing on single recommendations of the NAP, each leading to policy papers. The workshops and policy papers contributed to identification with the NAP and motivated the development of tools to promote health literacy.

Conclusions

The implementation strategy was effective as many stakeholders could be involved. It is also resource and time consuming which needs to be considered in project planning.

Exploring associated factors of subjective health literacy in school-aged children

Background

Health literacy (HL) has been acknowledged as a critical determinant of health. While HL and its potential determinants have been studied in adults, little research has been conducted with children. Therefore, this study investigates factors associated with children's subjective HL to explore potential entry points for the promotion of HL in childhood.

Methods

Cross-sectional data was collected from 4th-graders at German schools with a self-report questionnaire. Age, sex, family affluence, functional HL, self-efficacy, motivation to learn about health, and perceived parental health orientation were included as potential determinants, while the dependent variable subjective HL was assessed with a newly developed scale. We used hierarchical linear regression to explain variance in HL with different sets of predictors.

Results

n = 907 4th-graders (53.4% female) were surveyed. Subjective HL was high, with 82.2% reporting that it was “rather easy” or “very easy” for them to deal with health-related information. Age, sex, home language, and family affluence together were able to explain 2% of variance in subjective HL. In contrast, 19.3% of variance could be explained by all independent variables together, whereby family affluence, functional HL, self-efficacy, motivation, and perceived parental health orientation were significant predictors (p < .01). Motivation was the most potent predictor (β = .24), followed by parental health orientation (β = .18) and self-efficacy (β = .11).

Conclusions

This study was able to identify potential predictors of HL among children. Our data indicate that the promotion of health-related motivation and self-efficacy, but also of certain parental attitudes might be particularly fruitful in order to support the development of HL early in the life course. However, intervention research will need to provide further evidence on the extent to which these factors can be modified and actually lead to increased HL.

Key messages

This study was able to identify potential predictors of children’s HL which might be used to inform interventions. Further longitudinal research is necessary to verify our findings.

Promoting mental health literacy in schools

Background

Adolescence is the most suitable time for health promotion and prevention programs regarding mental illness to start. Given that, about half of the mental illnesses will develop by the age of 14, addressing this issue early in the life course is a particular public health goal in Europe. Mental health literacy is considered a key determinant of good mental health, as it comprises adequate knowledge positive attitudes towards mental health and help-seeking behavior. School-based interventions aimed at increasing mental health literacy are a promising method to reach most young people, at least in countries were school attendance is mandatory. The goal of our project is to evaluate a mental health school program, adapted from a Curriculum originating in Canada, in regard to its ability to increase the mental health literacy of adolescents and young adults within the German school setting.

Methods

Data is currently being collected within the school setting from adolescents and young adults attending regular secondary schools and vocational schools in Germany at three different time points: (T0) before the intervention, (T1) afterwards and (T2) 2-3 months later. A control group will be questioned as well. Data collection takes place between February and December 2020.

Results

Till October 2020 a sample size of about 200 to 400 participants will be reached. It is expected that the intervention group will have a significantly higher increase in mental health literacy, more positive attitudes towards help-seeking and a decrease in stigmatizing attitudes towards mental illness compared to the control group.

Conclusions

It is expected that, the mental health Curriculum will show to be an effective way of promoting the mental health literacy of young people attending different school forms in Germany. A national wide implementation might be a promising public health measure for fostering good mental health and mental health literacy in adolescents and young people.

Health literacy policy-making regarding children and adolescents

Background

There is an on-going and a well observable uptake of health literacy in the national and international agenda setting pertaining the development of new policy strategies to address the issue of promoting health literacy in whole societies. Even though children have been declared to be a priority target, no research is available that has analysed if and how children are addressed by these policy approaches. Therefore, the aim of this research is to analyse those policies on how they address children.

Methods

Policy documents on national levels that have been published by February 2019 were retrieved by using a two-pronged strategy comprising of (1) systematic review methods (database and online search) and (2) expert consultation.

Results

The search has identified 26 policies for 19 countries including case-laws and enacted statues, governmental strategies, polices driven by national key experts, and educational policies. No policies on children’s health literacy were found for South America and Africa. The policies differ in many ways, such as their embedding into general health policy making, policy and implementation processes, rationality and networks, and influence of governance. Children are either addressed by (1) specific programmes, (2) school health approaches, (3) their parents, (4) healthcare action, or (5) using a combination of those areas. However, there is almost no evaluation data available nor are these policies underpinned by health literacy evidence generated within the children`s population. Most policies are designed for adult populations rather than children.

Conclusions

Health literacy has developed into an important health policy-making target. While almost all policies address children somehow, several limitations make it difficult to evaluate the quality of the different policies. To secure and sustain more effective, child-focused policies, current knowledge gaps regarding research on children`s health literacy should be addressed.

P4697Complications and mortality related to non-cardiac surgery in adult congenital heart disease: Results of a nationwide study including 20,450 cases

Background

Adults with congenital heart disease (ACHD) represent a growing patient population with high morbidity and increasing health resource utilization. In addition to acute and chronic cardiac complications, these patients require numerous non-cardiac surgical procedures during their life-time. Limited data on the morbidity and mortality risk related to non-cardiac surgical procedures exist in contemporary CHD patients. The aim of this study was to analyse the frequency and outcome of non-cardiac surgical procedures in contemporary ACHD patients based on all hospital admissions in Germany between 2011 and 2016.

Methods

Based on the German diagnosis related groups data of patients treated between 2011 and 2016 we identified all ACHD patients treated surgically as inpatients for non-cardiac problems. The dataset contains information on patient demographics, primary and secondary diagnoses, interventional or surgical procedures, duration of stay and outcome including mortality. The primary endpoint of the study was surgery related mortality as well as major adverse events (defined as death or myocardial infarction, stroke, pulmonary embolism, sepsis or resuscitation).

Results

Overall, 48,872 ACHD cases were hospitalized during the study period. Of these, 20,450 (41.8%) were hospitalized for non-cardiac surgical procedures. The median age at surgery was 50.0 years and 62.9% of patients were male. The overall mortality rate following non-cardiac operations was 2.8% (95% CI 2.6–3.0%). The highest mortality rates were observed for procedure codes involving pharynx, larynx or trachea (27.2%; 95% CI: 22.3–32.1%) and lung surgery (15.4%; 95% CI: 13.3–17.8%). Abdominal surgery (9.2%; 95% CI: 7.7–10.9) and neurosurgical procedures (7.8%; 95% CI: 5.4–10.9) also had relative high mortality rates. The major adverse event rate overall was 12.7% (95% CI 11.7–12.7%). The highest major adverse event rates were observed for surgery of the airways (43.2%; 95% CI: 40.2%-46.4%).

Conclusions

Non-cardiac surgical procedures are common in ACHD patients and are associated with considerable mortality and morbidity in this cohort. Especially, surgical procedures involving the airways or neurosurgery emerged as risky procedures. However, even for routine abdominal or orthopaedic surgery considerable mortality and morbidity was observed. Overall, our data support careful pre-operative patient evaluation and concentration of surgical procedures at centres with extensive surgical and anaesthetic experience with ACHD patients.

Surface chemistry of 2,3-dibromosubstituted norbornadiene/quadricyclane as molecular solar thermal energy storage system on Ni(111)

Dwindling fossil fuels force humanity to search for new energy production routes. Besides energy generation, its storage is a crucial aspect. One promising approach is to store energy from the sun chemically in strained organic molecules, so-called molecular solar thermal (MOST) systems, which can release the stored energy catalytically. A prototypical MOST system is norbornadiene/quadricyclane (NBD/QC) whose energy release and surface chemistry need to be understood. Besides important key parameters such as molecular weight, endergonic reaction profiles, and sufficient quantum yields, the position of the absorption onset of NBD is crucial to cover preferably a large range of sunlight's spectrum. For this purpose, one typically derivatizes NBD with electron-donating and/or electron-accepting substituents. To keep the model system simple enough to be investigated with photoemission techniques, we introduced bromine atoms at the 2,3-position of both compounds. We study the adsorption behavior, energy release, and surface chemistry on Ni(111) using high-resolution X-ray photoelectron spectroscopy (HR-XPS), UV photoelectron spectroscopy, and density functional theory calculations. Both Br₂-NBD and Br₂-QC partially dissociate on the surface at ∼120 K, with Br₂-QC being more stable. Several stable adsorption geometries for intact and dissociated species were calculated, and the most stable structures are determined for both molecules. By temperature-programmed HR-XPS, we were able to observe the conversion of Br₂-QC to Br₂-NBD in situ at 170 K. The decomposition of Br₂-NBD starts at 190 K when C-Br bond cleavage occurs and benzene and methylidene are formed. For Br₂-QC, the cleavage already occurs at 130 K when cycloreversion to Br₂-NBD sets in.

Surface chemistry of 2,3-dibromosubstituted norbornadiene/quadricyclane as molecular solar thermal energy storage system on Ni(111)

Dwindling fossil fuels force humanity to search for new energy production routes. Besides energy generation, its storage is a crucial aspect. One promising approach is to store energy from the sun chemically in strained organic molecules, so-called molecular solar thermal (MOST) systems, which can release the stored energy catalytically. A prototypical MOST system is norbornadiene/quadricyclane (NBD/QC) whose energy release and surface chemistry need to be understood. Besides important key parameters such as molecular weight, endergonic reaction profiles, and sufficient quantum yields, the position of the absorption onset of NBD is crucial to cover preferably a large range of sunlight's spectrum. For this purpose, one typically derivatizes NBD with electron-donating and/or electron-accepting substituents. To keep the model system simple enough to be investigated with photoemission techniques, we introduced bromine atoms at the 2,3-position of both compounds. We study the adsorption behavior, energy release, and surface chemistry on Ni(111) using high-resolution X-ray photoelectron spectroscopy (HR-XPS), UV photoelectron spectroscopy, and density functional theory calculations. Both Br₂-NBD and Br₂-QC partially dissociate on the surface at ∼120 K, with Br₂-QC being more stable. Several stable adsorption geometries for intact and dissociated species were calculated, and the most stable structures are determined for both molecules. By temperature-programmed HR-XPS, we were able to observe the conversion of Br₂-QC to Br₂-NBD in situ at 170 K. The decomposition of Br₂-NBD starts at 190 K when C-Br bond cleavage occurs and benzene and methylidene are formed. For Br₂-QC, the cleavage already occurs at 130 K when cycloreversion to Br₂-NBD sets in.