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. 2025 Aug 4;40(4):daaf112. doi: 10.1093/heapro/daaf112

Organizational health literacy of schools in Germany: results of a cross-sectional study

Sandra Kirchhoff 1,2,#, Cara Krudewig 3,✉,#, Orkan Okan 4
PMCID: PMC12318714  PMID: 40754692

Abstract

A social gradient in health literacy is prevalent in children and adolescents, with those from lower socioeconomic backgrounds often having lower levels. Interventions aiming at an entire setting, such as the organizational health literacy approach, seem promising to tackle these inequities. Schools represent unique environments to implement such interventions. The HeLit-Schools project aimed at developing an organizational health literacy framework for schools. The framework contains eight quality standards, each underpinned by six indicators, and was translated into a self-assessment tool (OHLS-Q). In this cross-sectional study, the German version of the OHLS-Q was used to assess the implementation status of organizational health literacy in schools in Germany for the first time. School management members completed the questionnaire via an online survey, including sociodemographic, personal, and school information. Descriptive statistics were reported. The n = 598 participants from five federal states were Ø 52.3 years old and mainly female (73.6%). 49.1% worked in primary, 37% in secondary, and 13.9% in special education schools. Overall, respondents reported that 65.1% of the standards and indicators of the framework were (rather) highly implemented. A great variance can be found between the individual standards and indicators. Schools already participating in school health promotion programs or networks showed a higher percentage of implementation across all standards. A lack of resources (financial, time, and personnel) is reported. The results reveal important insights into barriers and facilitators for the implementation of organizational health literacy in schools. Future studies should focus on interventions that overcome identified barriers, targeting specific standards and indicators.

Keywords: organizational health literacy, school health literacy, health-literate school, questionnaire, measurement, school development, school health promotion

Contribution to Health Promotion International.

  • Schools are promising learning environments for children and adolescents to foster health literacy and, by that, promote their health. Organizational health literacy in schools is an environmental (whole-of-school) approach strengthening health literacy in the students.

  • This study provides first-time insights into the implementation of organizational health literacy in schools in Germany.

  • School principals in Germany reported a high percentage of implementation of organizational health literacy in schools. Promoting student health literacy is stressed to be especially strong, as well as the support of the leadership. In contrast, a lack of resources (time, financial, and personnel) and networking activities was reported.

INTRODUCTION

The relevance and necessity of enhancing individual and population health literacy is increasingly gaining traction in public health and health promotion, and recently has been echoed in calls to focus on children and adolescents through schools (World Health Organization 2021a). Health literacy summarizes a set of different competencies constituting an asset in accessing, understanding, appraising, and applying health information to make informed health choices and exercise healthier behaviours (Sørensen et al. 2012). As such, child and adolescent health literacy can be framed as a key skill set to better manage health information (Bröder et al. 2017). Several population health literacy studies conducted in various European countries over the past years indicate a widespread of low health literacy and digital health literacy among adolescents (Sukys et al. 2019, Loer et al. 2020, Ozturk and Ayaz-Alkaya 2020, Paakkari et al. 2020, BARMER 2023). In the age of digital and commercial determinants of health, critical appraisal of health information and distinguishing reliable from unreliable health claims and information represent core components of the child and adolescent health literacy model (Bröder et al. 2019). Low levels of child and adolescent health literacy generally translate to poor health information management skills, while critical thinking about health and appraisal of health information seem to be particular problematic areas for children and adolescents (Loer et al. 2020, Bollweg et al. 2021). In addition to supporting the understanding of health information, health literacy is associated with healthier lifestyle choices and behaviours in adolescents (Fleary et al. 2018). Moreover, studies reported that higher levels of health literacy in children and adolescents are linked to better health outcomes (Shih et al. 2016, Sendatzki et al. 2024), and that health literacy can mediate the association between social factors and adolescent health behaviour (Paakkari et al. 2019).

Health literacy in childhood and adolescence is also a matter of social justice as it follows a social gradient, with children (Fretian et al. 2020, Bollweg et al. 2021) and adolescents (Fleary et al. 2018, Paakkari et al. 2019, Loer et al. 2020, Ozturk and Ayaz-Alkaya 2020) from low-income families being disproportionately affected by low health literacy. Higher levels of health literacy are associated with better health behaviour and better health outcomes in children and adolescents (Shih et al. 2016, Sendatzki et al. 2024). Paakkari et al. (2019) found health literacy to be an independent factor that explained disparities in health outcomes in Finnish adolescents. In this context, health literacy is argued to be a strong explanatory factor for better health outcomes next to family affluence and can mediate the association between social factors and health behaviour (Paakkari et al. 2019) as well as health outcomes like health status or quality of life (Stormacq et al. 2019). While most social factors like family affluence are not modifiable factors, health literacy can be strengthened in children and adolescents, e.g. in school. Therefore health literacy can be considered as a modifiable factor to reduce health inequalities and needs to be considered in social justice approaches (Pelikan et al. 2018, Stormacq et al. 2019). Addressing child and adolescent health literacy through school health literacy approaches—both behavioural and structural—might help to mitigate health disparities (World Health Organization 2021a) and is discussed to reduce future health care costs (McDaid, 2024). Health literacy also plays a role in improving academic outcomes as lower levels of health literacy have been linked to poorer school and educational achievement (Paakkari et al. 2019), while better school achievement is seen as a predictor of higher health literacy (Sukys et al. 2019). Addressing health literacy in schools and education thus symbolizes a double-win approach: promoting health literacy could enable better educational outcomes, while promoting academic competencies could facilitate health literacy development (Okan et al. 2021). This positions health literacy as an important educational goal and learning outcome in schools as also discussed in previous literature (Simonds 1974, St Leger 2001, Paakkari and Paakkari 2012) and makes schools an ideal venue to address the development of health literacy in children and adolescents (Okan et al. 2020). While evaluated school-based interventions to enhance child and/or adolescent health literacy are scarce (Schulenkorf et al. 2021, Smith et al. 2021), the connection between education and health literacy needs to be further investigated through intervention and longitudinal studies exploring their interactions and co-benefits. In addition, a review on primary school health literacy found that current behavioural interventions for elevating their health literacy mostly address health education rather than health literacy (Nash et al. 2021b). Health literacy interventions that also modify the structural levers and determinants of a setting, and hence create a health literate setting, are discussed as promising, sustainable, and, in the long-term, cost-effective approaches, that improve the health literacy of individuals within these settings (Kickbusch et al. 2013, McDaid, 2024, Pelikan 2019, World Health Organization 2021a).

In the early 2010s, the World Health Organization (WHO) advocated for enhancing health literacy in schools by establishing health literacy-friendly environments, calling them health literate settings (Kickbusch et al. 2013). The terms health literate friendly and health literate settings, although the latter is clearly linked to the WHO settings approach, were derived from the health literate organization and organizational health literacy models by Brach et al. (2012). Organizational health literacy can be considered as the health literate settings approach and describes the degree to which organizations enable individuals to find, understand, and use information and services to inform health-related decisions and actions for themselves and others (Healthy People 2030 2020). Focusing on organizational development to transform organizations into health literacy-responsive settings is rooted in the relational model of health literacy based on Parker and Ratzan (2010). Schools, in particular, are consistent with the relational character inherent in health literacy, which suggests that an individual's personal health literacy is dependent upon the interplay of personal factors (e.g. academic skills and educational abilities) and situational demands and complexities of the school environment. In this context, a health literate school is defined as a school that ‘optimizes processes, structures and frameworks in such a way that health literacy can be developed, practised and enhanced within and through its setting. It enables everyone involved in the school to deal with and manage health information and to improve and reinforce health-literate behaviour’ (Kirchhoff et al. 2022, p. 6). This translates into two possible intervention approaches to enhance health literacy in the school setting: (i) educational interventions can be used to enhance personal skills (agency) of the students, staff, or parents and enable behaviour change and (ii) systemic interventions altering environmental factors (structure) can be applied to create a health literate school environment (e.g. change in school politics, investments in infrastructure, and modifying school development plans) and initiate social change (Kirchhoff et al. 2022). A detailed understanding of the complex interplay among educational stakeholders—including teachers, principals, administrators, learners, and caregivers—and the holistic school environment is required to gain insights into the multifaceted nature of school health literacy. For this purpose, the Health-Literate Schools framework (HeLit-Schools) was developed and represents a whole-of-school approach to health literacy targeting the socio-ecological school environment, structural determinants, and health literacy drivers and barriers (Kirchhoff et al. 2022).

The objective of this study is to collect and analyse data on the organizational health literacy capacities of schools in Germany, using the German version of the school-based self-assessment tool ‘Organizational Health Literacy of Schools Questionnaire (OHLS-Q)’ (Okan and Kirchhoff 2022, Okan et al. 2022). The survey was directed towards school principals and members of the school management board as the primary target population. School principals were chosen in light of their insights into the school's structures and practices at the organizational and management levels and their inherent leadership roles and capacities. School principals are also critical agents to enable and drive school health programs. Higher levels of (Covid-19 related) health literacy in school principals result in higher implementation rates of health promoting interventions at school-, staff-, and student-levels (Dadaczynski et al. 2020, Meyer et al., submitted for publication). To our knowledge, this is the first-time assessment of organizational health literacy in schools. The results presented in this paper document the implementation of organizational health literacy in schools in Germany and will provide insights to inform school-based health literacy interventions on the behavioural as well as organizational levels.

METHODS

Procedure

A cross-sectional online survey was conducted between November 2022 and July 2023 using EFS Survey software from Tivian (EFS Survey) to measure organizational health literacy of schools in five federal states in Germany. School principals, deputy principals, and members of the school's management teams were invited to participate in the study. The online survey could be accessed via computer, smartphone, or tablet and took about 20 min to complete. The study was approved by the Ethics Committee of Bielefeld University (Approval Code: 2021-024-S).

The recruitment strategy included contacting school principals’ associations, both national and statewide associations, and asking for support in conducting the study. Out of the contact points from the federal state associations, the directors of associations in North Rhine-Westphalia (NW), Baden-Wuerttemberg (BW), Hesse (HE), Saxony-Anhalt (ST), and Bremen (HB), one of only three city-states in Germany; as well as the director of the national principal's association agreed to facilitate the implementation of the survey. In NW, BW, and HE, the delegates from the state associations contacted the school principals via their mailing lists to invite members to participate in the study. Supported by the national association, the project team directly shared the study invitations with participants from ST and HB. School principals of the participating states were contacted several times: once to invite them to participate in the study, followed by two to three reminders. All correspondence and study invitations were distributed via e-mail. The period between the contacts was about 7–14 days each. Before launching the survey, ministerial approval for conducting the study in the school setting was sought and granted for the participating federal state, except for NW, the only state in Germany where no such permission is required.

Data was collected by convenience sampling in NW during November and December 2022, in BW during January and February 2023, and in HE, ST, and HB during June and July 2023. Participants were informed about the terms, conditions, and objectives of the study in advance by receiving informational invitation letters, informed consent forms, and the study's privacy and data protection policies. Informed consent from participants was collected through the online survey tool. They were automatically dropped from the survey upon not consenting. Participants from NW had the opportunity to participate in a draw after completing the questionnaire to receive HeLit-Schools print materials as a gesture of gratitude for participating and some of those had the opportunity to win a 50€ voucher. The ministries of the other federal states refused the use of incentives within a study. These differences in recruitment strategies for the federal states might have led to an inclusion bias, which cannot be ruled out due to the study design and due to the respective educational policies in place for each state.

Measures

Demographic information

Participants were asked to provide sociodemographic personal information (including gender, age, position at school, and years of professional experience in this position) and with respect to their school (e.g. school type, participation in programs, or networks of school-based health promotion). Most demographic items were adopted from a questionnaire that was developed and used in the COVID-HL school survey (Dadaczynski et al. 2021), while some were developed by the project team for the purpose of the present study.

Organizational health literacy

The German version of the OHLS-Q self-report instrument (hereinafter termed OHLS-Q) (Okan and Kirchhoff 2022) was employed to evaluate the extent of organizational health literacy implementation within schools. The comprehensive questionnaire was developed as a self-assessment tool for schools to generate a nuanced analysis of their performance across the eight standards described in the HeLit-Schools framework. The framework results from the HeLit-Schools project funded by the German Federal Ministry of Health (Kirchhoff et al. 2022). Drawing on existing, well-established frameworks for organizational health literacy across different settings and target groups, the HeLit-Schools framework has been iteratively developed together with stakeholders from the educational sector as well as health literacy, health promotion, and health policy experts. Each standard comprises one specific area of the school within which the enhancement of health literacy can be addressed. Table 1 lists the eight standards of the HeLit-Schools framework, defining what constitutes a health literate school.

Table 1.

Eight standards of health literate schools (HeLit-Schools concept) (Kirchhoff et al. 2022).

Standard 1: Include health literacy into the school's mission statement
Standard 2: Health literacy as part of school development
Standard 3: Promote and enhance health literacy in daily school life
Standard 4: Health literacy of students
Standard 5: Health literate school staff
Standard 6: Health literate communication at school
Standard 7: Enhance health literacy in the school environment
Standard 8: Networking and cooperation
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Each of the eight standards comprises six indicators, detailing the contents and objectives of the standards (e.g. Indicator 1 of Standard 1: ‘Health literacy is part of our school's mission statement’). The OHLS-Q instrument comprises 48 items in total, with six indicators allocated to each of the eight standards outlined in the HeLit-Schools framework. Utilizing a four-point Likert scale participating principals were asked to evaluate the extent to which each indicator had already been implemented within their school. The four-point Likert scale can be translated from German into ‘applies’, ‘rather applies’, ‘does rather not apply’, and ‘does not apply’.

Analysis

Descriptive data analysis was performed using IBM's Statistical Package for the Social Sciences version 28 (IBM Corp 2021). Frequencies of valid cases (in percent), means, standard deviations, and ranges were calculated for demographic information. Data were descriptively analysed by calculating frequencies of responses. For reporting purposes, the figures utilize the response options as described above, while response options can also be dichotomized. The response options ‘applies’ and ‘rather applies’ represent a high or rather high implementation, and collectively indicate a (rather) high level of organizational health literacy implementation in schools. Conversely, ‘does not apply’ and ‘does rather not apply’ responses are interpreted as low or rather low implementation, signifying an overall (rather) low level of organizational health literacy implementation. Frequencies of responses to the OHLS-Q were calculated as percentages for the entire instrument and independently for each of its eight standards. Additionally, the implementation for each standard and the overall scale was stratified according to three group variables, namely federal state, school type, and participation in school health promotion programs or networks. Participants who did not complete the OHLS-Q questionnaire were excluded from subsequent data analyses. Only valid cases are reported, leading to different numbers of cases (n) for subgroups. Cronbach's alpha was calculated to assess the internal consistency of the OHLS-Q for the overall scale as well as for each standard separately.

RESULTS

Sample description

In total, N = 604 participants took part in the survey. Six participants (NW n = 3, BW n = 3) were excluded from data analysis for not completing the questionnaire. Data from n = 598 participants were eligible for data analysis (NW n = 327, BW n = 154, HE n = 69, ST n = 37, and HB n = 11). The relatively small number of participants from HB is partly due to the equally small size of the federal state of HB. All questions were based on voluntary responses, resulting in a smaller sample for some of the reported information, which is why the number of cases (n) is varying as some of the questions were not answered by all of the participants. The participants’ mean age was 52.3 (SD = 7.1, range 32–67, n = 592). The sample comprises more female participants (73.6%, n = 592).

Predominantly school principals completed the questionnaire (80.7%), whereas 11.1% were deputy principals, and 8.1% reported to have a different position (e.g. interim school principal, member of extended school principals’ team, curriculum, and instruction coordinator) (n = 592). On average, the participants had 9.6 years of professional experience within their position (SD = 7.1, range 0–39, n = 588). In the sample population, 49.1% were employed in primary schools (Grades 1–4), 37% in secondary schools (grades from 5 onwards, including vocational schools), and 13.9% in special education schools (n = 581). Participation in school health promotion programs and networks were reported by 26.3% of the respondents (n = 593). Demographic characteristics of the whole sample, as well as for each federal state, are shown in Table 2.

Table 2.

Sample characteristics of HeLit-Schools Survey.

Total sample (n = 598) NW (n = 327) BW (n = 154) HE (n = 69) ST (n = 37) HB (n = 11)
Age (n = 592) (n = 324) (n = 154) (n = 68) (n = 35) (n = 11)
 M (SD) 52.3 (7.1) 52.8 (7.0) 51.3 (7.4) 51.3 (7.5) 52.4 (5.7) 52.2 (9.2)
 Range 32–67 35–66 36–67 37–63 32–65 33–64
Gender (n = 592) (n = 324) (n = 153) (n = 66) (n = 36) (n = 9)
 Female 73.6% 71.6% 71.2% 78.8% 88.9% 81.8%
 Male 26.4% 28.4% 28.8% 21.2% 11.1% 18.2%
Position (n = 592) (n = 326) (n = 153) (n = 67) (n = 35) (n = 11)
 Principal 80.7% 77.6% 87.6% 89.6% 71.4% 54.5%
 Deputy Principal 11.1% 11.0% 9.2% 10.4% 11.4% 45.5%
 Othera 8.1% 11.3% 3.3% — 17.1% —
Years of experience in position (n = 588) (n = 322) (n = 152) (n = 68) (n = 35) (n = 11)
 M (SD) 9.6 (7.1) 8.6 (6.4) 9.6 (6.6) 11.4 (6.5) 14.1 (12.4) 10.6 (6.9)
 Range 0–39 0–27 0–30 0.5–25 0–39 1.5–21
School typeb (n = 581) (n = 327) (n = 148) (n = 60) (n = 35) (n = 11)
 Primary 49.1% 37% 61.5% 85.0% 45.7% 54.5%
 Secondary 37.0% 50.8% 18.2% 13.3% 34.3% 18.2%
 Special education 13.9% 12.2% 20.3% 1.7% 20.0% 27.3%
Participation in health promoting program/network (n = 593) (n = 324) (n = 154) (n = 68) (n = 36) (n = 11)
 Yes 26.3% 31.2% 20.6% 25.0% 11.1% 27.3%
 No 73.7% 68.8% 79.4% 75.0% 88.9% 72.7%
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NW, North-Rhine Westphalia; BW, Baden-Wuerttemberg; HE, Hesse; ST, Saxony-Anhalt; HB, Bremen; M, mean; SD, standard deviation.

aMembers of the school's management teams (e.g. interim school principal, member of extended school principals’ team, and didactic head).

bPrimary schools = Grades 1–4; secondary schools = grades from 5 onwards including vocational schools; special education schools = Grades 1–10/11.

Organizational health literacy of schools

Across all eight standards, nearly two-thirds of participants assessed their schools` organizational health literacy implementation as either ‘rather high’ (25.4%) or ‘high’ (39.7%) (Fig. 1). Conversely, approximately one-third of participants (34.9%) indicated that the implementation of the standards and indicators was assessed ‘rather low’ (24.3%) or ‘low’ (10.6%).

Figure 1.

Figure 1.

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Eight standards of organizational health literacy of schools in Germany measured by OHLS-Q (German version) (Okan and Kirchhoff 2022); S1, Standard 1 ‘Include health literacy into the school's mission statement’; S2, Standard 2 ‘Health literacy as part of school development’; S3, Standard 3 ‘Promote and enhance health literacy in daily school life’; S4, Standard 4 ‘Health literacy of students’; S5, Standard 5 ‘Health literate school staff’; S6, Standard 6 ‘Health literate communication at school’; S7, Standard 7 ‘Enhance health literacy in the school environment’; S8, Standard 8 ‘Networking and cooperation’.

Looking at the individual standards (abbreviated as ‘S’), the results reveal differences between the eight standards. The implementation of Standards 4, 6, and 1 [‘Health literacy of students’ (S4), ‘Health literate communication at school’ (S6), and ‘Include health literacy into the school's mission statement’ (S1)] was assessed the highest, with 79.6%, 75%, and 72.3% of (rather) high implementation, respectively. In contrast, Standards 2 and 8 [‘Health literacy as part of school development’ (S2) and ‘Networking and cooperation’ (S8)] received the lowest assessment, with 44% and 48.4% of (rather) high implementation, respectively.

A comprehensive analysis of the standards, as outlined in Supplementary File S1, reveals that five indicators within Standards 2 and 8 received the lowest evaluation among all 48 indicators (hereafter referred to as ‘I’). In these standards, fewer than 30% of respondents rated the indicators as being (rather) highly implemented, particularly concerning those within Standard 2 that pertain to the availability of resources necessary for the effective implementation of health literacy promoting measures at school. The availability of personnel (I4), time (I5), and financial resources (I6) were reported to be (rather) low by 80.9%, 81%, and 76.3% of the participants, respectively. Within Standard 8, the indicators reflecting the school's performance in disseminating health literacy-related knowledge and experiences in their region (I3 = 28.6%) and in sharing exemplary practices through local media or conferences (I4 = 23.2%) exhibited the lowest scores.

Six additional indicators were assessed as being (rather) highly implemented, with less than 50% compliance in the corresponding domains of organizational health literacy in schools:

  1. S1, I6: ‘The school district administration supports our school to become a health literate school by providing financial and personnel resources’ (41.3%).

  2. S3, I4: ‘Our school provides health information and services that meet the diversity of our students (e.g. language or culture)’ (43.1%).

  3. S5, I4: ‘We employ various measures to implement health-related quality standards and processes (e.g. feedback, supervision, or quality manuals)’ (45.1%).

  4. S7, I3: ‘We provide initiatives and services that strengthen the health literacy of parents and guardians (e.g. parents’ evenings, open days, parenting courses, or project days)’ (44.5%).

  5. S8, I2: ‘Our school attends local/regional networking meetings, projects, and offers on health/health literacy’ (40.1%).

In contrast, the following six indicators were evaluated as having more than 85% of (rather) high implementation:

  1. S1, I2 and I5: ‘Strengthening health literacy of everyone at our school is considered an important goal in the context of school health promotion and prevention’. (87.7%), ‘Our school management team (e.g. principal or deputy principal) actively supports the implementation of measures to strengthen health literacy at our school’ (90.3%).

  2. S3, I6: ‘Our school principal, teachers and school staff act health literate and know how to organize daily school life in a way that benefits health of all’ (85.5%).

  3. S4, I4: ‘We address health literacy in different school subjects (e.g. health education, science, biology, physical education, or maths)’ (87.5%).

  4. S5, I1: ‘At our school, we provide training and professional development opportunities on health literacy for the entire school team (their own personal health literacy and health literacy teaching skills)’ (85,3%).

  5. S6, I1 and I2: ‘Our school team makes sure that communication on health topics is simple and understandable for everyone (e.g. in class, with colleagues, and parents or guardians)’. (86.1%), ‘At our school, we facilitate participation in professional training on health communication’ (94.1%).

  6. S7, I5: ‘Our school has a list of contact addresses of the most important internal and external persons and services (e.g. school psychologists, school social workers, or doctors), including their respective responsibilities’ (86.6%).

Group comparisons

Figure 2 displays the total organizational health literacy results stratified by federal state, school type, and previous participation in a school health promotion program or network. The largest difference can be observed for the variable of previous participation in a school health promotion program or network. Participants from schools that already participate in a school health promotion program or network reported 75.6% of (rather) high implementation of organizational health literacy in their schools. In contrast, only 61.4% of schools not participating in a school health promotion program or network reported a (rather) high implementation of the respective framework. In particular, the ratings for high implementation increased by 15.3% in favour of the participating schools.

Figure 2.

Figure 2.

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Total percentages of organizational health literacy of schools in Germany measured by OHLS-Q (German version) (Okan and Kirchhoff 2022). Results are divided by federal state (NW, North-Rhine Westphalia; BW, Baden-Wuerttemberg; HE, Hesse; ST, Saxony-Anhalt; HB, Bremen), school type, and *participation in program/network of school-based health promotion.

Comparing the federal states, small differences can be observed for the implementation of organizational health literacy in schools. Participants from schools in NW reported the highest implementation (67,8% (rather) high) compared to BW (61.1% (rather) high), HE (62.6% (rather) high), ST (63.3% (rather) high), and HB (64.1% (rather) high). The observed differences of the implementation of organizational health literacy between the school types were even smaller.

For a more in-depth assessment of the group differences see Supplementary File S2. Here, the differences are presented on indicator level.

Scale quality

A brief screening of the internal consistency measured by Cronbach's alpha for the OHLS-Q scale revealed a rather high value of α = 0.96 (n = 522). When looking at the individual scales for each standard, Cronbach's alpha remains on a high level with the following values: α = 0.84 (n = 585, S1); α = 0.83 (n = 589, S2); α = 0.85 (n = 584, S3); α = 0.83 (n = 586, S4); α = 0.87 (n = 586, S5); α = 0.81 (n = 581, S6); α = 0.77 (n = 573, S7); and α = 0.82 (n = 583, S8).

DISCUSSION

This study aimed to evaluate the implementation of organizational health literacy within schools in Germany for the first time. The findings from the descriptive analysis indicate that approximately two-thirds of the standards and indicators related to organizational health literacy have been (rather) highly implemented in schools. With one-third of the indicators across the standards being (rather) low implemented at school, there remains a considerable untapped potential for enhancing school health literacy. Furthermore, there exists a great variability in the implementation of various standards and indicators of school health literacy, as described by the HeLit-School framework.

The implementation status of Standard 2, which pertains to health literacy as a fundamental aspect of school development, was found to be the lowest among the eight standards of the framework. An analysis at indicator level reveals that schools frequently lack essential resources (S2, I4, I5, and I6) for the effective implementation of health literacy interventions, particularly in relation to personnel (S2, I4), time (S2, I5), and financial (S2, I6) resources. The absence of those can be considered detrimental to school health literacy activities or any school health initiatives in general. The broader literature indicates that insufficient community resources allocated to schools generally impede the successful implementation of school health programs (St Leger and Nutbeam 2000, Marks 2010, Lewallen et al. 2015). Furthermore, the lack of resources has been reported to be a key barrier for measures targeting organizational health literacy within other settings as well (Mehlis et al. 2021, Ayre et al. 2023). For example, in public health services the absence of time, equipment, funds, or specialists was identified as one key barrier for organizational health literacy in public health departments in Germany that was mentioned by all interviewees in a qualitative study (Mehlis et al. 2021). The findings from Standard 2 are supported by the result observed in Standard 1, Indicator 6, which reflects the extent of support—manifested through financial and personnel resources—provided by the school district administration. Notably, only 41.3% of respondents reported receiving such support from their district administration, which demonstrates a substantial gap in resource allocation for health literacy initiatives. This finding highlights the urgent need for a comprehensive reassessment of resource allocation strategies, aimed at ensuring adequate funding and infrastructure to support the effectiveness and sustainability of health programs at school.

In contrast to the obstacles identified within public health departments, such as insufficient leadership support (Mehlis et al. 2021), schools demonstrated a robust implementation of Standard 1, i.e. the integration of health literacy into the school's mission statement. Especially Indicator 5, which highlights the importance of school leadership support, was rated as (rather) highly implemented by 90.3% of respondents. The efficacy of school development initiatives and the advancement of school health literacy were found to be enhanced by the active involvement of school principals in health programs and how much they value such programs in another study (Nash et al. 2021a). Other studies propose that the principal's personal health literacy can serve as a predictor for the successful implementation of school health promotion programs in principals (Dadaczynski et al. 2020, Betschart et al. 2022, Meyer et al., submitted for publication). As health outcomes and educational achievements are connected, it is argued that principals who support health literacy contribute to improved health outcomes among students but also contribute positively to educational achievements (Schools for Health in Europe Network Foundation 2021). This underscores the necessity of empowering principals to invest in school health literacy, making it an important agenda item within the school’s mission statement as suggested by Standard 1.

Standard 4 focuses on measures aimed at enhancing the personal health literacy of students and achieved the highest implementation rate among all standards [79.6% (rather) high implementation]. With 87.5%, Indicator 4 (S4, I4), addressing health literacy across school subjects, was the highest-rated indicator across all 48 indicators. Nevertheless, these findings contrast with those of another German study investigating digital health literacy—a specific concept of health literacy—in schools, which revealed that 48.6% of students and two-thirds of teachers reported a lack of adequate learning or teaching of digital health literacy skills in their schools (BARMER 2023). Additionally, teachers in leadership positions reported more frequently that these skills are being taught compared to their counterparts without such roles. However, these teachers teach less frequently, which may lead to an inaccurate evaluation of the actual content being delivered in classrooms—a concern that may also help to explain the discrepancy. Despite the fact that digital health literacy is one specific concept of health literacy, the results are highly relevant, as there is no other comparable literature for German schools exploring whether (digital) health literacy is taught in schools in Germany from students’ and teachers’ perspectives. As has been shown in another study, health literacy is not part of the German school curriculum and, therefore, probably not taught so much at school (Schulenkorf et al. 2021). This raises questions about the validity of the assumption by school principals that health literacy is frequently addressed in schools. School principals, as leaders of their institutions, might provide biased responses that favourably portray their health (literacy) programs and initiatives. Their perspectives could be influenced by a desire to present their schools positively, potentially overshadowing the genuine challenges students and teachers face in acquiring essential health literacy skills.

In comparison to Standard 4, Standard 5 exhibited a lower percentage of (rather) high implementation concerning health literate school staff (66.3%). While a high proportion of schools (85.3%) reported offering training and professional development on health literacy (S5, I1), only 45.1% indicated the implementation of quality standards for these initiatives (S5, I4). Nevertheless, further studies from Germany indicate that a substantial proportion of teachers and school principals show low levels of digital health literacy, with 39.2% of teachers with limited self-reported digital health literacy (Rangnow et al. 2024), and 29.3% of school principals with limited health literacy (Dadaczynski et al. 2020). These findings highlight considerable opportunities for enhancement in this area. Higher levels of health literacy have been identified as a key predictor of various dimensions of health-promoting behaviour in Korean teachers (Bae and Yoon 2021). Consequently, health literate teachers can serve as effective role models for their students, a notion previously presented by Velardo and Drummond (2015). Also, as mentioned before, research involving school principals has demonstrated that elevated personal health literacy correlates with enhanced implementation of health promotion initiatives within schools (Dadaczynski et al. 2020, Betschart et al. 2022). These findings suggest that a health literate school workforce might cultivate greater awareness of health promotion and might increase the number of health-related initiatives within the school environment. Promoting Standard 5, particularly in the realm of quality management, represents a promising strategy not only for school staff but also for further enhancing health literacy among students and within the organizational framework of the school.

Only 51.9% of participants indicated that their school had appointed a contact person responsible for health literacy (S2, I3). A systematic review by Ayre et al. (2023) examined the existing literature on ‘health literacy champions’ as a strategic approach for implementing organizational health literacy across various settings through designated experts. The findings suggest that while health literacy champions may be effective in planning and implementing coordinated school health literacy activities and initiatives, there still remains a need to further investigate their role and contribution to the effectiveness of school health literacy. Given the substantial endorsement from the school management board, which in this study stands at 90.1% (S1, I5), the establishment of a dedicated champion team, inclusive of an appointed contact person, could represent a favourable strategy for promoting organizational health literacy within schools. In addition to collaborating with teachers and school staff as health literacy champions, school nurses may also serve as potential health literacy champions within schools. The advantages of school nurses are consistently discussed, examined, and tested through pilot projects conducted in German schools (Maulbecker-Armstrong et al. 2022). De Buhr and colleagues (2020) conducted a pilot study aimed at investigating the impact of school nurses on health literacy of children, teachers, and parents. The findings indicated significant short-term improvements in the health literacy levels of both children and their parents. Those findings are supported by a systematic review by Pawils et al. (2023), suggesting that school nursing services might play a crucial role in promoting health literacy within educational settings next to providing medical care and health promotion. A secondary analysis of the findings from this systematic review, which focused on health equity issues in schools, generally supports the implementation of school nurses, particularly in schools with a high proportion of socioeconomically disadvantaged students (Mays et al. 2024). Given that the HeLit-Schools framework is grounded in the organizational health literacy model—specifically designed to address health literacy disparities arising from sociodemographic factors—it is imperative to recognize the critical role of school nurses in effectively implementing school health literacy initiatives.

Another concerning finding is that only 44.5% of the schools in this study reported implementing initiatives to enhance parental and guardian health literacy (S7, I3). Like teachers, parents serve as critical role models for their children. Younger children, in particular, rely heavily on their guardians, who are tasked with guiding their health behaviours and making essentials health decisions on their behalf. Research over the past decade points at the possible impact of parental health literacy on child health outcomes, with studies indicating that higher parental health literacy correlates with positive health behaviours—such as healthier nutrition and regular tooth brushing—in healthy children (Buhr and Tannen 2020) and a link between poor parental health literacy and worse health behaviour and health outcomes in children with chronic diseases (Zaidman et al. 2023). These findings once again demonstrate the link between health disparities and social inequalities within families. Consequently, the limited initiatives to actively foster health literacy in parents reported by schools in our study highlight a missed opportunity not only to foster school health goals, but also to help tackling health inequalities between the students. At the same time, the cooperation with parents was reported to be (rather) highly implemented with 80.8% (S8, I5) in this study. The Australian HealthLit4Kids program (Elmer et al. 2021) recognizes parents as crucial stakeholders in fostering health literacy within schools, emphasizing their role not merely as consumers but active participants in health literacy initiatives. By involving parents in the co-creation of health literacy strategies, the sustainability and effectiveness of school health literacy programs and a health literacy responsive school environment may be increased (Elmer et al. 2021). This study does not explore how and where parents are involved in school health literacy strategies, but the results indicate that working with parents seems to be a valuable resource for school health literacy in Germany that should be considered.

Standard 8 emphasizes the importance of networking and cooperation of schools regarding health literacy. Only 48.4% of the schools reported (rather) high implementation of Standard 8. As already discussed above, cooperation with stakeholders in and outside of the school environment is essential to foster sustainable health promotion within schools, which is also applicable to organizational health literacy in schools. In a study exploring the barriers to implement organizational health literacy within public health departments, networking and cooperation were also mentioned as key barriers (Mehlis et al. 2021). Increased cooperation was discussed to be a possibility to facilitate resource distribution and conservation through exchange among stakeholders and institutions.

A higher implementation of organizational health literacy was observed in schools that are already engaged in school health promotion programs or networks. Especially the overall percentage of answers indicating a high implementation is 15.3% higher for participating schools. The higher implementation of organizational health literacy in participating schools in such programs could possibly be explained due to their increased awareness and familiarity with health-related topics. These results can be supported by a recent Dutch study showing that schools that identify as health promoting schools are implementing more (school) health promotion measures (Vennegoor et al. 2023). In Germany, health promotion programs are mostly based on the Health Promoting School (HPS) framework (BUG NRW n.d., Bayerisches Staatsministerium für Unterricht und Kultus n.d.), which also includes an environmental whole-of-school approach with promising effects: a systematic review and meta-analysis conducted by Langford et al. (2015) demonstrated that HPS interventions positively influence healthy behaviour, such as vegetable intake and physical activity, reduced body mass index, and reduced smoking. Recent developments indicate that health literacy has been incorporated as a target within the existing HPS frameworks (Schools for Health in Europe Network Foundation 2021, World Health Organization 2021b). Merging these frameworks could effectively advance health literacy and promote healthy behaviours simultaneously, optimizing resource use in schools.

The comparison of organizational health literacy in schools between the five participating federal states revealed only small descriptive differences in favour of NW. The present study is based on a convenience sample with large differences in the number of participants between the federal states, which complicates a direct comparison. The larger sample size might be due to the fact that NW is the most populous state in Germany. Also, the tradition of school health promotion strategies and programs is very popular in NW, so the reason for the small difference might also result from a higher percentage of schools already taking part in a school health promotion program or network and thus being more aware and involved in this area. Further investigation is needed to explore differences and possible influencing factors on federal state level.

Studies on organizational health literacy and health literacy responsiveness across various contexts highlight the lack of actionable solutions following the identification of critical areas for enhancing health literacy within those settings (Lloyd et al. 2018, Jensen et al. 2021). While existing health literacy tools may help to raise awareness for health literacy within an organization, they are inefficient in initiating organizational change processes (Lloyd et al. 2018). Jensen et al. (2021) conducted a qualitative study with Danish health care providers on the feasibility of a new assessment tool for organizational health literacy. The participants reported good feasibility, but some felt frustrated by a lack of solutions to meet the identified health literacy needs. Those observations concerning shortcomings are also applicable to schools. Future studies should focus on developing interventions based on the different standards and indicators of the HeLit-Schools framework to enable and facilitate the practical implementation of organizational health literacy for schools. While some identified standards and indicators are well suited to be improved within a change of school structures or the development of new interventions, others lay beyond the control of school organizations or research. In particular, the lack of resources cannot be adequately compensated for by the school itself but depends on educational policies and higher-level political and fiscal decisions.

Since this is the first quantitative study assessing organizational health literacy in schools or other settings targeting children and adolescents, comparable literature is scarce. For the same reason there is no gold standard established to classify our results or compare them to other studies, regions or target groups. Also, the present study has some limitations that need to be considered when interpreting the results: The study is not representative for Germany and is based on a convenience sample. Therefore, the participation rate could not be controlled due to the study design, which resulted in varying sample sizes between federal states. A participation bias cannot be ruled out, meaning that a certain interest in topics of school health or school research might have made study participation more likely in some participants. Another potential source of bias might be due to the nature of self-report data. In this study, the school principals and members of the school management board themselves responded to the questionnaire, which may have resulted in social desirable responses. Also, as some of the respondents might be less involved in teaching, they might also have been unaware about certain topics within the school organization, i.e. the actual teaching content, as discussed above. Moreover, we are unable to determine the participants’ understanding of health literacy, or whether this was partly confused with the term health promotion. To gain clarity and increase conceptual distention, it is essential to assess the participants’ understanding of (organizational) health literacy when replicating this study or using this questionnaire. Due to the different sample sizes in each federal state, a direct inductive comparison across states is not possible. Regarding the scale validity, a relatively high value of Cronbach's alpha = 0.96 (n = 522) for the whole scale was calculated for internal consistency. This is not surprising, given that in accordance with the HeLit-Schools framework organizational health literacy of schools was operationalized with a total of 48 items and that Cronbach's alpha values increase with scale length (Cronbach 1951). Nevertheless, the value might hint at potentially overlapping constructs or redundant items. A profound validating analysis of the OHLS-Q is ongoing and will be published soon (Krudewig et al., in preparation).

Despite these limitations, several strengths contribute to the study's value. To the author's knowledge, this is the first-time assessment of quantitative data on organizational health literacy conducted in educational settings. Thus, we gain valuable insights into existing health literacy-related resources and structures as well as shortcomings and needs. Furthermore, the online form allowed flexibility for the participants in place and time to complete the questionnaire. Five federal states from different geographical regions of Germany were included in this study. The study was supported by the school principals’ associations of the different federal states of Germany as well as the national association. These professional, occupational associations are well-known by the target group of this cross-sectional study, which might have led to a higher response and acceptance by the invited school principals. Given the fact that conducting research in school context is a difficult undertaking in terms of recruiting participants, collaboration with similar associations could act as a facilitating factor for future studies. Although a profound validating analysis of the OHLS-Q is currently missing, Cronbach's alpha´s values for each of the eight standards was calculated quite high (α = 0.77—α = 0.87) which indicates a good internal consistency.

CONCLUSIONS

Schools are important venues for promoting health literacy early in the life-course. This study examined the organizational health literacy capacities of schools which are assumed to facilitate health literacy development in school children. Key findings show pre-existing resources that can be used in context of school health literacy, e.g. leadership support, which is important for school development and the implementation of health promotion measures. However, it is striking that the areas of organizational health literacy in schools lying outside of the schools or the school administration board's responsibility achieved particularly poor results. Next to explicit measures promoting organizational health literacy, especially for the staff in schools, the underlying conditions such as time, financial and personnel resources, or the commitment of the schools’ districts administration have to be encouraged in school politics to prioritize the implementation of organizational health literacy. This would eventually lead to the effective planning, implementation, monitoring, and evaluation of school health literacy. Additionally, the results indicate that schools need to provide additional quality-assured training opportunities for staff members and intensify the involvement of parents and guardians. Finally, already established school health promotion programs and networks are promising entry points to foster organizational health literacy in schools, alongside the already known effects of the school principal's personal health literacy. Future studies should explore the relation of factors inside and outside of the school with the implementation of the HeLit-Schools framework. Furthermore, future studies should consider different target groups within the school (e.g. teachers and students) next to the school management to draw a holistic picture of organizational health literacy in schools. In the long run, new evidence-based interventions at the behavioural and structural levels targeting neglected areas of organizational health literacy in schools are needed to optimize positive health outcomes and educational attainment among students and staff. Such investigations may inform evidence-based policies that leverage the full potential of the school environment in fostering health literacy across school staff, guardians, and students.

Supplementary Material

daaf112_Supplementary_Data
daaf112_supplementary_data.zip (304.4KB, zip)

Acknowledgements

We thank the project partners, the advisory board, the partners from practice and schools that have supported the project since 2019, as well as the Alliance Health Literacy in Schools, which was launched as part of the project in 2021. Also, we thank our student assistance who helped with the recruitment of the study participants. We thank all study participants for sharing their insights as well as the participating school principals’ associations for their support in recruiting study participants.

Contributor Information

Sandra Kirchhoff, Department of Health and Sport Sciences, TUM School of Medicine and Health, WHO Collaborating Centre for Health Literacy, TUM Health Literacy Unit, Technical University of Munich, Am Olympiacampus 11, 80809 Munich, Germany; Department of Educational Sciences, Carl von Ossietzky University of Oldenburg, Ammerlaender Heerstraße 114 - 118, 26129 Oldenburg, Germany.

Cara Krudewig, Department of Health and Sport Sciences, TUM School of Medicine and Health, WHO Collaborating Centre for Health Literacy, TUM Health Literacy Unit, Technical University of Munich, Am Olympiacampus 11, 80809 Munich, Germany.

Orkan Okan, Department of Health and Sport Sciences, TUM School of Medicine and Health, WHO Collaborating Centre for Health Literacy, TUM Health Literacy Unit, Technical University of Munich, Am Olympiacampus 11, 80809 Munich, Germany.

Author contributions

S.K., C.K., and O.O. contributed to the conceptualization, methodology, investigation, and data curation. S.K. contributed to the analysis and visualization of the data. S.K. and C.K. did the writing—original draft preparation, reviewing, and editing. O.O. contributed to the reviewing and editing of the manuscript, as well as to funding acquisition, and supervision. All authors have read and agreed to the published version of the manuscript.

Supplementary data

Supplementary data is available at Health Promotion International  online.

Conflict of interest

None declared.

Funding

This research was funded by the Federal Ministry of Health Germany, grant numbers 2519 FSB 006 and 2522 FSB 006.

Data availability

The dataset that has been generated and analysed during the present study is not currently available to the public, as the data analysis is not yet complete. The dataset will be made available to the public once the data analysis has been completed. Until that time, interested parties may request the dataset from the corresponding author.

References

  1. Ayre  J, Zhang  M, Mouwad  D  et al.  Systematic review of health literacy champions: who, what and how?  Health Promot Int  2023;38:daad074. 10.1093/heapro/daad074 [DOI] [PMC free article] [PubMed] [Google Scholar]
  2. Bae  EJ, Yoon  JY. Health literacy as a major contributor to health-promoting behaviors among Korean teachers. Int J Environ Res Public Health  2021;18:3304. 10.3390/ijerph18063304 [DOI] [PMC free article] [PubMed] [Google Scholar]
  3. BARMER . Digitale Gesundheitskompetenz und Schule: Studienbericht 2023. Unpublished manuscript, 2023. https://www.durch-blickt.de/fileadmin/user_upload/Startseite/BARMER-DURCHBLICKT-Digitale-Gesundheitskompetenz-und-Schule.pdf (22 May 2023, date last accessed).
  4. Bayerisches Staatsministerium für Unterricht und Kultus . Good Healthy School Network Bavaria, n.d. https://www.ggs.bayern.de/ (7 November 2024, date last accessed).
  5. Betschart  S, Sandmeier  A, Skedsmo  G  et al.  The importance of school leaders’ attitudes and health literacy to the implementation of a health-promoting schools approach. Int J Environ Res Public Health  2022;19:14829. 10.3390/ijerph192214829 [DOI] [PMC free article] [PubMed] [Google Scholar]
  6. Bollweg  TM, Okan  O, Freţian  A  et al.  Dimensionen der Gesundheitskompetenz von Viertklässler*innen. Prävention und Gesundheitsförderung  2021;16:296–302. 10.1007/s11553-020-00822-9 [DOI] [Google Scholar]
  7. Brach  C, Keller  D, Hernandez  L  et al.  Ten Attributes of Health Literate Health Care Organizations. NAM Perspect  2012;02. 10.31478/201206a [DOI] [Google Scholar]
  8. Bröder  J, Okan  O, Bauer  U  et al.  Health literacy in childhood and youth: a systematic review of definitions and models. BMC Public Health  2017;17:361. 10.1186/s12889-017-4267-y [DOI] [PMC free article] [PubMed] [Google Scholar]
  9. Bröder  J, Okan  O, Bollweg  TM  et al.  Child and youth health literacy: a conceptual analysis and proposed target-group-centred definition. Int J Environ Res Public Health  2019;16:3417. 10.3390/ijerph16183417 [DOI] [PMC free article] [PubMed] [Google Scholar]
  10. BUG NRW . Gute Gesunde Schule [Good healthy school], n.d. https://www.bug-nrw.de/arbeitsfelder/gute-gesunde-schule (7 November 2024, date last accessed).
  11. Cronbach  LJ. Coefficient alpha and the internal structure of tests. Psychometrika  1951;16:297–334. 10.1007/BF02310555 [DOI] [Google Scholar]
  12. Dadaczynski  K, Okan  O, Messer  M. COVID-19 Health Literacy School Principals Survey (COVID-HL: School Principal): Questionnaire and Scale Documentation. Bielefeld/Fulda: Bielefeld University, Interdisciplinary Centre for Health Literacy Research and Fulda University of Applied Sciences, Public Health Centre, 2021.
  13. Dadaczynski  K, Rathmann  K, Hering  T  et al.  The role of school leaders’ health literacy for the implementation of health promoting schools. Int J Environ Res Public Health  2020;17:1855. 10.3390/ijerph17061855 [DOI] [PMC free article] [PubMed] [Google Scholar]
  14. de Buhr  E, Ewers  M, Tannen  A. Potentials of school nursing for strengthening the health literacy of children, parents and teachers. Int J Environ Res Public Health  2020;17:2577. 10.3390/ijerph17072577 [DOI] [PMC free article] [PubMed] [Google Scholar]
  15. de Buhr  E, Tannen  A. Parental health literacy and health knowledge, behaviours and outcomes in children: a cross-sectional survey. BMC Public Health  2020;20:1096. 10.1186/s12889-020-08881-5 [DOI] [PMC free article] [PubMed] [Google Scholar]
  16. Elmer  S, Nash  R, Kemp  N  et al.  HealthLit4Kids: supporting schools to be health literacy responsive organisations. Health Promot J Austr  2021;32:17–28. 10.1002/hpja.412 [DOI] [PubMed] [Google Scholar]
  17. Fleary  SA, Joseph  P, Pappagianopoulos  JE. Adolescent health literacy and health behaviors: a systematic review. J Adolesc  2018;62:116–27. 10.1016/j.adolescence.2017.11.010 [DOI] [PubMed] [Google Scholar]
  18. Fretian  A, Bollweg  TM, Okan  O  et al.  Exploring associated factors of subjective health literacy in school-aged children. Int J Environ Res Public Health  2020;17:2020. 10.3390/ijerph17051720 [DOI] [PMC free article] [PubMed] [Google Scholar]
  19. Healthy People 2030 . History of Health Literacy Definitions: The New Definitions. Unpublished manuscript, 2020. https://health.gov/healthypeople/priority-areas/health-literacy-healthy-people-2030/history-health-literacy-definitions (April 17, 2023, date last accessed).
  20. IBM Corp . IBM SPSS for Windows, Version 28. Armonk, NY: IBM Corp, 2021. [Google Scholar]
  21. Jensen  NH, Aaby  A, Ryom  K  et al.  A CHAT about health literacy—a qualitative feasibility study of the Conversational Health Literacy Assessment Tool (CHAT) in a Danish municipal healthcare centre. Scand J Caring Sci  2021;35:1250–8. 10.1111/scs.12943 [DOI] [PMC free article] [PubMed] [Google Scholar]
  22. Kickbusch  I, Pelikan  JM, Apfel  F  et al.  Health Literacy: The Solid Facts, 2013. https://apps.who.int/iris/handle/10665/326432 (8 December 2021, date last accessed).
  23. Kirchhoff  S, Dadaczynski  K, Pelikan  JM  et al.  Organizational health literacy in schools: concept development for health-literate schools. Int J Environ Res Public Health  2022;19:8795. 10.3390/ijerph19148795 [DOI] [PMC free article] [PubMed] [Google Scholar]
  24. Langford  R, Bonell  C, Jones  H  et al.  The World Health Organization’s health promoting schools framework: a Cochrane systematic review and meta-analysis. BMC Public Health  2015;15:130. 10.1186/s12889-015-1360-y [DOI] [PMC free article] [PubMed] [Google Scholar]
  25. Lewallen  TC, Hunt  H, Potts-Datema  W  et al.  The Whole School, Whole Community, Whole Child model: a new approach for improving educational attainment and healthy development for students. J Sch Health  2015;85:729–39. 10.1111/josh.12310 [DOI] [PMC free article] [PubMed] [Google Scholar]
  26. Lloyd  JE, Song  HJ, Dennis  SM  et al.  A paucity of strategies for developing health literate organisations: a systematic review. PLoS One  2018;13:e0195018. 10.1371/journal.pone.0195018 [DOI] [PMC free article] [PubMed] [Google Scholar]
  27. Loer  A-KM, Domanska  OM, Stock  C  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. 10.3390/ijerph17228682 [DOI] [PMC free article] [PubMed] [Google Scholar]
  28. Marks  R. Healthy schools and colleges: what works, what is needed, and why? Part II. Health Educ  2010;110:421–6. 10.1108/09654281011087233 [DOI] [Google Scholar]
  29. Maulbecker-Armstrong  C, Braksch  G, Janiczek  O  et al.  Schulgesundheitsfachkräfte in Deutschland—Vom Modell zum Regelangebot in zwei Bundesländern. Gesundheitswesen (Bundesverband der Arzte des Offentlichen Gesundheitsdienstes (Germany))  2022;84:280–4. 10.1055/a-1737-3171 [DOI] [PMC free article] [PubMed] [Google Scholar]
  30. Mays  D, Heumann  S, Metzner-Guczka  F  et al.  Fachbeitrag: Schulgesundheitsfachkräfte an öffentlichen Schulen—ein systematisches Review zur internationalen Studienlage unter Berücksichtigung sozial benachteiligter Kinder und Jugendlicher. Vierteljahresschrift für Heilpädagogik und ihre Nachbargebiete  2024;93:1–22. 10.2378/vhnplus202408 [DOI] [Google Scholar]
  31. McDaid  D. Investing in Health Literacy. Policy Brief 19. What Do We Know about the Co-benefits to the Education Sector of Actions Targeted at Children and Young People. World Health Organization, 2024. https://iris.who.int/bitstream/handle/10665/331987/Policy-brief-19-1997-8073-eng.pdf?sequence=1&isAllowed=y (7 November 2024, date last accessed). [PubMed]
  32. Mehlis  A, Locher  V, Hornberg  C. Barriers to organizational health literacy at public health departments in Germany. Health Lit Res Pract  2021;5:e264–71. 10.3928/24748307-20210809-01 [DOI] [PMC free article] [PubMed] [Google Scholar]
  33. Nash  R, Otten  C, Pill  S  et al.  School leaders reflections on their school’s engagement in a program to foster health literacy development. Int J Educ Res Open  2021a;2:100089. 10.1016/j.ijedro.2021.100089 [DOI] [Google Scholar]
  34. Nash  R, Patterson  K, Flittner  A  et al.  School-based health literacy programs for children (2–16 years): an international review. J Sch Health  2021b;91:632–49. 10.1111/josh.13054 [DOI] [PubMed] [Google Scholar]
  35. Okan  O, Kirchhoff  S. Fragebogen Organisationale Gesundheitskompetenz der Schule. GeKoOrg-Schule. Gefördert durch das Bundesministerium für Gesundheit. Technische Universität München: München, 2022. 10.14459/2022md1655484 [DOI] [Google Scholar]
  36. Okan  O, Kirchhoff  S, Krudewig  C. Questionnaire “Organizational Health Literacy of Schools (OHLS-Q)”: Questionnaire Long Form English. HeLit-Schools. Funded by the Federal Ministry of Health. Technical University of Munich, 2022. 10.14459/2022md1688119 [DOI] [Google Scholar]
  37. Okan  O, Paakkari  L, Aagaard-Hansen  J  et al.  Health Literacy in the Context of Health, Well-being and Learning Outcomes-The Case of Children and Adolescents in Schools: Concept Paper. World Health Organization Regional Office for Europe, 2021. https://iris.who.int/bitstream/handle/10665/344901/WHO-EURO-2021-2846-42604-59268-eng.pdf?sequence=1&isAllowed=y [Google Scholar]
  38. Okan  O, Paakkari  L, Dadaczynski  K. Health Literacy in Schools State of the Art. Schools for Health in Europe Network Foundation, 2020. https://www.schoolsforhealth.org/sites/default/files/editor/fact-sheets/factsheet-2020-english.pdf  (4 July 2025, date last accessed). [Google Scholar]
  39. Ozturk  FO, Ayaz-Alkaya  S. Health literacy and health promotion behaviors of adolescents in Turkey. J Pediatr Nurs  2020;54:e31–5. 10.1016/j.pedn.2020.04.019 [DOI] [PubMed] [Google Scholar]
  40. Paakkari  L, Paakkari  O. Health literacy as a learning outcome in schools. Health Educ  2012;112:133–52. 10.1108/09654281211203411 [DOI] [Google Scholar]
  41. Paakkari  L, Torppa  M, Mazur  J  et al.  A comparative study on adolescents’ health literacy in Europe: findings from the HBSC study. Int J Environ Res Public Health  2020;17:3543. 10.3390/ijerph17103543 [DOI] [PMC free article] [PubMed] [Google Scholar]
  42. Paakkari  LT, Torppa  MP, Paakkari  O-P  et al.  Does health literacy explain the link between structural stratifiers and adolescent health?  Eur J Public Health  2019;29:919–24. 10.1093/eurpub/ckz011 [DOI] [PubMed] [Google Scholar]
  43. Parker  R, Ratzan  SC. Health literacy: a second decade of distinction for Americans. J Health Commun  2010;15:20–33. 10.1080/10810730.2010.501094 [DOI] [PubMed] [Google Scholar]
  44. Pawils  S, Heumann  S, Schneider  SA  et al.  The current state of international research on the effectiveness of school nurses in promoting the health of children and adolescents: an overview of reviews. PLoS One  2023;18:e0275724. 10.1371/journal.pone.0275724 [DOI] [PMC free article] [PubMed] [Google Scholar]
  45. Pelikan  JM. Health-literate healthcare organization. In: Okan  O, Bauer  U, Levin-Zamir  D, Pinheiro  P, Sørensen  K (eds.), International Handbook of Health Literacy: Research, Practice and Policy Across the Life-Span. Bristol: Policy Press, 2019, 539–53. [Google Scholar]
  46. Pelikan  JM, Ganahl  K, Roethlin  F. Health literacy as a determinant, mediator and/or moderator of health: empirical models using the European Health Literacy Survey dataset. Glob Health Promot  2018;25:57–66. 10.1177/1757975918788300 [DOI] [PubMed] [Google Scholar]
  47. Rangnow  P, Fischer  L, Hartmann  A  et al.  Digital health literacy among primary and secondary school teachers-a quantitative study. Front Public Health  2024;12:1334263. 10.3389/fpubh.2024.1334263 [DOI] [PMC free article] [PubMed] [Google Scholar]
  48. Schools for Health in Europe Network Foundation (SHE) . European Standards & Indicators for Health Promoting Schools 2.0: Schools for Health in Europe Network Foundation (SHE), 2nd edn. Unpublished manuscript, 2021. https://www.schoolsforhealth.org/sites/default/files/editor/standards_and_indicators_2.pdf (12 April 2023, date last accessed).
  49. Schulenkorf  T, Krah  V, Dadaczynski  K  et al.  Addressing health literacy in schools in Germany: concept analysis of the mandatory digital and media literacy school curriculum. Front Public Health  2021;9:687389. 10.3389/fpubh.2021.687389 [DOI] [PMC free article] [PubMed] [Google Scholar]
  50. Sendatzki  S, Helmchen  RM, Moor  I  et al.  Health literacy of students in Germany—results of the HBSC study 2022. J Health Monit  2024;9:23–41. 10.25646/11870 [DOI] [PMC free article] [PubMed] [Google Scholar]
  51. Shih  S-F, Liu  C-H, Liao  L-L  et al.  Health literacy and the determinants of obesity: a population-based survey of sixth grade school children in Taiwan. BMC Public Health  2016;16:280. 10.1186/s12889-016-2879-2 [DOI] [PMC free article] [PubMed] [Google Scholar]
  52. Simonds  SK. Health education as social policy. Health Educ Monogr  1974;2:1–10. 10.1177/10901981740020S102 [DOI] [Google Scholar]
  53. Smith  C, Goss  HR, Issartel  J  et al.  Health literacy in schools? A systematic review of health-related interventions aimed at disadvantaged adolescents. Children (Basel, Switzerland)  2021;8:176. 10.3390/children8030176 [DOI] [PMC free article] [PubMed] [Google Scholar]
  54. Sørensen  K, van den Broucke  S, Fullam  J  et al.  Health literacy and public health: a systematic review and integration of definitions and models. BMC Public Health  2012;12:80. 10.1186/1471-2458-12-80 [DOI] [PMC free article] [PubMed] [Google Scholar]
  55. St Leger  L. Schools, health literacy and public health: possibilities and challenges. Health Promot Int  2001;16:197–205. 10.1093/heapro/16.2.197 [DOI] [PubMed] [Google Scholar]
  56. St Leger  L, Nutbeam  D. A model for mapping linkages between health and education agencies to improve school health. J Sch Health  2000;70:45–50. 10.1111/j.1746-1561.2000.tb07239.x [DOI] [PubMed] [Google Scholar]
  57. Stormacq  C, van den Broucke  S, Wosinski  J. Does health literacy mediate the relationship between socioeconomic status and health disparities? Integrative review. Health Promot Int  2019;34:e1–17. 10.1093/heapro/day062 [DOI] [PubMed] [Google Scholar]
  58. Sukys  S, Trinkuniene  L, Tilindiene  I. Subjective health literacy among school-aged children: first evidence from Lithuania. Int J Environ Res Public Health  2019;16:3397. 10.3390/ijerph16183397 [DOI] [PMC free article] [PubMed] [Google Scholar]
  59. Velardo  S, Drummond  M. Teacher health literacy: the importance of multiple healthy role models within the school environment. In: Proceedings of the 29th ACHPER International Conference, Adelaide, SA, Australia, 13–15 April. Adelaide, SA, Australia: Australian Council for Health, Physical Education and Recreation, 2015, 169–78. [Google Scholar]
  60. Vennegoor  G, van Assema  P, Molleman  GRM  et al.  Fidelity, adaptation and integration of whole-school health promotion within Dutch schools: a cross-sectional survey study. Health Promot Int  2023;38:daad173. 10.1093/heapro/daad173 [DOI] [PMC free article] [PubMed] [Google Scholar]
  61. World Health Organization . Health Literacy in the Context of Health, Well-being and Learning Outcomes- the Case of Children and Adolescents in Schools: Concept Paper. Unpublished manuscript, 2021a. https://apps.who.int/iris/handle/10665/344901 (8 December 2021, date last accessed).
  62. World Health Organization . Making Every School a Health-Promoting School: Global Standards and Indicators for Health-Promoting Schools and Systems, 2021b. https://iris.who.int/bitstream/handle/10665/341907/9789240025059-eng.pdf?sequence=1 (7 November 2024, date last accessed).
  63. Zaidman  EA, Scott  KM, Hahn  D  et al.  Impact of parental health literacy on the health outcomes of children with chronic disease globally: a systematic review. J Paediatr Child Health  2023;59:12–31. 10.1111/jpc.16297 [DOI] [PubMed] [Google Scholar]

Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

daaf112_Supplementary_Data
daaf112_supplementary_data.zip (304.4KB, zip)

Data Availability Statement

The dataset that has been generated and analysed during the present study is not currently available to the public, as the data analysis is not yet complete. The dataset will be made available to the public once the data analysis has been completed. Until that time, interested parties may request the dataset from the corresponding author.

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