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International Journal of Environmental Research and Public Health logoLink to International Journal of Environmental Research and Public Health
. 2020 Feb 27;17(5):1518. doi: 10.3390/ijerph17051518

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

Anne-Kathrin M Loer 1,*, Olga Maria Domanska 1, Ronny Kuhnert 1, Robin Houben 1, Stefan Albrecht 1, Susanne Jordan 1
PMCID: PMC7084343  PMID: 32120870

Abstract

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

Keywords: health literacy, youths, measurement, cross-sectional study, representativeness

1. Introduction

1.1. Background

Health literacy is attracting increasing attention in the public health field worldwide [1,2]. According to the widespread definition by Sørensen et al. [2] (p. 3), “Health literacy is linked to literacy and entails people’s knowledge, motivation and competences to access, understand, appraise, and apply health information in order to make judgments and take decisions in everyday life concerning healthcare, disease prevention and health promotion to maintain or improve quality of life during the life course”. Previous studies have mostly examined health literacy among adults. These studies showed that a low health literacy level is associated with perceived difficulties in accessing, understanding, evaluating and applying health information [3]. Further study results point out that a lower health literacy level is associated with a riskier health behavior, a poorer general health status, higher morbidity and mortality and higher total expenditure in health systems [3,4,5,6,7,8,9]. Health literacy is also discussed being associated with various antecedents of health disparities [10]. Therefore, strengthening health literacy has been receiving increased attention for reducing social inequalities [4,9,11,12].

The promotion of health literacy at a young age can have positive health effects across the life course [13,14,15,16]. As a result, the World Health Organization has identified children and adolescents as a relevant target group for the promotion of health literacy. This target group is characterized by specific vulnerabilities e.g., to risky behavior, such as substance misuse [17], or to demographic factors. These vulnerabilities are relevant for health literacy as they lead to specific health information and resource needs [14]. However, for promoting health literacy in this target group, a sound data basis for adolescents’ perceived relevance as well as the meaningfulness of health information and their current health literacy level and its distribution is a necessary condition for the development of any evidence-based interventions [14,18]. To date, less attention has been paid to the collection of dates focusing on adolescent health literacy [19,20,21,22], a situation which also applies to Germany. Few studies measuring adolescent health literacy focus on specific health literacy domains, age groups or subgroups [23,24,25,26,27,28,29]. There is no evidence concerning health literacy among 14−17 year-olds and only one population-based study drew a sample from population registries [27]. Until now, there have been no nation-wide representative data on self-reported generic health literacy focusing on adolescents in Germany. To close this gap, the online survey on “Health Literacy Among Adolescents” (GeKoJu) is being conducted in Germany. The online survey GeKoJu is part of the project ”Measurement of Health Literacy Among Adolescents”—Part Two (MOHLAA 2), carried out by the Robert Koch Institute (RKI). The RKI is the government’s central scientific institution in the field of biomedicine in Germany. It is charged with identification, surveillance and prevention of diseases as well as monitoring and analyzing long-term public health trends in Germany. The MOHLAA 2 project is part of the German Health Literacy in Childhood and Adolescence (HLCA) Consortium, funded by the German Federal Ministry of Education and Research (BMBF—grant number 01EL1824D) [20].

1.2. Objectives

MOHLAA 2 aims to provide the first nation-wide representative data on generic health literacy among adolescents in Germany. The GeKoJu survey objectives include: Objective 1: to assess the distribution of generic health literacy among adolescents in Germany; Objective 2: to identify socio-demographic and social factors related to health literacy; Objective 3: to assess the association of health literacy and health-related outcomes (e.g., subjectively assessed health status and health behavior). The following protocol presents the research design and methods as well as a discussion of methodological challenges, strengths and limitations relating to the study design and sampling strategy. The findings of the study will be presented in later publications and not in this publication, since the format of a study protocol does not aim to provide a presentation of results and conclusions. This approach allows the scientific community to assess whether collected data and prospective results are consistent with the original intent of the study [30]. The study protocol with essential information about the execution of our survey is drawn up to inform other international researchers focusing on health literacy and adolescents, as well as support them in their own study planning [30,31].

2. Research Design, Methodology, and Methods

2.1. Study Design

The study is a cross-sectional study measuring generic health literacy among adolescents living in Germany. Due to the fact that individuals from the target population use the internet at least several times per week, if not daily [32], data were collected online (Computer Assisted Web Interview-CAWI). Survey planning was carried out under the direction of MOHLAA 2 researchers within the “Health Behavior” unit at the RKI. To ensure data protection, the study design ensured there was separate collection, processing and storage of personal data and survey data. Personal data and survey data are handled by separate units at the RKI, also in cooperation with an external contractor, the market and social research institute USUMA GmbH.

2.2. Study Population

Individuals were selected for study participation according to the following inclusion criteria: (1) German-speaking adolescent with permanent residence in Germany, (2) aged 14–17 years at the date of sampling, (3) randomly selected from data in resident registration offices and (4) who provided their written informed consent form, with a personal and parent/guardian signature.

2.3. Sampling Strategies

The distribution of sample points is precisely planned and includes all regions in Germany, to achieve a nationally representative sample. The sampling protocol was developed in cooperation with GESIS Leibniz Institute for the Social Sciences, Mannheim, Germany. The survey sample was obtained using two-stage stratified cluster sampling.

Primary sampling units (PSUs) were sampled from an inventory of German communities stratified by district and according to the “BIK” classification system, which reflects the grade of urbanization, regional population density and administrative borders [33]. At the first stage, 50 sample points were selected throughout 13 federal states (“Bundesländer”) in Germany (see Figure 1).

Figure 1.

Figure 1

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Sample points of the online survey Health Literacy Among Adolescents (GeKoJu) (n = 50).

In the second stage, a pre-defined number of addresses were randomly drawn from local population registers at resident registration offices within selected PSUs. It has been observed in nation-wide health surveys [34] and in the RKI’s long-term study “German Health Interview and Examination Survey for Children and Adolescents” (KiGGS study) [35,36,37], that individuals with a migrant background show lower response rates than individuals without a migrant background. To achieve a sample representative of the population’s proportion of youths with a migrant background, a higher number of addresses were drawn in the 10 PSUs with the highest population density, to increase the likelihood of selecting individuals with a migrant background. This approach is based on evidence which demonstrates a tendency of individuals with a migrant background to live predominantly in larger cities [38]. Finally, a random sample of adolescents per birth cohort was drawn based on calculations which consider the community size and sample points (first birth cohort: 01.09.2001–31.08.2002; second birth cohort: 01.09.2002–31.08.2003; third birth cohort: 01.09.2003–31.08.2004; fourth birth cohort: 01.09.2004–31.08.2005). The calculated crude sample size was N = 4983 with an expected response rate of 21.75% based on the pilot study MOHLAA 1 in Berlin [39]. The response rate (17.3%) following the first batch of study invitations (n = 500) was lower than expected. To assure a net sample size of n = 1084, we expanded the crude sample size to N = 6608.

2.4. Data Protection and Ethics Approval

The study was approved by the Federal Commissioner for Data Protection and Freedom of Information without concern on July 09, 2019. To ensure data protection, the study design warranted separate collection, processing and storage of personal data and survey data. Personal data and survey data are handled in various subdivisions (subject areas) of the Robert Koch Institute and in cooperation with an external contractor, the market and social research institute USUMA GmbH. When processing social data, USUMA GmbH is contractually obliged to observe technical and organizational measures for data protection and data security [40]. Participants as well as their parents/legal guardians received detailed information materials about the study. Informational materials included a cover letter, a survey flyer with detailed survey information, a data protection declaration. Furthermore, USUMA GmbH provided participants with a hotline number and e-mail address. The written informed consent form has to be signed by adolescent and their parents/legal guardians.

Ethics approval was received from the ethics committee at the Alice Salomon Hochschule Berlin, University of Applied Sciences (Number 06-2019/26) on August 8, 2019.

2.5. Data Collection & Data Handling

Data are being collected from September until December 2019. The online survey duration is 25 to 30 min. Invitations for participation along with comprehensive informational materials for adolescents and their parents/legal guardians are distributed by USUMA GmbH through the postal mail. After obtaining written informed consent forms, signed by both minors and their parents/legal guardians, a letter containing the personal identification number (PIN) access code is sent to participants. Following the invitation letter, a reminder is sent within three weeks, to potential participants who (1) did not actively decline participation, (2) submitted an incomplete informed consent form or (3) did not participate following receipt of their personal identification access code. Following completion of the online questionnaire, participants received a thank you letter containing a voucher for 8 Euros of credit. Beforehand, they could choose between a voucher for a drugstore or an electronic store. Please see Figure 2 for an overview of the informed consent procedure and study flow.

Figure 2.

Figure 2

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Overview of the study flow and informed consent procedure.

The online questionnaire was programmed in the online survey and data collection software, VOXCO version 6.0.0.51 (Voxco, Montreal, Canada). The questionnaire was programmed using responsive design to ensure that the display was compatible across a variety of devices (mobile smart phone, notebook, laptop). The team relied on participant verification offered by the VOXCO software to prevent unauthorized participation in the online survey. Participant verification cross-references and verifies the self-reported year of birth and sex using data provided by the resident registration offices. If in some cases the information delivered by the registration office was wrong, then the participants were given the possibility to contact a person responsible via a hotline to adjust the data

2.6. Measurements

The standardized online questionnaire contains only scales that have already been validated and applied in other studies. Items capturing socio-demographics, subjective social status and health-related outcomes were assessed in a standardized manner, as previously assessed in the KiGGS study. Unless otherwise stated, the remaining questions were developed from previous population-based surveys at the RKI. Table 1 shows an overview of the topics and instruments used.

Table 1.

Overview of the topics and measures applied in the GeKoJu survey.

Topic/Parameter Measures Indication of Source Number of Items Used for Analyzing Follwing Objectives *
Socio-demographics Year and month of birth Study KiGGS 2 [37] 1 1, 2, 3
Sex (stated in the birth certificate) Study “German Health Update” (GEDA19-EHIS) [41] 1
Gender (subjective belonging) Study GEDA19-EHIS [41] 1
Education School attendence Study KiGGS 2 [37] 1 1, 2, 3
Type of school Study KiGGS 2, slightly adapted [37] 1
Achieved school certificate on the secondary level Study KiGGS 2 [37] 1
Socio-economic status of family Social Family Affluance Scale Study “Health Behavior in School-aged Children” (HBSC) [42] 6 1, 2, 3
Subjective social status (German version of MacArthur Scale) Study KiGGS 2 [43,44] 1
cultural capital through the number of books in the household Survey PISA 2015 [45] 1
Immigration background Respondent’s country of origin Study KiGGS 2 [37] 1 1, 2, 3
Mother’s country of origin Study KiGGS 2 [37] 1
Father’s country of origin Study KiGGS 2 [37] 1
Length of stay in Germany Study KiGGS 2 [37] 1
Self-reported language skills Native language Project “Improving Health Monitoring in Migrant Populations” (IMIRA) [46] 1 1
Self-rated German skills Project IMIRA [46] 1
Self-rated native language skills Project IMIRA [46] 1
Generic health literacy Measurement of Health Literacy Among Adolescents- Questionnaire (MOHLAA-Q) Study MOHLAA [39,47] 29 1, 2, 3
Reading comprehension and numeracy Health Literacy Measure for Adolescents (HELMA) Measurement HELMA, adapted [48] 3 1, 2, 3
Health literacy seeking behavior Sources and quantity of received health literacy information Survey “Teens, Health and Technology: a national survey”, adapted [49] 14 1, 2, 3
Health-related behavior Alcohol: harmful and binge drinking (Alcohol Use Disorders Identification Test, AUDIT-C) Study KiGGS 2 [37,50,51] 4 3
Smoking tabbaco use Study KiGGS 2 [37] 2
Physical activity (sport) Study KiGGS 2 [37] 1
Keeping safety rules Study KiGGS 2 [37] 4
Nutrition (fruits and vegetables consumption) Study GEDA 2014/2015 [52,53], slightly adapted 4
Social and personal resources Self-efficacy scale (Scale of General Self-efficacy) Study KiGGS 2 [54] 10 2, 3
Social support (the Multidimensional Scale of Perceived Social Support) Study HBSC [55,56] 8
Health status Subjective health status Study KiGGS 2 [37] 1 3
Anthropometry Self-reported height Study KiGGS 2 [37] 1 3
Self-reported weight Study KiGGS 2 [37] 1
Utilisation of health services Utilisation of doctor visits in the last 12 months Survey “The European Health Literacy Survey” (HLS-EU), adapted [57] 1 3
Utilisation of hospitals in the last 12 months Study KiGGS [35,36] 1
Utilisation of ambulances in the last 12 months Study KiGGS [35,36] 1
Total number 106
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* Objective 1: to assess the distribution of generic health literacy among adolescents in Germany; Objective 2: to identify socio-demographic and social factors related to health literacy; Objective 3: to assess the association of health literacy and health-related outcomes.

The focus of the GeKoJu survey is on generic health literacy as measured by the MOHLAA-Q tool. The instrument was developed and validated in the first funding phase of the project (MOHLAA 1) for use among 14–17 year-olds. The MOHLAA-Q consists of 29 items in four scales (Scale A-D): A. “Dealing with health-related information” (adapted HLS-EU-Q47-GER items, 12 items); B. “Communication and interaction skills” (4 items); C. “Attitudes toward one’s own health and health information” (5 items) and D. “Health-related knowledge” (8 items). The MOHLAA-Q tool is shown in Supplementary Materials. The four scales assess cognitive, behavioral and affective components of generic health literacy. In pretest, the MOHLAA-Q scales yielded acceptable validity indicators. The reliability coefficients (Cronbach’s α) of the scales reported were 0.54 to 0.77 [39]. The psychometric properties of the MOHLAA-Q indicated that the instrument can be used to assess different dimensions of health literacy. The development and validation process of this questionnaire were described elsewhere [39,47].

A further indicator of generic health literacy is an item capturing health literacy seeking behavior (i.e., Please indicate how much health information you have received from the following sources: your parents, health classes in school etc.), adapted from the USA survey “Teens, Health and Technology” [49]. The GeKoJu survey includes 3 items of the Health Literacy Measure for Adolescents (HELMA), which measures reading comprehension and numeracy skills as a proxy for functional health literacy. HELMA Items: 1. If a person drinks 3 cups of milk in one given day, how many carbohydrates has she/he received? (based on the given information in questionnaire). 2. Calculate the BMI of a person with height = 160 cm and weight = 70 kg? 3. What is this person’s BMI status? (based on the given information in questionnaire). Participants were allowed additional aids, such as a calculator, to respond to item 2.

2.7. Data Managament, Data Preparation and Data Analysis

Upon closure of the survey, response values will be calculated by USUMA GmbH according to American Association for Public Opinion Research (AAPOR) Outcome Rate Calculator (Mail/specifically named persons) [58].

A weighting factor will be used to ensure that prevalence estimates are representative of the age and gender distribution within Germany. This weighting also accounts for different participation probabilities and corrects for deviations in the design-weighted net sample from the German population, using German population statistics (as of 31 December 2018). Design weighting accounts for a higher number of addresses drawn from 10 sample points. Adjustment weighting is applied to the weighting factors age, gender and school type to guarantee representativeness of the sample and reduce non-response bias. The additional application of citizenship as a weighting factor is currently being tested.

Data transmission for quantitative analysis will be limited to anonymized survey and survey process data. Before conducting statistical analysis, plausibility and consistency checks will be made alongside exclusion of nonvalid cases. In order to meet basic requirements for statistical analysis, the first analytical step will be generation, recoding and categorization of variables. Before carrying out the test procedures, test-specific prerequisites will be verified. The distribution of specific dimensions of health literacy among adolescents (objective 1) will be assessed using descriptive analyses. Bivariate and multivariate analyses will be conducted to assess socio-demographic and social factors related to health literacy (objective 2) and to assess the association of health literacy and health-related outcomes (objective 3).

Data preparation and statistical analyses are planned from January 2020 onwards and will be performed by using the statistic software STATA ® version 15.1 (StataCorp LLC, Texas, TX, USA).

3. Discussion

The online survey GeKoJu will provide the first nation-wide representative data on self-reported generic health literacy for adolescents aged 14–17 years in Germany. The data will provide insights regarding the distribution of generic health literacy among adolescents in Germany. The analyses will also provide evidence regarding the association between health literacy levels and health-related outcomes and social factors. The data collected may also being used for the exploration of the relationship between health literacy and health disparities.

A major strength of the survey is the use of the age-adjusted, validated measurement tool MOHLAA-Q which addresses methodological and data gaps. MOHLAA-Q is methodologically tailored to characteristics of adolescents aged 14–17 years and measures generic health literacy in a sample which is representative of the German adolescent population. The use of objective and subjective measurement tools is currently being discussed. On the one hand, it is critically examined whether self-reporting provides valid data concerning health literacy [21]. On the other hand, the question is raised whether an objective measurement can cause feelings of shame or discomfort due to their abilities in low health literate persons [21]. Okan et al. [21] suggest that subjective (self-reported) and objective (performance-based) measurements should be combined for measurement of health literacy, in order to generate more detailed and profound data and richer results. These results may be used for the development of more problem-centered strategies addressing health literacy weaknesses [21]. MOHLAA-Q takes this debate into account and heeds this recommendation in its combination of performance-based items, measuring health-related knowledge and reading comprehension, with self-reported items.

The GeKoJu survey is important based on the public health relevance of health literacy. McCormack et al. highlight the importance of monitoring health literacy prevalence to inform national public health priorities for population health and to reduce inequalities [59]. Understanding the prevalence of health literacy is a first step for the development of evidence-based interventions for health promotion and health care. GeKoJu answers the call of McCormack et al. by collecting nationally representative health literacy data. Information about health literacy deficits, e.g., reading comprehension difficulties or difficulties in seeking health information, could be used to identify vulnerable groups. Survey results will be disseminated to scientists, practitioners and politicians. It can be assumed that the results will be of interest for those groups, as the health literacy concept has become increasingly attention in Germany in recent years. The increased attention is shown, e.g., in the fact that a National Action Plan Health Literacy has been developed by a group of scientists and practitioners supported by the then Federal Minister of Health, which provides scientifically validated guidelines on how health literacy should be promoted in Germany [60].

With regard to the sampling strategy, strengths and limitations can be discussed. Participants were randomly selected through population register sampling. The study pursues the strategy of collecting representative data on a nation-wide level. Hence, we chose a randomly selected sample over snowball sampling or purposive sampling. This selection is the most valid strategy for obtaining a representative sample, because each person in the population has an equal chance of selection [61]. It is used to reduce a sampling selection bias. The strategy of randomly selection of sample points on the first level and participants from local registries on the second level has some advantages over recruiting in single schools, which was also discussed during the study design planning phase. Firstly, by recruiting adolescents in communities across federal states in Germany, it is intended to reduce cluster effects which could occur when recruiting by school class. Secondly, recruitment via population registers allows inclusion of adolescents in various life situations. Adolescents in Germany aged 14–17 year experience an educational transition from secondary level education to one of two tracks: to a longer educational period (secondary level II) or to labor market entry (e.g., combined with a vocational training) [62]. In Germany, the school type in secondary levels I and II varies across federal states [63]. The selected sampling strategy allows visibility of pupils attending various types of secondary level schools, of school leavers and of adolescents who participate in vocational training. However, this sampling strategy is less effective in regard to achieve specific subgroups, e.g., adolescents with a temporary/illegal residence status or a non-German citizenship. One of the reasons for problems of non-accessibility within these subgroups are quality-neutral failures [64,65] such as a selected person has moved or his/her address is unknown. To overcome this limitation, we invited more adolescents living in large urban areas [38]. Further, an adjustment weight factor will be applied to reduce selection bias corresponding to lower response rates of certain groups.

In the current study phase, further limitations in study design should be addressed. The study must be designed to meet data protection standards outlined by the European General Data Protection Regulation (EU) [40]. After feedback from the RKI’s data protection officer on the planned study design, a written informed consent from adolescents as well as their parents/legal guardians must be obtained. Participants may only proceed to complete the online survey after submitting an informed consent form. Following submission of informed consent forms, they receive their PIN by mail. The extended time required to obtain parental/guardian consent, paired with the burden of obtaining parental consent (especially among 17 year-olds who are almost adults with full legal capacity) may affect negatively participant motivation and increase participation burden [66]. This in turn may result in a lower response rate, as observed by participation rates and nonresponse bias in the first batch [66,67]. Due to financial and time constraints, it is not possible to conduct a non-responder survey, which would provide additional insights into the validity of the results. Information regarding socio-demographic characteristics and health risk factors of non-responders as well as reasons for non-participation might help with estimation of non-responder bias [37].

4. Conclusions

The results of the GeKoJu survey will supply data which may identify deficits in generic health literacy among youths, which groups are especially vulnerable to health literacy deficits, and factors which influence health literacy among adolescents. Data from the GeKoJu survey may be used for the development of strategies to promote generic health literacy among families, in schools, communities and health care.

Acknowledgments

The authors want to thank the project team at USUMA GmbH for their great work managing participants and all colleagues at the Robert Koch Institute, for their support of the GeKoJu survey. Special thanks to the colleagues working in RKI’s in-house printing office for their infinite patience during creation of informational materials for the GeKoJu survey, and to Katherine Ombrellaro for her detailed feedback on the protocol.

Supplementary Materials

The following are available online at https://www.mdpi.com/1660-4601/17/5/1518/s1, Supplementary file 1: Measurement Health Literacy Among Adolescents Questionnaire (MOHLAA-Q).

Click here for additional data file. (193KB, pdf)

Author Contributions

Conceptualization, A.-K.M.L., O.M.D. and S.J.; methodology, A.-K.M.L., O.M.D., R.K., R.H., S.A. and S.J.; software, A.-K.M.L. and S.A.; data curation, O.M.D. and S.A.; writing—original draft preparation, A.-K.L. and O.M.D.; writing—review and editing, R.K., R.H., S.A. and S.J.; project administration, S.J.; funding acquisition, S.J. All authors have read and agreed to the published version of the manuscript.

Funding

This research was funded by the German Federal Ministry of Education and Research, grant number 01EL1824D.

Conflicts of Interest

The authors declare no conflict of interest. The funders had no role in the design of the study; in the collection, analyses, or interpretation of data; in the writing of the manuscript, or in the decision to publish the results.

References

  • 1.Van den Broucke S. Health literacy: A critical concept for public health. Arch Public Health. 2014;72:10. doi: 10.1186/2049-3258-72-10. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 2.Sørensen K., Van den Broucke S., Fullam J., Doyle G., Pelikan J., Slonska Z., Brand H. Consortium Health Literacy Project European. Health literacy and public health: A systematic review and integration of definitions and models. BMC Public Health. 2012;12:1–13. doi: 10.1186/1471-2458-12-80. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 3.Jordan S., Hoebel J. Health literacy of adults in Germany: Findings from the German Health Update (GEDA) study. Gesundheitskompetenz von Erwachsenen in Deutschland: Ergebnisse der Studie “Gesundheit in Deutschland aktuell” (GEDA) Bundesgesundheitsbl. Gesundh. Gesundh. 2015;58:942–950. doi: 10.1007/s00103-015-2200-z. [DOI] [PubMed] [Google Scholar]
  • 4.Magnani J.W., Mujahid M.S., Aronow H.D., Cene C.W., Dickson V.V., Havranek E., Morgenstern L.B., Paasche-Orlow M.K., Pollak A., Willey J.Z. Health Literacy and Cardiovascular Disease: Fundamental Relevance to Primary and Secondary Prevention: A Scientific Statement From the American Heart Association. Circulation. 2018;138:e48–e74. doi: 10.1161/CIR.0000000000000579. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 5.Moser D.K., Robinson S., Biddle M.J., Pelter M.M., Nesbitt T.S., Southard J., Cooper L., Dracup K. Health Literacy Predicts Morbidity and Mortality in Rural Patients With Heart Failure. J. Card Fail. 2015;21:612–618. doi: 10.1016/j.cardfail.2015.04.004. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 6.Bostock S., Steptoe A. Association between low functional health literacy and mortality in older adults: Longitudinal cohort study. BMJ. 2012;344:e1602. doi: 10.1136/bmj.e1602. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 7.Berkman N., Sheridan S., Donahue K., Halpern D., Viera A., Crotty K., Holland A., Brasure M., Lohr K., Harden E., et al. Health Literacy Interventions and Outcomes: An Updated Systematic Review. Evidence Report/Technology Assesment No. 199. (Prepared by RTI International–University of North Carolina Evidence-Based Practice Center under Contract No. 290-2007-10056-I. AHRQ Publication Number 11-E006) Agency for Healthcare Research and Quality; Rockville, MD, USA: 2011. [Google Scholar]
  • 8.Garcia-Codina O., Juvinya-Canal D., Amil-Bujan P., Bertran-Noguer C., Gonzalez-Mestre M.A., Masachs-Fatjo E., Santaeugenia S.J., Magrinya-Rull P., Salto-Cerezuela E. Determinants of health literacy in the general population: Results of the Catalan health survey. BMC Public Health. 2019;19:1122. doi: 10.1186/s12889-019-7381-1. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 9.World Health Organization Regional Office for Europe (WHO Europe) Health Literacy. The Solid Facts. [(accessed on 17 November 2019)]; Available online: https://apps.who.int/iris/bitstream/handle/10665/128703/e96854.pdf.
  • 10.Mantwill S., Monestel-Umana S., Schulz P.J. The Relationship between Health Literacy and Health Disparities: A Systematic Review. PLoS ONE. 2015;10:e0145455. doi: 10.1371/journal.pone.0145455. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 11.Chahardah-Cherik S.M., Gheibizadeh M.P., Jahani S.P., Cheraghian B.P. The Relationship between Health Literacy and Health Promoting Behaviors in Patients with Type 2 Diabetes. Int. J. Community Based Nurs Midwifery. 2018;6:65–75. [PMC free article] [PubMed] [Google Scholar]
  • 12.Rom K.M. Health Promotion for Children and Adolescents. Springer; Berlin/Heidelberg, Germany: 2016. [Google Scholar]
  • 13.Borzekowski D.L. Considering children and health literacy: A theoretical approach. Pediatrics. 2009;124(Suppl. 3):S282–S288. doi: 10.1542/peds.2009-1162D. [DOI] [PubMed] [Google Scholar]
  • 14.Bröder J., Okan O., Bauer U., Schlupp S., Pinheiro P. Advancing perspectives on health literacy in childhood and youth. Health Promot. Int. 2019:1–11. doi: 10.1093/heapro/daz041. [DOI] [PubMed] [Google Scholar]
  • 15.Bundesministerium für Familie, Senioren, Frauen und Jugend In Joint Responsibility: Policy for, with and by Youth. The Federal Government’s Youth Strategy. In Gemeinsamer Verantwortung: Politik für, mit und von Jugend. Die Jugendstrategie der Bundesregierung. [(accessed on 10 December 2019)]; Available online: https://www.bmfsfj.de/blob/141940/bfd79e3fc3acf5197251512ccec1d901/in-gemeinsamer-verantwortung-politik-fuer-mit-und-von-jugend-data.pdf.
  • 16.Bröder J., Okan O., Bauer U., Bruland D., Schlupp S., Bollweg T.M., Saboga-Nunes L., Bond E., Sorensen K., Bitzer E.M., et al. Health literacy in childhood and youth: A systematic review of definitions and models. BMC Public Health. 2017;17:1–25. doi: 10.1186/s12889-017-4267-y. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 17.Garcia O.F., Serra E., Zacares J.J., Calafat A., Garcia F. Alcohol use and abuse and motivations for drinking and non-drinking among Spanish adolescents: Do we know enough when we know parenting style? Psychol. Health. 2019:1–20. doi: 10.1080/08870446.2019.1675660. [DOI] [PubMed] [Google Scholar]
  • 18.Schaeffer D., Hurrelmann K., Bauer U., Kolpatzik K., Gille S., Vogt D. National Action Plan Health Literacy: Need, Objective and Content. Der Nationale Aktionsplan Gesundheitskompetenz-Notwendigkeit, Ziel und Inhalt. Gesundheitswesen. 2019;81:465–470. doi: 10.1055/a-0667-9414. [DOI] [PubMed] [Google Scholar]
  • 19.Manganello J.A. Health literacy and adolescents: A framework and agenda for future research. Health Educ. Res. 2008;23:840–847. doi: 10.1093/her/cym069. [DOI] [PubMed] [Google Scholar]
  • 20.Zamora P., Pinheiro P., Okan O., Bitzer E.-M., Jordan S., Bittlingmayer U.H., Kessl F., Lenz A., Wasem J., Jochimsen M.A., et al. “Health Literacy” in childhood and adolescence. Structure and objectives of a new German research consortium (HLCA Consortium). “Health Literacy” im Kindes- und Jugendalter. Struktur und Gegenstand eines neuen interdisziplinären Forschungsverbunds (HLCA-Forschungsverbund) Präv. Gesundh. 2015;10:167–172. doi: 10.1007/s11553-015-0492-3. [DOI] [Google Scholar]
  • 21.Okan O., Lopes E., Bollweg T.M., Bröder J., Messer M., Bruland D., Bond E., Carvalho G.S., Sørensen K., Saboga-Nunes L., et al. Generic health literacy measurement instruments for children and adolescents: A systematic review of the literature. BMC Public Health. 2018;18:1–19. doi: 10.1186/s12889-018-5054-0. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 22.Arvanitis M., Davis M.M., Wolf M.S. Topical Review: Proposing a Developmentally Informed Research Agenda for the Study of Health Literacy in Children. J. Pediatr. Psychol. 2019:1–5. doi: 10.1093/jpepsy/jsz086. [DOI] [PubMed] [Google Scholar]
  • 23.Wallmann B., Gierschner S., Froböse I. Health literacy: What do our students know about health? Gesundheitskompetenz: Was wissen unsere Schüler über Gesundheit? Präv. Gesundh. 2011;7:5–10. doi: 10.1007/s11553-011-0322-1. [DOI] [Google Scholar]
  • 24.Steckelberg A., Hülfenhaus C., Kasper J., Mühlhauser I. Ebm@school—A curriculum of critical health literacy for secondary school students: Results of a pilot study. Int. J. Public Health. 2009;54:158–165. doi: 10.1007/s00038-008-7033-1. [DOI] [PubMed] [Google Scholar]
  • 25.Steckelberg A., Hülfenhaus C., Kasper J., Rost J., Mühlhauser I. How to measure critical health competences: Development and validation of the Critical Health Competence Test (CHC Test) Adv. Health Sci. Educ. 2009;14:11–22. doi: 10.1007/s10459-007-9083-1. [DOI] [PubMed] [Google Scholar]
  • 26.Schmidt C.O., Fahland R.A., Franze M., Splieth C., Thyrian J.R., Plachta-Danielzik S., Hoffmann W., Kohlmann T. Health-related behavior, knowledge, attitudes, communication and social status in school children in Eastern Germany. Health Educ. Res. 2010;25:542–551. doi: 10.1093/her/cyq011. [DOI] [PubMed] [Google Scholar]
  • 27.Berens E.M., Vogt D., Messer M., Hurrelmann K., Schaeffer D. Health literacy among different age groups in Germany: Results of a cross-sectional survey. BMC Public Health. 2016;16:1151. doi: 10.1186/s12889-016-3810-6. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 28.Quenzel G., Schaffer D., Messer M., Vogt D. Health literacy among less well-educated young people: Influencing factors and consequences. Gesundheitskompetenz bildungsferner Jugendlicher: Einflussfaktoren und Folgen. Bundesgesundheitsbl. Gesundh. Gesundh. 2015;58:951–957. doi: 10.1007/s00103-015-2201-y. [DOI] [PubMed] [Google Scholar]
  • 29.Richter D., Mehnert A., Forstmeyer D., Ernst J., Geue K. Health Literacy in Adolescent and Young Adult Cancer Patients and Its Association with Health Outcomes. J. Adolesc. Young Adult Oncol. 2019:451–457. doi: 10.1089/jayao.2018.0118. [DOI] [PubMed] [Google Scholar]
  • 30.Ohtake P., Childs J. Why Publish Study Protocols? Phys. Ther. 2014;94:1208–1209. doi: 10.2522/ptj.2014.94.9.1208. [DOI] [PubMed] [Google Scholar]
  • 31.Summerskill W., Collingridge D., Frankish H. Protocols, probity, and publication. Lancet. 2009;373:992. doi: 10.1016/S0140-6736(09)60590-0. [DOI] [PubMed] [Google Scholar]
  • 32.Heim R., Konowalczyk S., Grgic M., Seyda M., Burrmann U., Rauschenbach T. Can you do it with the mouse?-A methodological study on online surveys in youth research. Geht’s auch mit der Maus?–Eine Methodenstudie zu Online-Befragungen in der Jugendforschung. Z. Erzieh. 2016;19:783–805. doi: 10.1007/s11618-016-0685-3. [DOI] [Google Scholar]
  • 33.BIK Aschpurwis und Behrens GmbH BIK Regions 2010. [(accessed on 27 November 2019)]; Available online: https://www.bik-gmbh.de/download/BIK-Regionen753_Methodenbeschreibung_lang.pdf.
  • 34.Saß A.-C., Grüne B., Brettschneider A.-K., Rommel A., Razum O., Ellert U. Participation of people with migration background in health surveys of the Robert Koch Institute. Beteiligung von Menschen mit Migrationshintergrund an Gesundheitssurveys des Robert Koch-Instituts. Bundesgesundheitsbl. Gesundh. Gesundh. 2015;58:533–542. doi: 10.1007/s00103-015-2146-1. [DOI] [PubMed] [Google Scholar]
  • 35.Hölling H., Schlack R., Kamtsiuris P., Butschalowsky H., Schlaud M., Kurth B.M. The KiGGS study. Nationwide representative longitudinal and cross-sectional study on the health of children and adolescents within the framework of health monitoring at the Robert Koch Institute. Die KiGGS-Studie. Bundesweit reprasentative Langs- und Querschnittstudie zur Gesundheit von Kindern und Jugendlichen im Rahmen des Gesundheitsmonitorings am Robert Koch-Institut. Bundesgesundheitsbl. Gesundh. Gesundh. 2012;55:836–842. doi: 10.1007/s00103-012-1486-3. [DOI] [PubMed] [Google Scholar]
  • 36.Kurth B.M., Kamtsiuris P., Hölling H., Mauz E. Strategies of the Robert Koch Institute for monitoring the health of children and young people living in Germany. Strategien des Robert Koch-Instituts zum Monitoring der Gesundheit von in Deutschland lebenden Kindern und Jugendlichen. Kinder Jugendmed. 2016;16:176–183. doi: 10.1055/s-0037-1616317. [DOI] [Google Scholar]
  • 37.Mauz E., Gößwald A., Kamtsiuris P., Hoffmann R., Lange M., Schenck U.V., Allen J., Butschalowsky H., Frank L., Hölling H., et al. New data for action. Data collection for KiGGS Wave 2 has been completed. JoHM. 2017;2:2–27. doi: 10.17886/rki-gbe-2017-105. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 38.Statistisches Bundesamt (DESTATIS) Population and employment. Population with Migration Background. Results of the Microcensus 2018. Bevölkerung und Erwerbstätigkeit. Bevölkerung mit Migrationshintergrund. Ergebnisse des Mikrozensus 2018. [(accessed on 2 December 2019)]; Available online: https://www.destatis.de/DE/Themen/Gesellschaft-Umwelt/Bevoelkerung/Migration-Integration/Publikationen/Downloads-Migration/migrationshintergrund-2010220187004.pdf?__blob=publicationFile.
  • 39.Domanska O., Bollweg T.M., Loer A.-K., Holmberg C., Schenk L., Jordan S. Development and psychometric properties of a questionnaire assessing self-reported generic ehalth literacy in adolescence. Int. J. Environ. Res. Public Health. doi: 10.3390/ijerph17082860. submitted. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 40.European Commission Regulation (EU) 2016/679 of the European Parliament and of the Council of 27 April 2016 on the Protection of Natural Persons with Regard to the Processing of Personal Data and on the free Movement of Such Data, and Repealing Directive 95/46/EC (General Data Protection Regulation) (Text with EEA relevance) [(accessed on 24 November 2019)]; Available online: https://eur-lex.europa.eu/legal-content/EN/TXT/PDF/?uri=CELEX:32016R0679.
  • 41.Robert Koch-Institut German Health Update (GEDA19-EHIS). [Gesundheit in Deutschland Aktuell (GEDA19-EHIS)] [(accessed on 9 December 2019)]; Available online: https://www.geda-studie.de/gesundheitsstudie/geda-2019-ehis.html.
  • 42.Hartley J.E., Levin K., Currie C. A new version of the HBSC Family Affluence Scale-FAS III: Scottish Qualitative Findings from the International FAS Development Study. Child Indic. Res. 2016;9:233–245. doi: 10.1007/s12187-015-9325-3. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 43.Adler N.E., Epel E.S., Castellazzo G., Ickovics J.R. Relationship of subjective and objective social status with psychological and physiological functioning: Preliminary data in healthy white women. Health Psychol. 2000;19:586–592. doi: 10.1037/0278-6133.19.6.586. [DOI] [PubMed] [Google Scholar]
  • 44.Lampert T., Höbel J., Kuntz B., Müters S., Kroll L.E. Socioeconomic status and subjective social status measurement in KiGGS Wave 2. JoHM. 2018;3:108–125. doi: 10.17886/RKI-GBE-2018-033. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 45.Bildungsinstitut Bildungsforschung (BIFIE) Materials. PISA 2015. Student Questionnaire. [Materialien. PISA 2015. Schülerfragebogen] [(accessed on 7 December 2019)]; Available online: https://www.bifie.at/wp-content/uploads/2017/04/Schuelerfragebogen.pdf.
  • 46.Schumann M., Kajikhina K., Polizzi A., Sarma N., Hoebel J., Bug M., Bartig S., Lampert T., Santos-Hövener C. Concepts for migration-sensitive health monitoring. JoHM. 2019;4:49–65. doi: 10.25646/6075. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 47.Firnges C., Domanska O., Jordan S. Developing an instrument for measuring the health literacy of adolescents: Lessons learned. In: Okan O., Bauer U., Levin-Zamir D., Pinheiro P., Sørensen K., editors. International Handbook of Health Literacy. Research, Practice and Policy across the Lifespan. Policy Press University of Bristol; Britain, UK: 2019. pp. 99–114. [Google Scholar]
  • 48.Ghanbari S., Ramezankhani A., Montazeri A., Mehrabi Y. Health Literacy Measure for Adolescents (HELMA): Development and Psychometric Properties. PLoS ONE. 2016;11:e0149202. doi: 10.1371/journal.pone.0149202. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 49.Wartella E., Rideout V., Montague H., Beaudoin-Ryan L., Lauricella A. Teens, Health and Technology: A National Survey. Media Commun. 2016;4:13–23. doi: 10.17645/mac.v4i3.515. [DOI] [Google Scholar]
  • 50.Bradley K.A., McDonell M.B., Bush K., Kivlahan D.R., Diehr P., Fihn S.D. The AUDIT alcohol consumption questions: Reliability, validity, and responsiveness to change in older male primary care patients. Alcohol. Clin. Exp. Res. 1998;22:1842–1849. doi: 10.1097/00000374-199811000-00034. [DOI] [PubMed] [Google Scholar]
  • 51.Bush K., Kivlahan D.R., McDonell M.B., Fihn S.D., Bradley K.A. The AUDIT alcohol consumption questions (AUDIT-C): An effective brief screening test for problem drinking. Ambulatory Care Quality Improvement Project (ACQUIP). Alcohol Use Disorders Identification Test. Arch. Intern. Med. 1998;158:1789–1795. doi: 10.1001/archinte.158.16.1789. [DOI] [PubMed] [Google Scholar]
  • 52.Mensink G., Schienkiewitz A., Lange C. Vegetable consumption among adults in Germany. JoHM. 2017:50–56. doi: 10.17886/rki-gbe-2017-042. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 53.Mensink G., Schienkiewitz A., Lange C. Fruit consumption among adults in Germany. JoHM. 2017:43–49. doi: 10.17886/rki-gbe-2017-041. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 54.Schwarzer R., Jerusalem M.H. Scales for Recording Teacher and Student Characteristics. Documentation of the Psychometric Procedures within the Framework of the Scientific Monitoring of the Pilot Project Self-Effective Schools. Freie Universität Berlin; Berlin, Germany: 1999. [Skalen zur Erfassung von Lehrer-und Schülermerkmalen: Dokumentation der psychometrischen Verfahrenim Rahmen der Wissenschaftlichen Begleitung des Modellversuchs Selbstwirksame Schulen] [Google Scholar]
  • 55.Zimet G.D., Dahlem N.W., Zimet S.G., Farley G.K. The Multidimensional Scale of Perceived Social Support. J. Pers. Assess. 1988;52:30–41. doi: 10.1207/s15327752jpa5201_2. [DOI] [Google Scholar]
  • 56.Zimet G.D., Powell S.S., Farley G.K., Werkman S., Berkoff K.A. Psychometric characteristics of the Multidimensional Scale of Perceived Social Support. J. Pers. Assess. 1990;55:610–617. doi: 10.1080/00223891.1990.9674095. [DOI] [PubMed] [Google Scholar]
  • 57.HLS-EU Consortium Comparative Report on Health Literacy in Eight EU Members States. The European Health Literacy Survey HLS-EU (Second Reviesed and Extended Version, Date 22 July 2014) [(accessed on 3 December 2019)]; Available online: https://cdn1.sph.harvard.edu/wp-content/uploads/sites/135/2015/09/neu_rev_hls-eu_report_2015_05_13_lit.pdf.
  • 58.American Association for Public Opinion Research (AAPOR) Standard Definitions. Final Dispositions of Case Codes and Outcome Rates for Surveys. [(accessed on 3 December 2019)]; Available online: https://www.aapor.org/AAPOR_Main/media/publications/Standard-Definitions20169theditionfinal.pdf.
  • 59.McCormack L., Haun J., Sorensen K., Valerio M. Recommendations for advancing health literacy measurement. J. Health Commun. 2013;18(Suppl. 1):9–14. doi: 10.1080/10810730.2013.829892. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 60.Schaeffer D., Hurrelmann K., Bauer U., Kolpatzik K.H. National Action Plan Health Literacy [Nationaler Aktionsplan Gesundheitskompetenz. Die Gesundheitskompetenz in Deutschland stärken] KomPart; Berlin, Germany: 2018. [DOI] [PubMed] [Google Scholar]
  • 61.Salkind N.J. Encyclopedia of Research Design. Sage; Newcastle, UK: 2010. [DOI] [Google Scholar]
  • 62.Walter U., Liersch S., Gerlich M.G., Raithel J., Barnekow V. Gesund jung?!: Herausforderung für die Prävention und Gesundheitsförderung bei Jugendlichen und Jungen Erwachsenen. Springer; Berlin/Heidelberg, Germany: 2011. The life phase of adolescence and young adults-social and age-specific challenges to promote health. [Die Lebensphase Adoleszenz und junge Erwachsene–gesellschaftliche und altersspezifische Herausforderungen zur Förderung der Gesundheit] pp. 3–30. [Google Scholar]
  • 63.Secretariat of the Standing Conference of the Ministers of Education and Cultural Affairs of the Länder in the Federal Republic of Germany. The Education System in the Federal Republic of Germany 2015/2016. A Description of the Responsibilities, Structures and Developments in Education Policy for the Exchange of Information in Europe. [(accessed on 29 November 2019)]; Available online: https://www.kmk.org/fileadmin/Dateien/pdf/Eurydice/Bildungswesen-engl-pdfs/dossier_en_ebook.pdf.
  • 64.Schenk L., Ellert U., Neuhauser H. Children and young people with a migration background in Germany. [Kinder und Jugendliche mit Migrationshintergrund in Deutschland.] Bundesgesundheitsbl. Gesundh. Gesundh. 2007;50:590–599. doi: 10.1007/s00103-007-0220-z. [DOI] [PubMed] [Google Scholar]
  • 65.Frank L., Yesil-Jürgens R., Born S., Hoffmann R., Santos-Hövener C., Lampert T. Improving the inclusion and participation of children and adolescents with a migration background in KiGGS Wave 2. JoHM. 2018;3:126–142. doi: 10.17886/RKI-GBE-2018-034. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 66.Lohr S.L. Sampling: Design and Analysis. 2nd ed. Brooks/Cole; Boston, MA, USA: 2010. [Google Scholar]
  • 67.Koch A., Blohm M. Nonresponse Bias. [(accessed on 4 December 2019)]; Available online: https://www.gesis.org/fileadmin/upload/SDMwiki/Nonresponse_Bias_Koch_Blohm_08102015_1.1.pdf.

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