Strengthening health literacy in
Education sector

On February 19, 2018, the “National Health Literacy Action Plan” (NAP) was presented to the public (Schaeffer et al., 2018). Following the example of other countries, it lists the most important challenges for improving the population's health education and promoting health communication among professional staff in educational and care facilities (see Figures 1 and 2) and then makes targeted recommendations. The project was financially supported by the Robert Bosch Foundation, the AOK Federal Association, Bielefeld University and the Hertie School of Governance in Berlin. It is headed by Prof. Dr. Doris Schaeffer, Prof. Dr. Klaus Hurrelmann, Prof. Dr. Ullrich Bauer and Dr. Kai Kolpatzik. The following article addresses the first of the NAP's 15 recommendations, which focuses on strengthening health literacy in the education sector.

>> The spectrum of illnesses in today's societies is characterized by an ongoing change from infectious and acute illnesses to long-lasting and overlapping chronic illnesses. In the area of chronic illnesses in children and adolescents, there has been a shift from more somatic to more psycho- and socio-somatic disorders over the past two decades. This is also confirmed for the health situation of children and adolescents in Germany by the basic survey of the Robert Koch Institute's Child and Adolescent Health Survey (KiGGS) (RKI, 2008). It shows a clear shift from acute to chronic illnesses (e.g. allergies, diabetes, asthma) and from somatic to psychological abnormalities (e.g. drug and medication abuse, depression, attention disorders, eating disorders). This trend was confirmed by the KiGGs follow-up survey (1st wave) (RKI, 2014) and is therefore also reflected in the recently published results of the 2nd wave (RKI, 2018).
The health chances in life for children and young people in Germany are socially unequally distributed. For example, the prevalence of traffic accidents, somatic diseases, developmental disorders, overweight and obesity, eating disorders and psychological problems follow a social gradient: children from socially disadvantaged family backgrounds are exposed to increased health risks (Lampert et al., 2010).
Nevertheless, childhood and especially adolescence are more or less “safe” periods in which health is relatively protected compared to other periods in the life course. However, this also makes it difficult to find a suitable motivational basis for health education approaches, because subjective awareness of impairment caused by illness is largely missing. The knowledge gaps are particularly large in the younger population groups, as the 2017 health report shows (Stada, 2017). Teenagers and young adults in particular do not actively inform themselves because they do not yet consider the topic of health to be really urgent. They believe that they naturally have their body and mind under control. The vast majority of them actually do not have to worry about illness, care procedures or medication. As life progresses, this takes its toll, as physical and psychological impairments can become so severe that young people become irritated by the sheer volume of demands and, not least, by the complexity of care.
The Stada health report also shows the interesting finding that young women are significantly more sensitive than young men. They inform themselves more often about health topics, assess their knowledge better and actually end up with a better level of knowledge, although the level is still low overall. This makes it clear that even at a young age they are more concerned about their own physical and psychological well-being than young men. This continues throughout life and also when choosing a career. More and more young women are currently flocking to the health professions, especially medicine (or: the medical profession). In the future, health will be a field dominated by women.
Against these and other backgrounds, the health literacy of children and adolescents is becoming increasingly important in research (Okan et al., 2018; Bröder et al., 2017). However, there is only a limited amount of meaningful data available so far, and research in Germany is still in its early stages. However, some interesting developments from international research can be reported. In the Health Behavior in School-aged Children Study (HBSC) of the World Health Organization (WHO), a scale for measuring health literacy has recently been integrated into the questionnaire, in particular to examine associations with health behavior in school children (Paakkari et al., 2018) . In the study, seventh and ninth graders were surveyed and for Finland the evaluations show that 30% of the young people rate their health literacy as good, 60% as moderate and 10% as low. Girls rate their health literacy higher than boys, and older people rate it better than younger people. Detailed results from the HBSC study, including for other countries, can therefore be expected in the near future.
The world's largest study measuring health literacy was recently conducted in Taiwan. Over 160,000 6th grade students (11 to 12 years old) were surveyed in 2,400 schools (Shih et al., 2016). While 44% of the children had high or medium health literacy, the values for low (26.6%) or very low (29.5%) health literacy were in 56%. In addition, numerous studies from different countries show that low health literacy among children and adolescents is associated with different health-risk behaviors (cf. Fleary et al., 2018), e.g. B. with alcohol and tobacco consumption, unhealthy eating habits and low physical activity. Furthermore, various studies in children and adolescents have found associations between low health literacy and higher body mass index values or overweight and obesity (Shih et al., 2016; Lam & Yang, 2014; Chari et al., 2014; Sharif & Blank, 2010).
Research on health literacy in childhood and adolescence is currently expanding, including broader contexts such as Internet and media use (Ghaddar et al., 2012), mental health and stigma (Kutcher et al., 2015), and chronic illness (Chisolm et al., 2015, 2011). Numerous studies also examine parental health literacy as a proxy for their children's health behavior and health status (Keim-Malpass et al., 2015). The authors of these studies consistently advocate integrating strengthening health literacy into school education.
An early start in the acquisition of health knowledge and health literacy is an important prerequisite for preventing the onset of chronic illnesses, postponing them or enabling successful management of these illnesses. It is similarly emphasized in approaches to health promotion, in which the great importance of the life phases of childhood and youth for the imparting of health-relevant knowledge and learning to deal critically with information is emphasized (Hurrelmann et al., 2014; Ravens-Sieberer & Ottova, 2012; Wulfhorst & Hurrelmann, 2009). The discussion about promoting health literacy can be linked to the debate there.
Strengthening health literacy is an important social task that is becoming increasingly important. The education and training system is particularly challenged here, because education strengthens cognitive, linguistic and literate skills, but at the same time it also strengthens the opportunity and ability to deal with health-relevant information and to behave in a competent and health-promoting manner.
Initial approaches to implementing practical measures
For all of these reasons, the promotion of health knowledge and health literacy in children and adolescents is considered a key topic for educational work in institutions of the education system (WHO, 2017; McDaid, 2016). It is clear that the importance of the early stages of life is central to the further development of health and well-being and to strengthening health literacy. This applies both to the action level at which different ways of dealing with health are trained, as well as to the level of social structures and contexts that can guide, control or prevent individual health behavior.
In practice, however, teaching health topics is still given too little importance. For example, in the Stada Health Report (2017), only just under a quarter of the 18 to 25 year old young people surveyed reported having learned something about common diseases, prevention/prevention or the health system at school. Overall, 69% say that health does not play an important role at school. The topics that perform best are contraception, nutrition and dental health. The overwhelming majority of young people therefore want their own subject or at least a strong systematic integration of health topics into various subjects. Two thirds of them want to learn about prevention/prevention. This is remarkable: The young adults themselves advocate that they be prepared for the topic in a systematic and structured manner. They are also aware of the deficits in their knowledge of how the health system works, and here too they want structured and reliable school information.
In contrast, school health education has so far been deficient
- Also in Germany. Health literacy first appeared in the educational literature in the 1970s in the context of school concepts for health education in the US discussion (Simonds, 1974). The Joint Committee on National Health Education Standards (NHES), which is responsible for teaching and learning curricula in school health education in the USA, presented the report “Achieving Health Literacy” in 1995 (Joint Committee on NHES, 1995). Health literacy is defined as health-related information and problem-solving skills, transferred into didactic teaching measures in health education and linked to concrete learning objectives. However, similar to the recommendations of the Conference of Ministers of Education and Cultural Affairs (KMK, 2012) in Germany, these standards are not binding. Although the importance of health literacy for health socialization in children and adolescents has been repeatedly emphasized, the practical anchoring in school health education and therefore the hoped-for effect initially failed to materialize (Nielsen-Bohlman et al., 2004).
The WHO included health literacy in its health promotion strategy as health-related education as early as the 1990s (Nutbeam, 1998). At the same time, health literacy was closely linked to the WHO approach of the “health-promoting school” (St Leger, 2001). In addition to the US one, school curricula for health literacy are now available in Finland (Finnish national board of education 2014) and Australia (Australian Curriculum, Assessment and Reporting Authority, 2012). In this context, the WHO has now published an evidence report for the European Region on promoting health literacy in schools and the education system and recommends anchoring health literacy in ongoing education (McDaid, 2016).
In another evidence report published by Health
Evidence Network (HEN), coordinated by the WHO Regional Office for Europe under the European Health Information Initiative (EHII), identifies a total of 46 health policies and strategies for 19 European countries to strengthen health literacy (Rowlands et al., 2018 ).
In many of these approaches, health literacy is defined as a central area of action for early prevention measures within the national education and training systems. Nevertheless, from a population-based perspective, children and young people still represent a target group that receives little attention.
For this reason, the NAP also recommends that the topic of health literacy be firmly anchored in the curricula of health-related advisory and educational offerings in schools and, more generally, that health aspects be taken into account in the organizational processes in schools. The outstanding position of the education system in teaching health literacy is expressly emphasized and it is pointed out that the professions working in daycare centers, schools, extra-curricular educational institutions, universities, adult education centers and other institutions for training, further education and training have a lot to support can contribute to health literacy. It is also recommended to expand implementation and evaluation research in this area.
Strategies to further promote the
Health literacy in the education system
The first recommendation of the “National Health Literacy Action Plan” refers to the “living worlds” area of action (see Fig. 3) and reads (Schaeffer et al., 2018, p. 31):
“Enable the education system to promote health literacy as early as possible
CV to begin.”

To implement this recommendation, the following coordinated strategies must be addressed:
• “Establish health literacy firmly in the educational and curricula of daycare centers, primary schools, secondary schools, universities, youth education and vocational training institutions as well as in adult education.
• Conduct project weeks on health literacy in daycare centers, schools and other educational institutions and, if possible, establish health as a school subject in the long term, but in any case integrate it into lessons as a cross-disciplinary, cross-sectional aspect.
• Institutionally anchor first aid combined with psychological, nursing and medical advice in the form of school health care in educational institutions.
• Employees of educational and educational institutions through training
“Term education enables us to make a targeted contribution to promoting health literacy” (Schaeffer et al., 2018, p. 32).

The experts at the first workshop developed three strategic suggestions for the implementation and realization of the first recommendation to promote health literacy in the education system, which must also be placed in the context of the five principles of implementation proposed in the NAP (see Fig. 4):
First: Strengthening health literacy should begin early in the life course in daycare centers and schools, continue throughout the life course and include adult education facilities. The prevention and health promotion strategies that have already been successfully implemented in recent years should be supplemented accordingly.
Reason: With the adoption of the Prevention Act in 2015, Germany has a legally binding framework into which approaches to strengthening health literacy can be integrated in educational institutions (German Bundestag, 2015). It is important to clearly emphasize that the promotion of health literacy goes beyond the existing approaches to prevention and health promotion and focuses on the previously neglected abilities and skills of finding, understanding, assessing and applying health-relevant information. Acquiring this competence is essential in modern knowledge and information societies in order to shape everyday life, maintain and promote health and also to be able to cope with health impairments and illnesses.

Secondly: Strengthening health literacy in the population has become extremely important due to the digitalization of all areas of life and the associated almost unlimited availability of health information via digital media. Adequate handling of information and especially health information is increasingly becoming a key competency in the knowledge society.
Reason: By paying particular attention to strengthening health literacy, an increased emphasis can be placed on the cognitive, linguistic and “literary” skills of reading, writing and arithmetic in the education system. Strengthening health literacy requires training in the skills that make it possible to find, understand, evaluate and apply health information. This training has become extremely important in today's world because the amount of digitally available information has increased immeasurably, but the ability to process it has not grown adequately. Strengthening health literacy helps educational institutions to fulfill the core of their educational mission.

Third: In order to provide concrete strategies for strengthening
Implementing health literacy should be directly linked to the recommendations that have already been developed in a differentiated manner in preschool, school and adult education.
Reason: According to this recommendation, in the daycare centers, in addition to strengthening basic skills (life skills in the sense of the WHO and the EU), the acquisition of health-specific skills and knowledge should also be integrated as important in the educational plans in order to start promoting the Begin health literacy.
According to the experts from the workplace, schools should
shops, which are based on the recommendations of the KMK from 2012 (KMK, 2012). Health promotion and prevention are “perceived as fundamental tasks of school and extracurricular work” (p. 3), which “give students, teachers and other educational staff the opportunity to acquire skills in healthy lifestyles and in shaping their environment in a health-promoting way ” (p. 3). These requirements should be expanded to include the aspect of health literacy and updated and continued accordingly.
According to the experts at the workshop, in adult education the aspect of literacy and basic education, which is already crucial for adult education, can be given greater emphasis again. Many adult education structures are close to employment, so that the transition into the labor market and thus the topic of health literacy in the world of work, including the problems of people with disabilities and impairments, can also be addressed here. <<