Addressing Health Literacy in Schools in Germany: Concept Analysis of the Mandatory Digital and Media Literacy School Curriculum. — TEI-tagged view

Tessa SchulenkorfpersName, Verena KrahpersName, Kevin DadaczynskipersName, Orkan OkanpersName (2021date). “Addressing Health Literacy in Schools in Germany: Concept Analysis of the Mandatory Digital and Media Literacy School Curriculum..” Frontiers in Public Healthtitle·j.

Object of study — the mandatory media literacyterm·key curriculum of North Rhine-Westphaliaterm·key and its intersections with health literacyterm·dom

Research question — how health literacyterm·dom could be introduced to schools without additional effort, through existing teaching frameworks

Contribution — a curriculum analysis that can serve as a methodological blueprint for including health literacyterm·dom in existing curricula

Full text — tagged

Addressing Health Literacyterm·dom in Schools in Germany: Concept Analysis of the Mandatory Digital and Media Literacyterm·key School Curriculumterm·key.

Abstract It is generally agreed upon that the development of health literacyterm·dom should be addressed from an early age onwards in order to empower children to develop their full health potential. Schools can be seen as an ideal venue for strengthening health literacyterm·dom because they reach almost all school-aged children throughout their school years. The development of health literacyterm·dom at a young age is a catalyst for healthy development throughout across the life span. Evidence shows that health and education are intertwined with favorable effects for health (e.g., health behavior, knowledge) and education outcomes (e.g., academic achievement). However, health literacyterm·dom is often not sufficiently integrated into the school curriculumterm·key despite its importance to health and education. Integrating health literacyterm·dom into schools is challenging, as both schools and teachers already face numerous educational requirements that may prevent them from addressing health in the classroom because they perceive it as an additional task. This is why taking a sensitive approach is important, adapted to the needs of schools and highlighting the benefits of health literacyterm·dom. Installing health literacyterm·dom in schools succeeds more easily if it can be linked to existing curricular requirements. In this context, curriculum and instruction on media literacyterm·key, information literacyterm·key, and digital literacyterm·key are most promising subjects to include health literacyterm·dom because these concepts share many commonalities with health literacyterm·dom and often are already part of the school curriculumterm·key. The aim of this article is to (1) analyze a mandatory curriculum on media literacyterm·key in the state of North-Rhine-Westphalia in Germany, (2) highlight its intersections with health literacyterm·dom, and (3) show how it can be used to address health literacyterm·dom. The state media literacy frameworkterm·dom is based on the federal standards for “digital educationterm·key” developed by the German Conference on Education Ministries und Cultural Affairs (KMK). As education policy and practice is decentralized with sixteen federal states in Germany, each of them has got their own media literacy frameworkterm·dom, or they are currently developing it. This curriculum analysis may serve as a methodological blueprint for educationalists, teachers, and policy-maker elsewhere in order to include health literacyterm·dom into existing curricula both health and non-health. It may help to integrate health literacyterm·dom into schools when combined with existing curricula.

Keywords: health literacyterm·dom, school, curriculum, school-aged children, Germany, media literacyterm·key Introduction In a rather conservative approach to the concept, health literacyterm·dom merely describes a person's ability to deal with his or her health-related functional literacy skills and navigate the health care system ( 1 ). However, the health literacyterm·dom concept has evolved into a modern key competence of health promotion and prevention equally focusing on finding, understanding, and communicating health information, making critical judgments about health claims, and empowering individuals to make informed health decisions, practice healthier behaviors, and modifying the personal determinants of health ( 2 , 3 ). In this context, many models and definitions appeared over the past decades for adults ( 4 , 5 ) as well as for children and adolescents ( 6 , 7 ). A common and often quoted definition of health literacyterm·dom, also representing the main commonalities across available definitions, is the one presented by Sørensen et al. ( 4 ): “Health literacyterm·dom 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”.

The core of this definition focuses certain action areas related to competencies to deal with health information, namely (i) accessing, (ii) understanding, (iii) appraising, and (iv) applying. In this sense, health literacyterm·dom can also be conceptualized as information literacyterm·key with regard to health topics ( 8 , 9 ). New communication channels have emerged with increasing digitalization. This means that information is not only sought in analog form, but rather and especially in digital media such as social media ( 10 ). The concept of digital health literacyterm·dom conveys this understanding of health literacyterm·dom specifically to digital contexts and environments ( 11 ). Children and adolescents seek, adopt, and produce digital information on the internet partly also on social media ( 10 ). Thus, there is a close conceptual relationship between health literacyterm·dom on the one hand and media, information, and digital literacyterm·key on the other ( 12 – 14 ). They essentially share the competencies to deal with (health) information. Hence, strengthening health literacyterm·dom fits well with strengthening these literacies.

Emerging evidence suggests that fostering health literacyterm·dom as early in life as possible is preferable since it is associated with better proximal and distal health and social outcomes ( 15 – 17 ). Focusing on early life helps children and adolescents to grow into health literate adults, who have learned and internalized the skills, competencies, knowledge, attitudes, and beliefs to handle health information on an individual level ( 18 – 21 ). This is why it is important that health literacyterm·dom is embedded into a socioecological approach, encompassing behavioral and structural components ( 22 ). Schools have long been identified as strong venues for health promotion and health education ( 19 , 23 – 25 ) since schools can reach almost all school-aged children regardless of their social, cultural, or economic background. This is particularly important because studies indicate a social gradient in the incidence of low health literacyterm·dom in children and adolescents ( 26 – 28 ). School-based interventions aiming at promoting health literacyterm·dom can contribute to reduce health inequalities ( 20 ). Low health literacyterm·dom in adolescence is associated with harmful and risky health behavior in adulthood and poorer health in general ( 20 , 29 ). It is also relevant that students 1 develop skills to learn about (their own) health because much of the lexical knowledge will be insignificant when they are adults ( 24 ). In the Shanghai Declaration on promoting health in the 2030 Agenda for Sustainable Development ( 30 ), the World Health Organization (WHO) also calls for the early promotion of health literacyterm·dom in the education system: “Health literacyterm·dom is founded on inclusive and equitable access to quality education and lifelong learning. It must be an integral part of the skills, and competencies developed over a lifetime, first and foremost through the school curriculumterm·key”.

However, health literacyterm·dom goes beyond an individualistic and behavioral approach and includes the structural and environmental levels ( 22 , 31 ). In the context of education, health literacyterm·dom can be addressed at the organizational level of schools in order to improve structural factors and lower barriers that hinder appropriate action on health literacyterm·dom ( 20 ). Related to this, the health literacyterm·dom of teachers, principals, and school staff is just as important as the health literacyterm·dom of their students, especially because studies have shown that teachers' and principals' health literacyterm·dom are associated with the implementation status of health promotion in schools ( 20 , 32 – 34 ). In the best-case scenario, school-based interventions to promote health literacyterm·dom should address both, the individual and organizational level as part of a holistic Health Promoting Schoolterm·dom (HPSterm·dom) approach ( 20 , 21 ). However, HPSterm·dom is not available in all countries but similar concepts or whole of school approaches could be used as well to address and implement health literacyterm·dom ( 20 , 21 ).

Health literacyterm·dom is known to be the outcome of health education at schools ( 1 , 20 ). However, in Germany health education is not part of the mandatory school curriculumterm·key, which makes it difficult to address health literacyterm·dom in school. Health, including health promotion and prevention, is often implemented in an unsystematic way, e.g., through school projects limited in time and scope ( 35 ). Often, health interventions introduced to the school context fail to be successfully incorporated into the curriculum and thus are not sustainable. One reason for this is rooted in teachers' and school professionals' perceived lack of fit between the subject matter of health and the core mandate of education, which in turn has to be understood as a key barrier in its own right, impeding uptake and sustainable implementation of health topics in schools ( 36 ). Another factor that hinders the uptake of health in schools is an overcrowded curriculum, missing time and professional resources, and, partly, the lack of competencies and knowledge of the school staff ( 18 – 20 ). Altogether, this makes it difficult to systematically address health in schools. It will need approaches that overcome these barriers, especially when aiming at strengthening health literacyterm·dom in schools. In the German federal state of North Rhine-Westphaliaterm·key (NRW), like in most other German states, there are specific non-mandatory state programs to address school health promotion and education. In NRW, the state program ‘health and education’ includes the promotion of health literacyterm·dom as one of the objectives to be accomplished by 2022 ( 37 ). By strengthening health literacyterm·dom, it is supposed to improve overall health outcomes and educational opportunities of students in the long term. However, the state program is not mandatory, and many schools do not participate in the program, which is why health literacyterm·dom has not been included systematically and across schools to the curriculum. For it to be included to the curriculum or classroom activities, it will be important to align health literacyterm·dom with the core tasks and goals of schools. The health literacyterm·dom learning activities must be easily adaptable to daily school routines without additional efforts for teachers and no need for additional resources for the schools ( 20 , 21 ).

Since there is no mandatory health education in schools in Germany with health literacyterm·dom as the desired outcome, different approaches and entry points are needed. In order to identify such entry points for health literacyterm·dom within the school curriculumterm·key and possible intersections with the core school tasks and concepts, existing school curricula should be analyzed first. This way, subject areas, which can be easily linked with health literacyterm·dom, can be identified. On the national level, a framework for digital educationterm·key and digital literacyterm·key in schools ( 38 ) has been introduced recently, which consists six dimensions how to address ‘education in a digital world’ in schools. This framework has been adapted into the school media literacy frameworkterm·dom on the state level. The new framework was designed as a cross cutting theme that can be used across subjects or other cross-sectional school topics and issues. The framework comprises digital literacyterm·key, media literacyterm·key, and information literacyterm·key, which share many similarities and commonalities with health literacyterm·dom as highlighted earlier ( 9 , 12 , 13 ). Therefore, the new media literacy frameworkterm·dom seems to be such an entry point and hence a promising opportunity for addressing health literacyterm·dom in schools. Especially since (digital) media-related competencies are becoming more important as a result of increasing digitalization and the digital transformation of society ( 39 , 40 ). In contrast to existing curricula, media literacy frameworksterm·dom are still fairly new in Germany and will only become compulsory in summer 2021 ( 41 ), although there is a long tradition of media education and pedagogy in schools dating back to the 1990s.

The aim of this article is to discuss how health literacyterm·dom could be introduced to schools, taking into consideration ( 1 ) that no additional efforts are required but ( 2 ) it would be integrated into existing teaching and learning frameworks. First, the German digital educationterm·key framework and the new mandatory curriculum on media literacyterm·key of North-Rhine-Westphalia will be presented and the underlying concepts will be analyzed. Second, the intersections with health literacyterm·dom will be highlighted. In addition, this approach to curriculum analysis can be seen as a methodological blueprint that can be easily adapted to educational systems of other countries so that they could integrate health literacyterm·dom in their curricula without the need of any extra resources and in alignment with their educational goals.

Concept Analysis of National Pedagogical Framework To assess state or federal school standards in Germany that share similarities and commonalities with health literacyterm·dom, we have reviewed available documents of the education sector in online databases (both federal and state-level) as well as on the website of the KMK. We focused the concept analysis on: identifying governmental frameworks and recommendations for topic-based or cross-cutting issues, analyzing available concepts that provide possible interfaces to address health literacyterm·dom.

In the available school curricula various subjects, topics, and competency frameworks were found to intersect with the core action areas addressed by health literacyterm·dom. After analyzing the findings, the study team decided to use the national digital educationterm·key and digital literacyterm·key framework and the state-level media literacy frameworksterm·dom because they show the best fit to health literacyterm·dom.

Through their recently introduced strategic concept ‘Education in the Digital World’ (In German: “Bildung in der digitalen Welt”) ( 38 ), the KMK presented new national standards for addressing digital educationterm·key and digital literacyterm·key in the school. This framework was developed in collaboration with all 16 German federal states and involved stakeholders from science, unions, associations, and different levels of administration and practice. Three strategies make up one federal act based upon three key documents: (i) The Education campaign for the digital knowledge society' (“Bildungsoffensive für die digitale Wissensgesellschaft” in German) ( 42 ), (ii) The ‘Digital Pact Schools’ (“DigitalPakt Schule” in German) ( 43 ) and (iii) The concept ‘Education in the Digital World’. Together they also aim at preparing students, teachers, schools, and the whole education sector for the digital transformation of society and challenges associated with digital changes in all areas of life, including education. Part of the strategy is to establish a digital infrastructure in schools (including computers and internet access) and to create new training and education opportunities for in-service and pre-service teachers and educational staff. On the state-level, this new strategy includes a mandatory educational framework to foster digital literacyterm·key in schools, which will be implemented nation-wide, starting in 2021. Based on the digital literacyterm·key approach, the states have defined their own teaching and learning goals for promoting digital media skills in schools. Therefore, in the state-level education systems the national digital educationterm·key and digital literacyterm·key framework is translated into a ‘media literacy frameworkterm·dom’, and will also be a mandatory curriculum item in teacher training at University levels in all federal states, also starting in 2021.

The national framework outlines six action areas (also called ‘competence areas’) to ensure that all children have been taught media and digital skills in schools by 2026. These six areas of “Education in the Digital World” are briefly described below ( Table 1 ).

Strategy and competence framework for digital educationterm·key and literacy by the KMK ( 38 ).

This concept is based on earlier life-skills and digital literacyterm·key approaches and defines the areas of competence in which students should learn digital and media skills at school and classroom levels. Like many school topics in Germany, this strategy is meant to be a cross-cutting issue that should be addressed across subjects and not only in specific school subjects such as math, science, or language. This framework represents both a guidance and action plan to further develop digital educationterm·key in Germany.

Due to the federal states' sovereignty in Germany, each state is responsible for defining its own strategy for digital educationterm·key. Many states have already adapted the strategy for education in the digital world and have embedded it in their own frameworks, which historically are often rooted in media education and media literacyterm·key (sometimes also called ‘media pedagogy’). On the state level in North Rhine-Westphaliaterm·key, the national model was adapted into the Media Literacy Frameworkterm·dom (“Medienkompetenzrahmen NRW” in German) ( 41 ) using slightly modified titles and content for the dimensions compared to the original model ( Table 2 ).

Media literacy frameworkterm·dom North-Rhine Westphalia, Germany ( 41 ).

This framework is to be understood as rather generic and covers all areas relevant to educating students to become digitally literate. In Germany, educational efforts are meant to be inclusive and integrative. They not only focus on narrow skill areas but holistically address a concept in a broader sense, which is why it makes sense to think of health literacyterm·dom holistically, too. Ideally, the students learn all necessary competencies, the relevant factual and practical knowledge etc. Then, health literacyterm·dom can be linked to other relevant dimensions of the framework that go beyond the health literacyterm·dom definition by Sørensen, et al. ( 4 ) presented earlier. If health literacyterm·dom is understood (as part of) a process of developing this competencies rather than a cognitive concept to be transferred to the student, students will automatically learn more than just health-related information literacyterm·key skills while achieving the aims of the core health literacyterm·dom action areas. They must learn techniques of media use, communication, problem-solving skills, and many more as outlined in Table 2 . Therefore, embedding health literacyterm·dom into this framework departs from the definition presented earlier as it interlinks health literacyterm·dom with various competence areas. In addition, it significantly contributes to a holistic conceptualization of health literacyterm·dom as expected by the education sector. Doing so has several benefits, as the curriculum addresses the core action areas of health literacyterm·dom (the information literacyterm·key skills), allows linking health literacyterm·dom to the context of digital media and (communication) technology environments and associated requirements, includes components to address social, emotional, ethical, and psychological development to support the learning of self-regulation, identity creation, and opinion forming in context of health literacyterm·dom, and permits the linking of necessary health literacyterm·dom skills with other critical skills that are needed when aiming at finding, understanding, evaluating, and using information to promote health.

In the following we present the six core dimensions in more detail, including the 24 sub-dimensions of the framework, and adapt them to health literacyterm·dom ( Table 3 ). The model provides a curriculum and associated learning achievement goals across age-grades, including primary, secondary and upper-secondary students. While the dimensions are the same for all age groups, the age-adapted goals differ in their complexity and depth, increasing with age and children's cognitive and social development stages. For the purpose of our analysis, we will focus on the model itself rather than on specific age groups. The exemplary exercises in the third column are based on the learning and teaching examples given in the original framework. They are thought to demonstrate various possibilities and help to imagine how to operationalize and implement the promotion of health literacyterm·dom in the school setting.

Main dimensions and competence areas of the media literacy frameworkterm·dom in North-Rhine Westphalia, Germany ( 41 ), and pertinent exemplary health literacyterm·dom exercises.

There are many entry points and intersections for addressing various actions connected to the handling of information and knowledge relevant to health and well-being. Especially the second dimension, “Informing and researching” and its sub-dimensions 2.1, “Information seeking”, 2.2, “Analyzing information”, 2.3, “Evaluating information”, and 2.4, “Critical information review and use”, can function as interfaces to strengthen health literacyterm·dom. Here, this understanding of health literacyterm·dom can be applied seamlessly and there is no need to alter it in terms of the dimensional specifications.

To practice and strengthen health literacyterm·dom and digital health literacyterm·dom skills, other dimensions of the media literacy frameworkterm·dom may be of use, too. When students search for various health information, e.g., on a smartphone, computer, or tablet, effectively, they “operate and apply” digital media (Dimension 1). In addition, group and tandem work, which is regularly practiced in schools, automatically addresses the third dimension, “Communicating and cooperating”, and also includes the social component which is important to health literacyterm·dom. Dimension 4, “Producing and presenting”, is addressed when the search results need to be prepared for class presentations. Dimension 5, “Analyzing and reflecting” of media, is closely related to the health literacyterm·dom action areas “critical thinking” and “appraisal of health information”. If students frequently search for health-related content on the internet, they will need the skills to reflect and analyze the content they access and distinguish accurate from false and misleading information. Dimension 6, “Problem solving and modeling”, is trained when students encounter digital problems during their research and have to solve them. This is also closely related to applying information. In the long run, they are trained in data literacy and in their understanding and use of algorithms to detect patterns in information flow and communication. This understanding can then be used to identify digital principles and use them consciously. The fifth and the sixth dimensions also share intersections with evaluating information and critical thinking about health claims. While the competencies and action areas presented here seem to go beyond the common health literacyterm·dom concept, reviews on health literacyterm·dom concepts and measurement tools for children and adolescents show that most of the competencies and action areas are in fact used in many of the available concepts and tools ( 7 , 15 , 44 , 45 ).

Discussion on the Practical Implications Opportunities Based on a socioecological understanding of health as presented by Whitehead and Dahlgren ( 46 ), there is a wide array of factors determining health development of students. The peril of addictive substance abuse (such as nicotine, cannabis, alcohol, or synthetic drugs), the influence of fitness trends and nutritional advice on social media, dealing with changes in the body, and being confronted with body ideals in print media and in the digital realm are important topics, affecting children and young people, and their peer groups. Many of these health-related topics are communicated on media channels, especially the internet and social media. Combining media and health skills would help students navigating these contents and environments. It would also equip them with the ability to critically evaluate online health messages and claims as well as their digital sources and suppliers. Educating and teaching students the competencies and facilitating the development of attitudes and beliefs in relation to media is necessary because today‘s generation grows up being socialized with social media as national ( 47 , 48 ) and international studies ( 49 ) show. A German study from 2019 with 140 students from different types of schools in the 9th grade showed that their self-perceived skills to critically think about and deal with online sources and information tends to be overestimated compared to their actual performance ( 50 ). When selecting health information from a Google search, 19.2% tended to take a marketing website that advertises pharmacy products to be credible. In addition, 18.6% indicated that they never or rarely cross-check online information with other sources. The study also showed that students tended to take the number of followers as an indicator of the validity of information within a raffle on social media ( 50 ). Another German study revealed that adolescents frequently reported difficulties in searching for, evaluating, and assessing the personal relevance of digital health information ( 51 ). Despite growing up with digital and social media, it seems that adolescents are still inexperienced regarding the critical assessment and handling of digital health information and, above all, fail to make accurate judgments about health claims and messages. These issues are important to address through health literacyterm·dom in schools.

Challenges Consequently, several challenges have to be mentioned, and they have to be considered in present educational efforts and prospectively. Addressing health and health promotion, including health literacyterm·dom, in the school setting requires professional knowledge about the health-related needs of a heterogenous group of students with different cultural norms and social beliefs. Educator's health literacyterm·dom is an enabling factor for the development of adequate students' health literacyterm·dom, which is why teachers' and principals' health literacyterm·dom should be equally strengthened in order to improve the quality of school health educationterm·key ( 20 , 21 , 32 ). Teachers are required to be familiar with digital tools and teaching in, about, and by using virtual environments in order to motivate students to learn about and engage with health literacyterm·dom. Accordingly, media skills and building up the confidence to use digital educationterm·key tools in classroom should be part of the teacher training curriculum, not only at universities but also in practical trainings of pre-service teachers at schools. In-service teachers will need vocational training and education to become familiar with digital educationterm·key and literacy teaching and learning to be able to pass on the knowledge, competencies, and values to their students, including various instructional and didactical methods.

In addition, materials, programs, and interventions must be available for teachers and schools to address health literacyterm·dom. Presently, there are few teaching materials and their didactic implementation often is difficult. Therefore, interventions and didactic materials are much needed.

Conclusion To prepare and facilitate a better implementation of health literacyterm·dom in schools, it is highly important to “speak the language” of education and understand the needs of teachers, schools, and the education sector ( 18 ). A most promising approach to include health literacyterm·dom as a learning goal to schools is to identify entry points in existing school curricula and educational policies, which can be done by analyzing the national and/or local school curriculumterm·key and seek for concepts, topics and themes that share commonalities with health literacyterm·dom. With the German strategic framework for digital educationterm·key and the associated media literacy frameworksterm·dom on the state levels, we identified such entry points, which may exist in other countries as well. They provide a foundation for integrating health literacyterm·dom and developing educational interventions to strengthen health literacyterm·dom in school, and they can be interlinked with further cross-cutting topics such as health promotion, physical activity, or mental health. In addition, as this framework is also meant to be addressed in University curricula for teacher training and education, teachers would be able to use health literacyterm·dom within a framework they are familiar with already. When using these frameworks for addressing health literacyterm·dom, teachers would not have to make an extra effort. Analyzing existing curricula, identifying entry points, and adapting the frameworks accordingly could be a methodological blueprint for other countries to analyse their curricula and address health literacyterm·dom through digital, media, and information literacyterm·key, other literacy frameworks or even whole new topics that allow to incorporate health literacyterm·dom.

Data Availability Statement The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author.

Author Contributions TS, VK, KD, and OO wrote sections of the manuscript. All authors contributed to manuscript revision, read, and approved the submitted version.

Conflict of Interest The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Acknowledgments We acknowledge the financial support of the German Research Foundation (DFG) and the Open Access Publication Fund of Bielefeld University for the article processing charge. We would like to thank David Lambert for English language editing.

References Associated Data Data Availability Statement The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author.