The Conceptualization of a Competency-Based Health Literacy Intervention for a German University

Abstract

Gesundheitskompetenz, also known as health literacy in German, is an essential capacity to lead a healthy life. Education plays a major role in the development of health literacy. Health literacy is seen as an asset to be built focusing on actions to develop age- and context-specific health knowledge and skills that enable people to exert greater control over their health and health-related decisions. Conceptualizing health literacy in this way has important implications for the design, scope, and content of health education programs and interventions. While many health education interventions are developed with attention to the use of behavior change theories, little attention is given to the instructional foundation of how individuals learn information and acquire skills. This article explores the relevance of health literacy and articulates an approach to promote health literacy among university students, using inquiry-based mobile learning and the integration of multiple health behavior theories, Bloom’s revised taxonomy, adult learning principles, health education standards, and professional health competencies, into university program planning. This article offers a framework of health literacy to depict the main domains of health literacy and influencing factors to inform, guide, and support the university-based health literacy effort. A logic model is also provided to map out the major conceptual ideas connecting program activities to anticipated participant outcomes.

Keywords

health literacy health behavior teaching health literacy

Introduction

This article articulates a vision for advancing the health and well-being of university students at a German university informed by the areas of health literacy, health behavior and learning theories, health education standards, and professional health competencies. By combining the health and education fields, this article presents a student-centered and research-based instructional program called e-Vitality for Generations (eVG) for health and learning. The mission of our instructional program using inquiry-based mobile learning is to promote Gesundheitskompetenz (health literacy) among preservice teachers. eVG is an interactive virtual health database and interactive health library designed for promoting health literacy and, thus, improving health-related knowledge, behaviors, skills, and attitudes among students at the university level. The health database component contains a profile questionnaire, whereby participating students collect and analyze data for three generations from their immediate family and surrounding living environment (e.g., student, parents/guardians, grandparents) to build a databank. The health library component of eVG contains a health multimedia library offering user-friendly, credible health content and resources related to health conditions and staying healthy. Students participate in data collection and analysis using the databank, interpret results, and consider which preventive measures in the form of behavior modifications they could take in order to reduce the prevalence of certain health conditions. The project culminates with a student exchange where students create a video to convey their eVG findings, reflections, and recommendation for a health action plan. The goal of the program is twofold: (1) to promote health and prevent disease of those participating students, and members of their family and university; and (2) to prepare students to ensure their actions contribute to and create a health-literate society as a public health priority.

This project brings together student inquiry and engagement by appealing to a digitally literate audience. Technology is already an important part of young adult lives (e.g., the Internet, social media, apps). The e-learning platform of the university (ILIAS), which provides an online learning environment to all faculties and students, houses the eVG program (questionnaire and health library). This particular learning management system is similar to other universities/colleges’ systems such as Blackboard, WebCT, CourseSpaces, allowing for the design of learning spaces for intended outcomes with Technical Support for instructors and students. The initial focus of eVG will be on the university student population enrolled in teacher education and health-related degree programs at the University of Cologne; however, it is intended to have eventual application to a broader student population, and expansion to other countries for international comparisons. The Metropolitan University located in the German Federal State of North Rhine-Westphalia in Western Germany is one of the largest universities in the country with a student enrollment of over 48,000 students. It is the sixth oldest university in central Europe with a wide-reaching international network comprising 20 university-level and about 200 faculty-level partnerships based on cooperation agreements (University of Cologne, 2015). The intervention is currently limited to our university students who can obtain access using their university email account and personal user ID. The intervention will be expanded to external students from interested partnership universities within the country (e.g., northern, southern, and eastern Germany) and beyond. eVG materials translated in languages other than German will also be made available in the future.

Health Literacy

Gesundheitskompetenz, also known as health literacy in German, is an essential capacity to lead a healthy life. Research has consistently shown that poor health literacy adversely affects people’s health and well-being (Kickbusch, Wait, & Maag, 2005). Low health literacy is linked to poorer health outcomes (D. Baker et al., 2007), increasing rates of chronic disease (McGowan, 2005), and increasing health care costs (Eichler, Wieser, & Brügger, 2009). The concept of health literacy is closely related to the social determinants of health (e.g., education, culture, age, socioeconomic status), health behaviors, and health outcomes. Over the past decade interest in health literacy has expanded from a narrow medical concept to a much broader preventative health concept associated with skills contributing to individual and social empowerment. Increasing health literacy levels of the population is an effective health intervention (Mitic & Rootman, 2012).

Internationally, the World Health Organization (WHO) introduced the concept of health literacy with a health promotion perspective in its 1998 glossary of health promotion terms (Nutbeam, 1998). Since that time, different definitions of health literacy have been developed. For this study, we adopt the European Health Literacy Project (HLS-EU) Consortium comprehensive definition:

Health literacy is linked to literacy and entails peoples’ knowledge, motivation and competencies 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. (Sørensen et al., 2012, p. 3)

This implies that health literacy is an interaction between the individual and the system, as well as various settings they are in across the life-course.

The importance of health literacy for the education and promotion of health has been recognized by international organizations. Health literacy has been mentioned as an area of priority action in the European (EU) Commission’s Health Strategy 2008-2013 (Commission of the European Communities, 2007) where it is linked to the core value of citizen empowerment and the priority actions for the promotion of health for different age groups. The Health 2020 policy framework has been adopted by all member states of the WHO EU Region, which focuses on education and health using a life course approach for empowerment to improve health literacy and essential life skills (World Health Organization Regional Office for Europe, 2012). A new consensus paper on how to advance health literacy in Europe was launched at the 2013 European Health Forum Gastein (2015). The paper recommends EU action on health literacy noting well-informed people who take responsibility for their own health are less likely to develop chronic disease, feel healthier, and live longer. Among the recommended EU actions to advance health literacy, our project taps directly into two of them: supporting the integration of health literacy as part of capacity-building of health-related professionals and promoting health literacy through means of e-health and the Internet. This project is timely with major gaps in health literacy in Europe as revealed by the HLS-EU with 47% of the population on average in eight European countries (Austria, Bulgaria, Germany, Greece, Ireland, the Netherlands, Poland, Spain) estimated to have insufficient or problematic levels of health literacy (Sørensen et al., 2015).

Education for Health Literacy

Education plays a major role in the development of health literacy (Vamos & Rootman, 2013). Education as a key social determinant of health aims to increase peoples’ knowledge and skills necessary for the development and maintenance of individual, family, and community health and learning (Kickbusch, Maag, & Saan, 2005). Improving health literacy in a population involves effective school health education and adult education (Nutbeam, 2008; St. Leger, 2001). Specifically, there is growing interest in health literacy as an essential skill among university students (Ickes & Cottrell, 2010), especially those in medical and health-related professions. A recent university-based project was designed to train student health professionals in plain language skills needed to ensure that patient education materials are easy to understand to help address the high demands of health information having a negative impact on health decisions on individuals (Hadden, 2015). Moreover, research indicates that patients want their physicians to be able to guide them in finding reliable information and to help them apply it to their situation as seen in a Medlineplus kiosk project, which involved a pictorial touchscreen kiosk and website at a university hospital (Teolis, 2010).

While the Internet is the preferred resource of health information for millennials—generally understood as those born between 1982 and 2002 (Heuberger & Ivanitskaya, 2011), access alone does not ensure university students are skilled at finding credible information or critically evaluating the information that they retrieved (Robb & Shellenbarger, 2014). This ability of individuals to seek, find, understand, and appraise health information from electronic resources and apply such knowledge to addressing or solving a health problem is referred to as eHealth literacy (Norman & Skinner, 2006). A systematic review of eHealth literacy levels among students between the ages 17 and 26 attending various 4-year colleges and universities located around the world found that many students lack eHealth literacy skills, indicating that there is significant room for improvement in students’ ability to obtain and evaluate health information on the Internet (Stellefson et al., 2011). Interestingly, a study by Robb and Shellenbarger (2014) found undergraduate students perceived that they knew how to use the Internet to answer questions about health, but scored the lowest on confidence in using this information to make health decisions. Moreover, a study by Hsu, Chiang, and Yang (2014) showed that eHealth literacy played an intermediary role in the association between individual factors and health behaviors among university students, suggesting that schools strengthen university students’ eHealth literacy to promote positive health behaviors. These results suggest universities should consider incorporating learning activities using mobile technology to help students develop the knowledge, skills, and confidence to improve health literacy and to take these new skills with them into the field after they graduate to influence health practices of others.

A major challenge facing educators, school officials, health researchers, and policymakers is “how” to incorporate health literacy in the education system, given that the concept has evolved to a more complex interrelated set of abilities applicable to everyday life in a range of settings. Health literacy involves knowledge, motivation, and activation, which is a multifaceted concept to influence and measure (Peerson & Saunders, 2009). Our project uses the university setting within an enrolled course context as a guided learning environment for students to gain experience in the scientific process and health literacy competencies related to their living environment. The following sections present key factors informing our project. Table 1 presents the project phases and the relationship to standards, competencies, targets, and learning objectives.

Table 1.

Phases of eVG Project and Relationship to Health Standards, EU Health Promotion Competencies, National Target of Living Competency, and Bloom’s Taxonomy.

Phases of the e-VG project	U.S. national health education standards	Core health promotion competencies in Europe	German national target of living competency	Bloom’s revised taxonomy of learning objectives for the cognitive domain	Learning objectives for affective and psychomotor domain
PHASE 1: Students collect data for three profile questionnaires (student, parent, grandparent)
• Students answer the profile questionnaire themselves to generate a first data set	Use Interpersonal Communication Skills (Students apply communications skills when interviewing other people)	Communication (Students will effectively communicate with the interviewees)	Communication and Interpersonal Relationships (see remarks on the left)	Remember (Students will list health conditions present among their personal and family health profiles after answering the questionnaires)	Responding-Affective (Students will demonstrate sensitivity toward diversity with respect to all individuals [cultural, age, ethnicity, race, gender] and health issues)
• Students interview two people of different generations (one parent/guardian and one grandparent) using the profile questionnaire to generate two additional data sets for the health database					Perception-Psychomotor (Students will demonstrate effective communication skills including written, verbal, nonverbal, and listening skills)
• Students enter the three data sets into the online health databank
PHASE 2: Students use all data sets in the online health databank for analysis
• Students explore what proportion of poor health conditions or diseases occur in the group of interviewed participants belonging to three different generations	Comprehend Health Concepts (Students comprehend connections between lifestyle behaviors and various A to Z health conditions/diseases)	Enable change (Students will see the need to change certain lifestyle behaviors as they discover the relationship to certain lifestyle diseases and become more sensitized)	Self-Awareness (Students will increase self-awareness about how life style corresponds to certain diseases when analyzing the database)	Understand (Students will report on data sets in the database by translating numbers and content)
• Students explore what proportion of different lifestyle behaviors are present in the group of interviewed participants		Evaluation and Research (Students will use basic research strategies to evaluate which prevalent nonhealthy lifestyles and secondary diseases have in the population recorded in the data bank)		Analyze (Students will differentiate databank data to determine prevalent health conditions and risk behaviors, and connections between these two components)
• Students explore which type of lifestyle behaviors might result in poor health conditions		Assessment (Students will review and appraise data from the health databank to inform themselves of the societal state of health)
• Students explore which type of lifestyle behaviors might result might in good health conditions
PHASE 3: Students use the online multimedia health library component
• Students access reliable, national studies to describe current health trends in Germany	Access Valid Health Information (Students use information technology including the online health library provided with multimedia, links, and apps to obtain credible health information)	Assessment (Students will collect, review, and appraise data from the health library to tackle health issues with positive health actions)	Self-Awareness (Students will raise self-awareness that the factors underpinning certain diseases with reference to their own lifestyle behavior)	Remember (Students will recall their personal and family health profile results)	Mechanism-Psychomotor (Students will use technology and multimedia to receive health promotion information)
• Students obtain credible background information on relevant and prevalent health conditions related to databank and national trends (e.g., information concerning physiological mechanisms how certain lifestyle behaviors affect good or bad health conditions, prevention measure and reasons why they are effective)	Comprehend Health Concepts (Students engage themselves with the health multimedia library to comprehend how certain behaviors lead to certain diseases over time)			Understand (Students will locate and read health library information, and construct meaning in order to find an explanation for databank results)
				Apply (Students will interpret how culture, technology, media, and other external factors influence personal and family health using the health library)
PHASE 4: Students chose a target group (themselves, parent, grandparent, others/friends) with a health behavior of concern and create a health action plan for this target group
• Students develop a health action plan	Use Goal-Setting (Students determine which target group and which kind of health-related intervention are most important to achieve associated short-term and long-term goals)	Planning (Students will identify appropriate health-related goals and objectives with reference to existing needs and assets identified)	Critical and Creative Thinking (Students will use critical and creative thinking strategies to develop feasible health action plans)	Create (Students will develop a health action plan to improve the health status of a target group)	Organization-Affective (Students will prioritize time and other living conditions effectively to meet the health needs of self, family, and community)
• Students self-evaluate their health plan to determine:	Practice Health-Enhancing Behaviors (Students test the self-developed health action plan)	Mediate Through Partnership (Students will identify external partners (e.g., health insurance companies, public health authorities) from different sectors to actively contribute to their health action plan and/or refer to materials produced by such partners)	Problem Solving (Students will generate a set of health options and outcomes to develop feasible action plans)	Evaluate (Students will test whether their health-related plan is applicable/realistic)
○ whether it is feasible	Use Decision-making Skills (Students weigh which strategies in their health action plan are effective and applicable; if expectations are too high suggestions for behavioral change will not be put into practice by the target group)	Assessment (Students will analyze whether their health program works)	Taking Decisions (Students will examine barriers that can hinder healthy decision making by testing their action plans; thus deciding whether the instructions and steps should be modified for effectiveness)
○ any barriers/enablers of participating in their health plan	Analyze External Influences on Health (Students use mobile apps in multimedia library to track health behaviors and factors of relevance)	Implementation (Students will identify culturally appropriate processes and resources needed for effective self-testing of their health action plan, but apart from this testing phase they do not put the action plan into practice on a broader scale)
○ by which means the barriers could be overcome		Evaluation and Research (Students will use research and evidence-based strategies to inform recommendations within health action plan; evaluation of the health plan is only in a preliminary, formative, small-scale way)
• Students optimize their health action plan based on experiences they have gained by personally testing it
PHASE 5: Students reflect on and disseminate their health action plan to peers.
• Students will reflect on their project experiences by producing a short video to raise awareness of prevalent health concerns in their living environment and use advocacy strategies to articulate needs, resources, and capacities required for health action	Use Decision-making Skills (Students discuss how their personal decision-making process may have changed due to participation in the project)	Advocate for Health (Students will share advocacy efforts via videos to disseminate their ideas of how to live a healthier lives)	Communication and Interpersonal Relationships (Students will communicate to others about their experiences with the self-developed health action plans)	Create (Students will create a video to showcase recommendations for health promotion and disease prevention based on their experiences in Phases 1 to 4 of the eVG project)	Origination-Psychomotor (Students will design a video to share reflections with others on their health action plans at the individual level using a digital video platform [e.g., iMovie, GoAnimate, etc.])
	Advocate for Personal, Family, and Community Health (Students share efforts of self-developed health action plans and the reasons for its usefulness with others)	Leadership (Students will be the creators of their action plans and by this leaders to facilitate empowerment and participation toward recommendations for better health)	Emotion and Stress Management (Students will reflect on their emotions when as they as “test subjects” followed the health action plans in Phase 4; in their reflections they will report any stressful situations and associated coping mechanisms)
		Communication (Students will use effective interpersonal communication to exchange their experiences to facilitate empowerment toward better health [e.g., motivation, decision-making, problem-solving, goals-setting])

Health Targets and Risk Behaviors

Studies in the United States, Australia, and Europe have found that health literacy has significant implications for students’ health, well-being, and quality of life, and it is of critical importance to their interactions with formal and informal health services (Kolbe, 2005; St. Leger, 2001). In 2000, numerous German organizations in the health system joined together and founded the national forum “gesundheitsziele.de” to develop consensus-based health objectives to serve as a common framework for planned actions for better health. Seven health targets have been defined: (1) reducing the risk of type 2 diabetes; (2) reducing mortality and improving information about breast cancer; (3) preventing depressive disorders; (4) reducing tobacco use; (5) supporting growing up healthy via living competence, physical activity, and nutrition; (6) strengthening patient sovereignty; and (7) supporting healthy aging (Thietz & Hartmann, 2012). An eighth target was recently added in 2015, which relates to the reduction of alcohol consumption (GVG, 2015). These targets are relevant to students because health problems often commence in adolescence when certain forms of behaviors develop. Students will have the opportunity to develop “living competence” during eVG as shown in Table 1. People are classified as “living competent” when they have developed the following skills: (1) self-awareness, (2) critical and creative thinking, (3) communicating and establishing interpersonal relationships, (4) decision taking, (5) problem solving, and (6) managing emotions and stress (Bühler & Heppekausen, 2005). This set of psychosocial abilities should enable people to efficiently handle the demands of everyday live, which are seen as a substantial prerequisite for an extensive healthy well-being (GVG, 2015).

The Health Behaviour in School-aged Children (HBSC) Study has provided important insight on the health situation and behaviors of young people 11 through 15 years of age living in Germany. The HBSC draws important conclusions about the association between prevention and health promotion measures and individual health across time. The HBSC survey conducted in 2009-2010 revealed several critical points (HBSC, 2012), a few of which include the following: (1) 8.5% of girls and 10.8% of boys (between 11 and 15 years) are overweight or obese; (2) at age 15 only 8.6% of girls and 13.6% of boys are sufficiently physical active whereby obesity might be prevented; (3) 15% of 15-year-old girls and boys smoke at least once a week; and (4) compared to 11- and 13-year-old children the 15-year-old children show the highest prevalence of drunkenness with 27.8% of the girls and 34.4% of the boys have been fully drunk on at least two occasions during their lives. Moreover, large-scale German health studies such as the German Health Interview and Examination Survey for Children and Adolescents and the German Health Interview and Examination Survey for Adults targeting residents of Germany aged 18 to 79 years of age are part of the health monitoring system at the Robert Koch Institute. The development of the health profile questionnaire and the scope and nature of contents for the health library will be informed by such relevant health studies, surveys, and trends.

Skills and Standards

To achieve health literacy, the U.S. National Health Education Standards (NHES) are used as a useful framework to guide and describe the knowledge and skills or competencies essential to the development of health literacy through instruction in health education (Joint Committee on National Health Education Standards, 2007). The following four characteristics have been identified as being reflective of a health-literate individual and are woven throughout the NHES: (1) a critical thinker and problem solver; (2) a responsible, productive citizen; (3) a self-directed learner; and (4) an effective communicator. Research has shown that it is critical to develop these characteristics during adolescence as adults with poor health literacy have been shown to have worse health outcomes (D. W. Baker et al., 1996). While the NHES includes performance indicators outlining what students should know and do from K-12, employing the framework in a university setting provides an opportunity to infuse the broad areas of knowledge and skills needed to become health literate individuals. Table 1 provides specific examples of how eVG incorporates each national standard.

Competencies for Health Professionals

The importance and use of core competencies were highlighted at the Galway Consensus Conference (Barry, Allegrante, Lamarre, Auld, & Taub, 2009) and the International Union for Health Promotion and Education’s (IUHPE, 2007) “Shaping the Future of Health Promotion” statement whereby both consider that core competencies provide common direction for curriculum development, academic preparation, and build the capacity of health promotion workforce. The CompHP Project on Developing Competencies and Professional Standards for Health Promotion in Europe was developed to respond to the demand for new and evolving competencies required to address current health challenges including health inequities and noncommunicable diseases and to promote healthy ageing, positive mental health, and well-being (Barry, Battel-Kirk, & Dempsey, 2012). These 11 competency-based professional standards for health promotion practice in Europe are useful to any working professionals who are involved in sectors as partners to promote health or healthy environments such as teachers (Barry, Battel-Kirk, Davison, et al., 2012). These competencies guide the development of student activities as shown in Table 1.

Theories, Models, and Frameworks

Bloom’s Learning Taxonomy

Bloom and his colleagues (Anderson & Krathwohl, 2001) define learning as a positive change in behavior in three domains of learning—(1) cognitive (knowledge), (2) affective (attitudes), and (3) psychomotor (skills)—each of which are divided into categories or levels or expertise. This original taxonomy (Bloom, Engelhart, Furst, Hill, & Krathwohl, 1956) has been applied by generations of K-12 and university-level educators to define their educational objectives and guide the design of their instructional programs.

In the revised Bloom’s taxonomy (Anderson & Krathwohl, 2001), the updated cognitive framework uses a classification with verbs (remember, understand, apply, analyze, evaluate, create). To promote long-term behavior change, it is important for educators to carry out instruction designed to address lower and higher levels of learning and across all three domains of learning (Anderson & Krathwohl, 2001). Learning objectives for this project using Bloom’s revised taxonomy is shown in Table 1.

Adult Learning Theory

Adult learning theory posits that children and adults learn differently, and thus, university-aged students can benefit from learning experiences that incorporate adult learning principles. Regarding orientation to learning, adults are life-centered or task-centered compared to children’s and youths’ subject-centered orientation (Knowles, 1989).

While there are numerous theories and models that seek to explain how adults learn, general themes emerge that can be categorized into the following five main principles (Bryan, Kreuter, & Brownson, 2009) and applied to plan and deliver training: (1) adults need to know why they are learning, (2) adults are motivated to learn by the need to solve problems, (3) adults’ previous experience must be respected and built upon, (4) adults need learning approaches that match their background and diversity, and (5) adults need to be actively involved in the learning process. Our project emphasizes Principles 1, 2, 3, and 5 as the activities draws on the adults’ personal background and living environment to highlight the relevance of learning, thus motivating learners to become actively engaged in their learning and education for health literacy.

Behavior Change Theories

Health education/promotion theories can help in planning, implementing, and evaluating health programs as they provide a conceptual framework by identifying information needed for intervention development and outline reasons why people may not behave in healthy ways (Cottrell, Girvan, & McKenzie, 2015). The world we live in influences all of us. A socio-ecological approach (Cottrell et al., 2015) helps recognize the importance of the large social system of behaviors and levels that influence, including intrapersonal (knowledge, skills, attitudes), interpersonal (family, friends, social networks), organizational (organizations, institutions), community (relationships among organizations), and public policy (local, state, national, international laws). The envisioned design and outcomes of eVG is influenced by a framework that encompasses the innovation itself (health database and interactive health library), those adopting the innovation (students), and the system into which the innovation is being adopted (university system). Moreover, the health belief model (HBM) will be highlighted to guide practice and integrate individual approaches to behavior change (Rosenstock, 1974). In particular, the HBM contains concepts that predict why people will take action to prevent, screen, or control health conditions, including susceptibility, seriousness, benefits, and barriers to a behavior, cues to action, and self-efficacy (Cottrell et al., 2015). Learners will be exposed to a health library of information and messages using HBM constructs to support an individualized health action plan.

Health Literacy Model

There are a number of existing theoretical models and frameworks (published and unpublished) available to guide health literacy efforts. To help articulate many interconnected factors of eVG, we offer a model of health literacy that conceptualizes health literacy as a dynamic scaffolding (Vamos, unpublished data, 2010), as presented in Figure 1. This model draws on the work of Kwan, Frankish, and Rootman (2006) in highlighting four health literacy domains as processes and/or outcomes and identifying various health contexts. Health literacy is positioned as an interaction between individuals and health contexts. There are a number of intervention agents, which are drawn from the Canadian Expert Panel on Health Literacy (Rootman & Gordon-El-Bihbety, 2008) that can influence health literacy. A novel contribution of this model is the inclusion of eight associated major skill cues, which are drawn from the U.S. NHES (Joint Committee on National Health Education Standards, 2007). The model also identifies eight further influencing components that represent hypothesized tools and mechanisms that people can use to enhance health literacy. Each of the tools and mechanisms supports the others and reflect a coordinated school health approach (Kolbe, 2005)—more recently referred to as the whole school, whole community, whole child (WSCC) approach. Similar to other existing models, this model proposes that health actions (e.g., supporting early intervention, preventing chronic diseases, and promoting public health) are expected to lead to positive health outcomes (e.g., improve people’s health knowledge, beliefs, and behaviors, improve self-care, improve support, decrease preventable disease rates, decrease hospital admissions, decrease in health care costs, etc.). In sum, this model provides one means of developing appropriate actions to improve health literacy by identifying the major antecedents and precursors to low health literacy as well as the domains and cues to bringing about sustained change. This model notes that people require the ability to apply multiple skills that are relevant to addressing their health problems within their particular situation and context.

Figure 1.

Health literacy model (Vamos, unpublished data, 2010).

Inquiry-Based Mobile Learning

Inquiry-based learning is a concept that encourages educators to provide learners opportunities to be exposed to authentic situations and explore, analyze, and solve problems related to real life (Li & Lim, 2008). Through investigation students become involved in higher order thinking, develop a deeper understanding of the subject, and “learn how to learn” (Price, 2001). This program provides an opportunity for students to understand and use scientific ways of thinking and make connections with applications to their world beyond the classroom, while faculty responsibilities include mentoring student research and reflection guiding students to use their own analysis to uncover correlations and make informed decisions about their health and well-being.

Mobile learning is whereby the learners use mobile devices with digital content (e.g., laptops, iPads, smartphones) to learn in “anytime, anywhere” situations (Liu & Hwang, 2010). This project aims to develop an inquiry-based mobile learning system whereby the students are situated in a learning scenario that combines both the real world (interview family) and the virtual world (use mobile device to access database/library; create video using software programs to disseminate health action plan) to extend their learning experience. By using mobile devices the students will have a more customized learning experience and can control their pace during the scientific process.

Connecting the Dots

In the past, numerous intervention and prevention programs have been implemented to deter youth and adults from risky behaviors and to encourage them to engage in healthier lifestyle choices. Many of these programs have focused on isolated topics such as physical activity, weight loss, stress management, substance abuse, and violence and injury prevention. These efforts tend to divide at-risk issues and often isolate core components specific to cognitive, psychomotor, and/or affective skill. Coordinating a broad combination of these strategies in one interactive virtual inquiry-based learning environment may serve to be a potent force to promote health literacy and facilitate behavior change.

We believe that there is a need to develop and implement programs that provide individuals with the knowledge, skills, attitudes, values, and competencies needed to live productive and healthy lives. eVG presents an exciting technological medium for students aimed at enhancing skills and abilities within the complexities of contexts of which they act, defined as fundamental to health literacy. A logic model illustrating essential project elements is provided in Figure 2.

Figure 2.

eVG health literacy program logic model.

Limitations to this intervention should be considered when examining the results. The online health profiles are completed in the absence of faculty/investigators, creating room for possible misinterpretation of questions as well as influential dialogue among students and their family members. In addition, it is not known whether the students and family members answer the questions in a socially desirable manner. We are relying on the honesty of the participants and some may perhaps be less likely to be honest about measures relating to sensitive issues such as sexual behavior or drug use. Due to the limited size of the questionnaire and health library multimedia resources only key health-related behavioral aspects and conditions will be addressed as informed by the current German national targets and health trends. Nevertheless, eVG is intended as one evolving tool for disease prevention and health education, which invites student interaction, active participation, reflection, and critical analysis.

Health literacy means understanding the conditions that determine health, knowing how to change them, and adjusting practices accordingly (Abel, 2008). The proposed project provides an opportunity for students to reflect on their general living conditions and contexts, develop skills and competencies, and act on health literacy practices.

Footnotes

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

References

Abel

(2008). Measuring health literacy: Moving towards a health-promotion perspective. International Journal of Public Health, 53, 169-170. doi:10.1007/s00038-008-0242-9

Anderson

Krathwohl

(2001). A taxonomy for learning, teaching and assessing: A revision of Bloom’s taxonomy of educational objectives. New York, NY: Longman.

Baker

Wolf

Feinglass

Thompson

J. A.

Gazmararian

J. A.

Huang

(2007). Health literacy and mortality among elderly persons. JAMA Internal Medicine, 167, 1503-1509. Retrieved from http://archinte.jamanetwork.com/article.aspx?articleid=412862

Baker

D. W.

Parker

R. M.

Williams

M. V.

Pitkin

Parikh

N. S.

Coates

Imara

(1996). The health care experience of patients with low literacy. Archives of Family Medicine, 5, 329-334.

Barry

M. M.

Allegrante

J. P.

Lamarre

M.-C.

Auld

M. E.

Taub

(2009). The Galway Consensus Conference: International collaboration on the development of core competencies for health promotion and health education. Global Health Promotion, 16(2), 5-11. doi:10.1177/175975909104097

Barry

M. M.

Battel-Kirk

Davison

Dempsey

Parish

Schipperen

. . . Zilnyk

(2012). The CompHP project handbooks. Paris, France: International Union for Health Promotion and Education.

Barry

M. M.

Battel-Kirk

B. B.

Dempsey

(2012). The CompHP core competencies framework for health promotion in Europe. Health Education & Behavior, 39, 648-662. doi:10.1177/109019811246520

Bloom

B. S.

Engelhart

M. D.

Furst

F. J.

Hill

W. H.

Krathwohl

D. R.

(1956). Taxonomy of educational objectives: Cognitive domain. New York, NY: McKay.

Bryan

Kreuter

M. W.

Brownson

R. C.

(2009). Integrating adult learning principles into training for public health workforce. Health Promotion Practice, 10, 557-563. doi:10.1177/1524839907308117

10.

Bühler

Heppekausen

(2005). Gesundheitsförderung durch lebenskompetenzprogramme in Deutschland. Grundlagen und kommentierte Übersicht [Health promotion by life skills programs in Germany. Fundamentals and commented overview]. Köln, Germany: Bundeszentrale für gesundheitliche Aufklärung (BZgA).

11.

Commission of the European Communities. (2007). Together for health: A strategic approach for the EU 2008-2013. Retrieved from http://ec.europa.eu/health/ph_overview/Documents/strategy_wp_en.pdf

12.

Cottrell

Girvan

J. T.

McKenzie

J. F.

(2015). Principles & foundations of health education and health promotion (6th ed.). San Francisco, CA: Benjamin Cummings.

13.

European Health Forum Gastein. (2015). EHFG 2013: New consensus paper calls for EU action on health literacy. Retrieved from http://www.ehfg.org/health-literacy.html

14.

Eichler

Wieser

Brügger

(2009). The costs of limited health literacy: A systematic review. International Journal of Public Health, 54, 313-324. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3785182/

15.

GVG/Gesellschaft für Versicherungswissenschaft und -gestaltung e.V. (2015). Nationale gesundheitsziele [National health objectives]. Retrieved from http://gvg.org/

16.

HBSC. (2012). Faktenblätterübersicht der HBSC-Studie [Fact sheets overview of HSBC study]. Retrieved from http://www.gbe-bund.de/gbe10/f?f=HBSC-Studie_14467D

17.

Hadden

K. B.

(2015). Health literacy training for health professions students. Patient Education and Counseling, 98, 918-920. doi:10.1016/j.pec.2015.03.016

18.

Heuberger

R. A.

Ivanitskaya

(2011). Preferred sources of nutrition information: Contrasts between younger and older adults. Journal of Intergenerational Relationship, 9, 176-190. doi:10.1080/15350770.2011.567919

19.

Hsu

Chiang

Yang

(2014). The effect of individual factors on health behaviors among college students: The mediating effects of eHealth literacy. Journal of Medical Internet Research, 16(12):e287. doi:10.2196/jmir.3542

20.

Ickes

M. J.

Cottrell

(2010). Heath literacy in college students. Journal of the American College Health, 58, 491-498.

21.

International Union for Health Promotion and Education. (2007). Shaping the future for health promotion: Priorities for action. Promotion Education, 14, 199-202.

22.

Joint Committee on National Health Education Standards. (2007). National health education standards, second edition: Achieving excellence. Washington, DC: American Cancer Society.

23.

Kickbusch

Maag

Saan

(2005). Enabling healthy choices in modern health societies (European Health Forum Badgastein 2005). Retrieved from http://old.ilonakickbusch.com/health-literacy/Gastein_2005.pdf

24.

Kickbusch

Wait

Maag

(2005). Navigating health: The role of health literacy. Retrieved from http://www.ilcuk.org.uk/images/uploads/publication-pdfs/pdf_pdf_3.pdf

25.

Knowles

M. S.

(1989). The making of an adult educator. San Francisco, CA: Jossey-Bass.

26.

Kolbe

L. J.

(2005). A framework for school health programs in the 21st century. Journal of School Health, 75, 226-228.

27.

Kwan

Frankish

Rootman

(2006). The development and validation of measures of “health literacy” in different populations. Vancouver, British Columbia, Columbia: University of British Columbia Institute of Health Promotion Research & University of Victoria Centre for Community Health Promotion Research.

28.

D. D.

Lim

C. P.

(2008). Scaffolding online historical inquiry tasks: A case study of two secondary school classrooms. Computers & Education, 50, 1394-1410. Retrieved from http://www.researchgate.net/publication/222114375_Scaffolding_online_historical_inquiry_tasks_A_case_study_of_two_secondary_school_classrooms._Computers_in_Education_50_1394-1410

29.

Liu

G. Z.

Hwang

G. J.

(2010). A key step to understanding paradigm shifts in e-learning: Towards context-aware ubiquitous learning. British Journal of Educational Technology, 41(2), E1-E9. Retrieved from https://www.academia.edu/6669788/A_key_step_to_understanding_paradigm_shifts_in_e-learning_towards_context-aware_ubiquitous_learning

30.

McGowan

(2005, September). Self-management: A background paper. Paper presented at New Perspectives: International Conference on Patient Self-Management, Victoria, British Columbia, Canada.

31.

Mitic

Rootman

(2012). Intersectoral approach to improving health literacy for Canadians. Vancouver, British Columbia, Canada: Public Health Association of British Columbia. Retrieved from http://www.cpha.ca/uploads/portals/h-l/intersectoral_e.pdf

32.

Norman

C. D.

Skinner

H. A.

(2006). eHealth literacy: Essential skills for consumer health in a networked world. Journal of Medical Internet Research, 8(2), e9.

33.

Nutbeam

(1998). Health promotion glossary. Geneva, Switzerland: World Health Organization. Retrieved from http://www.who.int/healthpromotion/about/HPR%20Glossary%201998.pdf

34.

Nutbeam

(2008). The evolving concept of health literacy. Social Science & Medicine, 67(12), 2072-2078. Retrieved from http://www.sea-mist.se/hal/halsoteknik.nsf/bilagor/Nutbeam2009a_pdf/$file/Nutbeam2009a.pdf

35.

Peerson

Saunders

(2009). Health literacy revisited: What do we mean and why does it matter? Health Promotion International, 24, 285-296.

36.

Price

(2001). Enquiry-based learning: An introductory guide. Nursing Standard, 15(5), 45-52.

37.

Robb

Shellenbarger

(2014). Influential factors and perceptions of eHealth literacy among undergraduate college students. Online Journal of Nursing Informatics, 18(3), 1.

38.

Rootman

Gordon-El-Bihbety

(2012). A vision for a health literate Canada: Report of the expert panel on health literacy. Retrieved from http://www.cpha.ca/uploads/portals/h-l/report_e.pdf

39.

Rosenstock

(1974). Historical origins of the health belief model. Health Education & Behavior, 2, 328-355. doi:10.1177/109019817400200403

40.

Sørensen

Pelikan

J. M.

Röthlin

Ganahl

Slonska

Doyle

. . . Brand

(2015). Health literacy in Europe: Comparative results of the European Health Literacy Survey (HLS-EU). European Journal of Public Health, 25, 1053-1058. doi:10.1093/eurpub/ckv043

41.

Sørensen

Van Den Broucke

Fullam

Doyle

Pelikan

Slonska

Brand

(2012). Health literacy and public health: A systematic review and integration of definitions and models. BMC Public Health, 12, 80. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3292515/

42.

St. Leger

(2001). Schools, health literacy and public health: Possibilities and challenges. Health Promotion International, 16, 197-205. Retrieved from http://heapro.oxfordjournals.org/content/16/2/197.full.pdf+html

43.

Stellefson

Hanik

Chaney

Tennant

Chavarria

E. A.

(2011). eHealth literacy among college students: A systematic review with implications for eHealth education. Journal of Medical Internet Research, 13(4), e102. doi:10.2196/jmir.1703

44.

Teolis

M. G.

(2010). A MedlinePlus kiosk promoting health literacy. Journal of Consumer Health on the Internet, 14(2), 126-137. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2929770/

45.

Thietz

Hartmann

(2012). Das spannungsfeld von gesundheitszielen im föderalismus in Deutschland [The field of stress concerning health objectives in federalism in Germany]. Prävention und Gesundheitsförderung, X, 1-8. doi:10.1007/s11553-012-0351-4

46.

University of Cologne. (2015). Internationalization. Retrieved from http://www.portal.uni-koeln.de/uniprofil_international.html?&L=1

47.

Vamos

Rootman

(2013). Health literacy as a lens for understanding non-communicable diseases and health promotion. In McQueen

(Ed.), Global handbook on non-communicable diseases and health promotion (Chapter 11, pp. 169-187). Berlin, Germany: Springer Business + Science Media.

48.

World Health Organization Regional Office for Europe. (2012). Health 2020: A European policy framework supporting action across government and society for health and well-being. Retrieved from http://www.euro.who.int/__data/assets/pdf_file/0009/169803/RC62wd09-Eng.pdf