Health literacy, health status and health behaviors of German students– study protocol for the “Healthy Habits” cohort study

The emerging adulthood (age span of 18–25) is traditionally viewed as a time of optimal health with low levels of morbidity and chronic disease [1, 2]. At the same time, young adults appear to be more prone to psychosomatic health symptoms, depending on their individual life satisfaction and perceived future outlook [3, 4]. Characterized by changing life circumstances, personal growth and the manifestation of a certain lifestyle, the emerging adulthood is a distinct life phase [5, 6]. In comparison with other age groups, young adults tend to consume more alcohol, tobacco and drugs [7, 8]. Therefore, this life stage occurs as a vulnerable and critical time, in which specific health interventions might help paving the way for a healthy lifestyle. Especially university life can hold several challenges for students impeding the manifestation of a health supporting behavior [9].

On the one hand, the variety of study formats opens up considerable freedom for individually adaptable life concepts, such as studying alongside a part-time or full-time job, flexible lecture periods or studying during parental leave. The proportions on the spectrum from purely physical presence on site to exclusively digital forms of learning and examination from home can be selected according to the students’ individual life situation [10]. The university setting receives increased attention in the context of prevention, both because of the described health situation of students and a steady growth of the higher education sector [10]. Especially Universities of Applied Sciences (UAS) register an increasing number of students due to offering simplified access for professionally qualified persons, (study) flexibility and a high diversity of studies in the form of dual and part-time courses [10, 11].

On the other hand, this freedom and flexibility seem to come with a price. Changes in stress situations and strain parameters can be observed when it comes to meeting work and study requirements. Some studies identified factors such as double and multiple burdensome-situations, a disruptive study-family-balance, an uneven study-leisure-time-balance and severe work-related psychological stress situations [12‐15]. Other requirements that students face during their studies include, for example, mastering demanding curricula, time-consuming workloads as well as mental and emotional challenges [16]. Current research of students’ health in Germany reveals an increased burn-out potential, an overall increased stress load, an above-average level of anxiety, sleep disorders, physical symptoms such as body aches or back pain and an overall subjectively lower-rated health status than comparable cohorts [12, 17‐21]. As part of the HISBUS Panel, a large-scale cross-sectional study with a total net sample of n = 6198, female participants in particular reported physical and psychological complaints. Additionally, about 75% of the HISBUS cohort stated to suffer from physical complaints several times a month [17]. The students’ health status seems to reflect the consequences of permanent overload in diverse ways.

Studies indicate, that a poor state of health might result from the interaction of multiple factors, e.g., an insufficient health behavior or a low degree of health literacy [22]. The majority of studies pictures a linear relationship between the three health dimensions, stating that health literacy influences the health behavior of a person and thereby impacts health outcomes [23]. Contrary to that, some studies report a different constellation of the three health dimensions, where this linearity has not been observed at all or not even discover an association between health literacy and certain health behaviors, e.g. smoking health professionals [24, 25]. In fact, current studies on college students’ health behavior and health literacy point to a linear as well as reciprocal relationship. Accordingly, a linear view with only consecutive seems to fall short, for the dynamic of interactions, feedback effects as well as antecedents and consequences cannot be integrated [26]. Accompanying, external or social factors can increase the interaction of the health dimensions, influencing the state of health positively or negatively. With regard to health behavior, the above-mentioned stressors have a negative effect on the amount of students’ physical activity and nutritional behavior [17, 27, 28]. Drug and alcohol consumption have also been shown to increase among students [17, 29]. Although to interpret with caution, the HISBUS Panel [17] attested students a poorer health behavior in many aspects compared to non-students of the same age. In particular, the results revealed lower levels of physical activity, increased alcohol and nicotine use [29], abuses of cocaine and cannabis, as well as increased intake of painkillers [17].

In this context, health literacy is an important individual competence and related to an overall literacy. It includes knowledge, as well a set of cognitive, social and motivational skills, enabling people to access, understand, appraise, and apply health information [26, 30, 31]. Also, health literacy entails the capacity of making health-related judgements, taking decisions and establishing health-promoting behaviors on a daily basis (e.g., a healthy diet, physical activity, stress management) [32‐34]. This understanding suggests, that health literate students are more likely to address the requirements and burdens described.

Despite the need of gaining more understanding of the complex nature of the relationship between the above-mentioned health dimensions, these studies also show different characteristics of the health dimensions among the students. This suggests the necessity of different approaches within the framework of possible health interventions.

Against this background, the aim of this cohort study is to gain insight in the relationship and change of UAS students’ health literacy, health status and health behaviors during their studies. Empirical inventories of student health differ both in their understanding of health and in the indicators collected [35, 36]. Thus, the cohort study’s assessment incorporates the broad categories of Dietz et al’s systematic umbrella review [36] to provide further clarification on the factors influencing student health (substance use, mental health/wellbeing, diet and nutrition, physical activity, sleep hygiene, media consumption and others). In this context, the following research questions will be addressed:

The German health promotion initiative “health-promoting university” is the overarching framework of the initiated Healthy Habits research project [37]. The cohort study is founded on a biopsychosocial and salutogenetic approach and assumes a multidimensional health continuum [38, 39]. If the salutogenetic approach is applied to the health of individuals, a three-way split emerges, where the state of health dynamically results from the aspects of health behavior as a generalized source of resistance and health competence as a superordinate empowerment in the sense of coherence. In summary, this leads to an understanding of health as a multidimensional and dynamically interacting construct, with the three core dimensions health status, health literacy and health behavior (see Fig. 1).

Attending a university or UAS is a lifechanging event in general and can be a very formative phase of life for young adults. Students will learn to deal with stress, the burden of learning for exams, setbacks as well as successes and overall to take responsibility for themselves. Unfortunately, taking care of one’s own health is not always priority number one during that phase of life. Current studies provide indications that students show a poor health behavior [17, 29]. The overall consequences of an unhealthy lifestyle as well as the insufficient management of psychophysical requirements are not only reflected in a poorer state of health, but also have an impact on the course of the study. Lower academic performance, a significantly longer duration of study and even drop-outs are possible consequences [16, 74]. According to the German Center for Higher Education and Science Research (original: Deutsches Zentrum für Hochschul- und Wissenschaftsforschung [DZHW]) the dropout rate ranges between 15 to 35% depending on the type of study and the subject [75].

To address these aspects efficiently and sustainably with interventions, requires a further understanding of how health changes during the course of study as well as of the impact of influencing factors. A mere consideration of health status does not fulfill the complexity, since it is not always known whether a poor health status results from an insufficient health behavior or a lack of competence. Recent research shows that only about 30.3% of students have sufficient health literacy [76]. There are also significant differences between male and female students. Furthermore, students with a migrant background as well as students with lower degrees (bachelor’ degrees) and first semester students have significantly poorer health literacy [77‐79]. These studies also suggest the existence of different target groups within the setting of UAS students which in turn should be approached differently with tailored interventions. To the authors best knowledge such comprehensive studies have not been sufficiently conducted yet in an UAS setting.

Contrary to growing scientific interest in student health research in recent years, the current amount of data is consistently inadequate. Most of the existing studies either looked at the three health dimensions separately from each or are mostly based on cross-sectional examinations [9, 17, 20, 41]. Longitudinal studies on the three health dimensions over the course of the study, on the other hand, are rare. Also, the quantity and quality of studies investigating the association between the described health dimensions and their mutual influence among themselves within the setting of students are insufficient as well.

Another potential distortion can be caused by assessment. After completing the app-based questionnaire, the results are displayed in form of a radar chart. Each health dimension is displayed separately, reflecting aspects of the selected assessment instruments. The authors are aware of the fact, that receiving an evaluation of one’s questionnaire responses might be seen as a first health intervention, increasing students’ awareness for health topics. The overarching intention is to motivate students to participate in the assessment sustainably.