Background: Digital communication technologies are playing an important role in the health communication strategies of governments and public health authorities during the COVID-19 pandemic. The internet and social media have become important sources of health-related information on COVID-19 and on protective behaviors. In addition, the COVID-19 infodemic is spreading faster than the coronavirus itself, which interferes with governmental health-related communication efforts. This jeopardizes national public health containment strategies. Therefore, digital health literacy is a key competence to navigate web-based COVID-19–related information and service environments. Objective: This study aimed to investigate university students’ digital health literacy and web-based information-seeking behaviors during the early stages of the COVID-19 pandemic in Germany. Methods: A cross-sectional study among 14,916 university students aged ≥18 years from 130 universities across all 16 federal states of Germany was conducted using a web-based survey. Along with sociodemographic characteristics (sex, age, subjective social status), the measures included five subscales from the Digital Health Literacy Instrument (DHLI), which was adapted to the specific context of the COVID-19 pandemic. Web-based information-seeking behavior was investigated by examining the web-based sources used by university students and the topics that the students searched for in connection with COVID-19. Data were analyzed using univariate and bivariate analyses. Results: Across digital health literacy dimensions, the greatest difficulties could be found for assessing the reliability of health-related information (5964/14,103, 42.3%) and the ability to determine whether the information was written with a commercial interest (5489/14,097, 38.9%). Moreover, the respondents indicated that they most frequently have problems finding the information they are looking for (4282/14,098, 30.4%). When stratified according to sociodemographic characteristics, significant differences were found, with female university students reporting a lower DHLI for the dimensions of “information searching” and “evaluating reliability.” Search engines, news portals, and websites of public bodies were most often used by the respondents as sources to search for information on COVID-19 and related issues. Female students were found to use social media and health portals more frequently, while male students used Wikipedia and other web-based encyclopedias as well as YouTube more often. The use of social media was associated with a low ability to critically evaluate information, while the opposite was observed for the use of public websites. Conclusions: Although digital health literacy is well developed in university students, a significant proportion of students still face difficulties with certain abilities to evaluate information. There is a need to strengthen the digital health literacy capacities of university students using tailored interventions. Improving the quality of health-related information on the internet is also key.

Implementing complex and multi-level public health programmes is challenging in school settings. Discrepancies between expected and actual programme outcomes are often reported. Such discrepancies are due to complex interactions between contextual factors. Contextual factors relate to the setting, the community, in which implementation occurs, the stakeholders involved, and the characteristics of the programme itself. This work uses realist evaluation to understand how contextual factors influence the implementation process, to result in variable programme outcomes. This study focuses on identifying contextual factors, pinpointing combinations of contextual factors, and understanding interactions and effects of such factors and combinations on programme outcomes on different levels of the implementation process. Schools which had participated in a school-based health promotion programme between 2012 and 2015 were included. Two sets of qualitative data were collected: semi-structured interviews with school staff and programme coordinators; and written documents about the actions implemented in a selection of four schools. Quantitative data included 1553 questionnaires targeting pupils aged 8 to 11 in 14 schools to describe the different school contexts. The comparison between what was expected from the programme (programme theory) and the outcomes identified in the field data, showed that some of the mechanisms expected to support the implementation of the programme, did not operate as anticipated (e.g. inclusion of training, initiation by decision-maker). Key factors which influenced the implementation process included, amongst other factors, the mode of introduction of the programme, home/school relationship, leadership of the management team, and the level of delegated power. Five types of interactions between contextual factors were put forward: enabling, hindering, neutral, counterbalancing and moderating effects. Recurrent combinations of factors were identified. Implementation was more challenging in vulnerable schools where school climate was poor. A single programme cannot be suited or introduced in the same manner in every context. However, key recurrent combinations of contextual factors could contribute to the design of implementation patterns, which could provide guidelines and recommendation for grass-root programme implementation.

Background: In the recent decades, the number of apps promoting health behaviors and health-related strategies and interventions has increased alongside the number of smartphone users. Nevertheless, the validity process for measuring and reporting app quality remains unsatisfactory for health professionals and end users and represents a public health concern. The Mobile Application Rating Scale (MARS) is a tool validated and widely used in the scientific literature to evaluate and compare mHealth app functionalities. However, MARS is not adapted to the French culture nor to the language. Objective: This study aims to translate, adapt, and validate the equivalent French version of MARS (ie, MARS-F). Methods: The original MARS was first translated to French by two independent bilingual scientists, and their common version was blind back-translated twice by two native English speakers, culminating in a final well-established MARS-F. Its comprehensibility was then evaluated by 6 individuals (3 researchers and 3 nonacademics), and the final MARS-F version was created. Two bilingual raters independently completed the evaluation of 63 apps using MARS and MARS-F. Interrater reliability was assessed using intraclass correlation coefficients. In addition, internal consistency and validity of both scales were assessed. Mokken scale analysis was used to investigate the scalability of both MARS and MARS-F. Results: MARS-F had a good alignment with the original MARS, with properties comparable between the two scales. The correlation coefficients (r) between the corresponding dimensions of MARS and MARS-F ranged from 0.97 to 0.99. The internal consistencies of the MARS-F dimensions engagement (ω=0.79), functionality (ω=0.79), esthetics (ω=0.78), and information quality (ω=0.61) were acceptable and that for the overall MARS score (ω=0.86) was good. Mokken scale analysis revealed a strong scalability for MARS (Loevinger H=0.37) and a good scalability for MARS-F (H=0.35). Conclusions: MARS-F is a valid tool, and it would serve as a crucial aid for researchers, health care professionals, public health authorities, and interested third parties, to assess the quality of mHealth apps in French-speaking countries.

Purpose: Implementing health promotion programmes in schools is key to improving children’s health and well-being but difficulties in achieving expected results are often reported in the research literature. Discrepancies between expected and achieved outcomes can originate from differences in contexts. Understanding how interactions between contexts and programmes generate variable outcomes is, therefore, critical. The purpose of this paper is to explore the outputs of a programme implemented in different school contexts. The focus is to pinpoint outputs, understand the involvement of combinations of contextual factors and identify recurrences in these combinations. Design/methodology/approach: This retrospective study covers a period from 2006 to 2016. Data collection includes two sets of data in eight high schools in the Rhône-Alpes Region in France: written documents and interviews with school staff. Realist evaluation is used to attempt to pinpoint outputs and relating contextual factors. Findings: Results highlight the limited outputs of the programme. Differences between schools appear to originate from existing school policy prior to participation, existence of a project team, identification of the issue as priority and staff turnover. Analysis of contextual factors led to considering the implementation process as enabling health capacity building and enhanced the capacity of settings and communities to promote health. Research limitations/implications: The data provided remain partial as there was high staff turnover, reluctance to participate due to failure to implement the project, and schools being over burdened with other requests. Originality/value: Previous research suggests that top-down implementation of a standard programme is not an efficient strategy for all schools to engage in the development of suitable health promotion policies. A potential way forward is to base support for the local development of health promotion in schools on a better understanding of the contexts in which implementation occurs.

Background: Capacity building and community-level participation are important to enhance the efficiency and sustainability of health promotion programmes, as well as to promote empowerment and decision-making power. However, stakeholders’ participation in the design and implementation of health promotion projects often involves the provision of information and consultation rather than partnership or citizen control, especially in school settings. Co-creation could be a means to support higher levels of participation, yet its definition remains unclear. A further challenge relates to the methods needed to promote participation. Examining what co-creation represents for health promoters could help in both of these respects. Objectives and goals: This study explored how school health promotion professionals perceived and defined co-creation to gain insight into how to encourage co-creation processes in school-based health promotion. Methods: Qualitative data including documents and illustrations were collected during creative thinking activities undertaken with school health promotion professionals. All data collected were transcribed and analysed using a three-stage screening process. Results: Co-creation is a multi-dimensional construct. Based on our findings, it is a voluntary-based process of bottom-up collaboration informed by values of diversity, mutual trust, openness, autonomy, freedom, respect and shared expertise, responsibility and decision-making. Co-creation can result in out-of-the-box, new or improved tailored health-promoting practices and projects, which address a co-defined need, for the benefit of all members of the group. Conclusion: Co-creation is timely and key in school health promotion practices. Further research is needed into the specific competences needed to promote co-creation, as well as the methods used to evaluate achievements and added value of co-creation at different levels of implementation.

• Health promotion programmes in various settings are effective means to improve the health of the population. • Despite substantial research, results from programme implementation remain unclear and challenging to evaluate. • A shift from ‘one size fits all’ evidence-based fidelity to anchoring and tailoring interventions to their contexts is needed. • Recurrences in combinations of contextual factors (namely Typical Contextual Equations) occur in a given type of context. • TCEs focus on a selection of the key critical factors that have drastic impact on implementation.