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Competing Interests: 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.

Background: The first 3 years of life offer an opportunity to prevent allergic diseases. Pediatricians are an important source of health information for parents. However, a certain degree of health literacy is necessary to understand, appraise, and apply preventive behavior, which can be supported by health literacy (HL) sensitive consultations and a HL friendly environment., Objective: In this study, we want to shed light on how pediatricians in outpatient care in Germany advise on early childhood allergy prevention (ECAP) and how they consider parental HL., Methods: We conducted 19 semi-standardized telephone interviews with pediatricians from North-Rhine-Westphalia and Bavaria. The interviews were audio-recorded, transcribed, pseudonymized, and subjected to content analysis., Key Results: Current ECAP recommendations were well known among our sample. Despite the shift of evidence from avoidance of allergens toward early exposure, providing advice on ECAP was considered non-controversial and it was widely assumed that recommendations were easy to understand and apply for parents. However, ECAP was treated as an implicit topic resonating among others like infant nutrition and hygiene. Regarding HL, our interview partners were not aware of HL as a concept. However, they deemed it necessary to somehow assess parental information level and ability to understand provided information. Formal HL screening was not applied, but implicit strategies based on intuition and experience. Concerning effective HL-sensitive communication techniques, interviewees named the adaptation of language and visual support of explanations. More advanced techniques like Teach Back were considered too time-consuming. Medical assistants were considered important in providing an HL-sensitive environment. Time constraints and the high amount of information were considered major barriers regarding HL-sensitive ECAP counseling., Conclusion: It seems warranted to enhance professional education and training for pediatricians in HL and HL-sensitive communication, to reach all parents with HL-sensitive ECAP counseling. [ HLRP: Health Literacy Research and Practice . 2024;8(2):e47-e61. ].

Background: Health professionals such as physicians and nurses may play an important role in the transformation process towards a healthy, sustainable and climate-sensitive society. However, little is known about their climate-specific health literacy. This study aimed to assess knowledge regarding climate change and its impacts on health and climate-specific health literacy in health professionals., Methods: In July/August 2022, a cross-sectional, questionnaire-based study was carried out at the University Hospital Regensburg, Germany, to assess climate-specific health literacy in nurses and physicians from various clinical specialties. Descriptive and exploratory statistical analyses were performed., Results: The study population consisted of 142 participants (57.7% women; response rate: 24,7%). Most participants (93%) considered climate change to be highly relevant. However, only 12% of respondents stated to be very well informed regarding the general consequences of climate change. Although 57% of all participants had never mentioned climate change in relation to health to their patients, participants with higher levels of knowledge regarding the effects of climate change were more likely to mention it compared to those with lower levels of knowledge. The most frequently stated obstacle to integrate the topic of climate change in clinical work was lack of time during work (79%), not enough information (42%) and lacking materials (39%). Differences between health professions were apparent., Conclusion: The results of our survey suggest that the current state of climate-specific health literacy differs between different groups of health professionals. There is a need to improve health professionals' levels of climate-specific health literacy and to increase the potential in interprofessional cooperation regarding planetary health., Competing Interests: 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., (Copyright © 2023 Albrecht, Reismann, Leitzmann, Bernardi, von Sommoggy, Weber and Jochem.)

Background: Pediatricians are important sources of information for parents regarding their children's health. During the COVID-19 pandemic, pediatricians faced a variety of challenges regarding information uptake and transfer to patients, practice organization and consultations for families. This qualitative study aimed at shedding light on German pediatricians' experiences of providing outpatient care during the first year of the pandemic., Methods: We conducted 19 semi-structured, in-depth interviews with pediatricians in Germany from July 2020 to February 2021. All interviews were audio recorded, transcribed, pseudonymized, coded, and subjected to content analysis., Results: Pediatricians felt able to keep up to date regarding COVID-19 regulations. However, staying informed was time consuming and onerous. Informing the patients was perceived as strenuous, especially when political decisions had not been officially communicated to pediatricians or if the recommendations were not supported by the professional judgment of the interviewees. Some felt that they were not taken seriously or adequately involved in political decisions. Parents were reported to consider pediatric practices as sources of information also for non-medical inquiries. Answering these questions was time consuming for the practice personnel and involved non-billable hours. Practices had to adapt their set-up and organization immediately to the new circumstances of the pandemic, which proved costly and laborious as well. Some changes in the organization of routine care, such as the separation of appointments for patients with acute infection from preventive appointments, were perceived as positive and effective by some study participants. Telephone and online consultations were established at the beginning of the pandemic and considered helpful for some situations, whereas for others these methods were deemed insufficient (e.g. for examinations of sick children). All pediatricians reported reduced utilization mainly due to a decline in acute infections. However, preventive medical check-ups and immunization appointments were reported to be mostly attended., Conclusion: Positive experiences of reorganizing pediatric practice should be disseminated as "best practices" in order to improve future pediatric health services. Further research could show how some of these positive experiences in reorganizing care during the pandemic are to be maintained by pediatricians in the future., Competing Interests: 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., (© 2023 von Sommoggy, Grepmeier, Apfelbacher, Brandstetter and Curbach.)

Background: When parents want to make health-related decisions for their child, they need to be able to handle health information from a potentially endless range of sources. Early childhood allergy prevention (ECAP) is a good example: recommendations have shifted from allergen avoidance to early introduction of allergenic foods. We investigated how parents of children under 3 years old access, appraise and apply health information about ECAP, and their respective needs and preferences., Methods: We conducted 23 focus groups and 24 interviews with 114 parents of children with varied risk for allergies. The recruitment strategy and a topic guide were co-designed with the target group and professionals from public health, education, and medicine. Data were mostly collected via video calls, recorded and then transcribed verbatim. Content analysis according to Kuckartz was performed using MAXQDA and findings are presented as a descriptive overview., Results: Parents most frequently referred to family members, friends, and other parents as sources of ECAP information, as well as healthcare professionals (HCPs), particularly pediatricians. Parents said that they exchanged experiences and practices with their peers, while relying on HCPs for guidance on decision-making. When searching for information online, they infrequently recalled the sources used and were rarely aware of providers of "good" health information. While parents often reported trying to identify the authors of information to appraise its reliability, they said they did not undertake more comprehensive information quality checks. The choice and presentation of ECAP information was frequently criticized by all parent groups; in particular, parents of at-risk children or with a manifested allergy were often dissatisfied with HCP consultations, and hence did not straightforwardly apply advice. Though many trusted their HCPs, parents often reported taking preventive measures based on their own intuition., Conclusion: One suggestion to react upon the many criticisms expressed by parents regarding who and how provides ECAP information is to integrate central ECAP recommendations into regular child care counseling by HCPs-provided that feasible ways for doing so are identified. This would assist disease prevention, as parents without specific concerns are often unaware of the ECAP dimension of issues such as nutrition., Competing Interests: 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., (Copyright © 2023 Lander, Bitzer, von Sommoggy, Pawellek, Altawil, John, Apfelbacher and Dierks.)

Objectives: Focus groups used for data collection in health research are increasingly conducted online. In two multi-center health research projects, we applied available methodological instructions for synchronous online focus groups (SOFGs). We describe necessary changes and specifications regarding the planning (recruitment, technology, ethics, appointments) and conduct (group composition, moderation, interaction, didactics) to enhance knowledge about the planning and conduct of SOFGs., Results: Recruiting online proved to be challenging and necessitated direct and analogue recruiting, too. To ensure participation, less digital and more individual formats may be offered, e.g. telephone calls. Explaining verbally the specifics of data protection and anonymity in an online setting can foster participants' confidence to actively engage in the discussion. Two moderators, one moderating, one supporting technically, are advisable in SOFGs, however, due to limited nonverbal communication, roles and tasks need to be defined beforehand. Participant interaction is central to focus groups in general, but sometimes difficult to achieve online. Hence, smaller group size, sharing of personal information and moderators increased attention to individual reactions appeared helpful. Lastly, digital tools such as surveys and breakout rooms should be used with caution, as they easily inhibit interaction., (© 2023. The Author(s).)

Background: Ensuring motivated and successful study participation is a key challenge in the design and conduct of health research studies. Previously, recruitment barriers and facilitators have been identified mainly from experience, and rarely based on theoretical approaches. We developed a framework of intentional and actional components of engaged participation in public health research studies (INTACT-RS), informed by psychological behavioral models. We aimed a) to identify precise indicators for each framework component and b) to better understand which components and decision processes are essential for study participants., Methods: Within a multicenter research network, we applied various approaches to recruit parents of newborns, pediatricians, and midwives. All recruitment processes were documented from the perspective of both participants and researchers. We used different qualitative and quantitative data material, which we applied in a multistage process according to the basic principles of qualitative content analysis., Results: INTACT-RS encompasses pre-intentional, intentional and actional phases with a total of n = 15 components covering all aspects of an individual's involvement with a research study. During intention formation, an understanding of efforts and benefits, why participation is valuable beyond contributing to research, and how others perceive the study, were particularly important to (potential) participants. Subsequently (intentional phase), participants consider how and when participation is compatible with their own resources, ability and availability, and hence seek for close communication with, and flexibility and support from the research team. During and after (initial) participation (actional phase), participants' assessment of whether expectations and interests have been met impact crucial further steps, especially the willingness to continue and to recommend participation to others. A strong topic-wise and or supportive participation interest as well as active, continuous exchange with the researchers appeared to be central determinants of study completion and data validity., Conclusions: A theoretical framework is now available to plan and conduct recruitment of different target groups, which accounts for essential motivational and volitional decision-making processes. Based on empirically specified constructs, possible barriers can be addressed even before the initial recruitment process. Therefore, recommendations for scientific practice have been formulated., (© 2023. The Author(s).)

Education for planetary health could be one of the key levers of the much-needed civilizational turn toward a sustainable and healthy future. Education goes beyond information provision and passing on of knowledge and includes competencies to transfer knowledge from one decision situation to another. There are a range of different literacy concepts from various research perspectives that aim to improve such competencies. While many contain aspects highly relevant for planetary health, there is still no comprehensive and integrative planetary health approach. To fill this research gap, we present a conceptual model of planetary health literacy. By zooming into the model, further details on the necessary core competencies of accessing, understanding, appraising, and applying information in order to make judgements and take decisions regarding planetary health can be found. Zooming out of the model allows a holistic planetary health perspective and shows the potential and opportunities of planetary health literacy for the health of humans and ecosystems. Planetary health literacy encompasses both a life-course and a transgenerational approach, at the individual, societal, and global level. Future educational programs focusing on planetary health could integrate the conceptual model to increase planetary health literacy of individuals, including relevant health literacy agents, and of societies., Competing Interests: 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., (Copyright © 2023 Jochem, von Sommoggy, Hornidge, Schwienhorst-Stich and Apfelbacher.)

In Germany, midwives are involved in extensive antenatal and postnatal care. As health professionals, they can play a key role in strengthening health literacy (HL) of parents on how to prevent chronic allergic diseases in their children. The objective of this study is to explore midwives' perspectives regarding HL-sensitive counselling in early childhood allergy prevention (ECAP). Twenty-four qualitative semi-structured interviews were conducted with midwives, and data were analyzed using qualitative content analysis. Only a small number of study participants were aware of HL as a concept. However, most of these use screening and counselling strategies which consider individual information needs and which support parental HL. HL sensitivity in counselling is largely based on the midwives' "gut feelings" and counselling experience, rather than on formal education. The midwives were largely aware of evidence-based ECAP recommendations; however, allergy prevention was not seen as a stand-alone topic but as part of their general counselling on infant feeding and hygiene. They found parents to be more open to receiving complex prevention information during antenatal counselling. In order to strengthen midwives' roles in HL-sensitive ECAP counselling, their formal education should provide them with explicit HL knowledge and counselling skills. ECAP should be an inherent part of antenatal care.

Introduction: Paediatricians, general practitioners (GPs) and midwives in primary care are important sources of information for parents on early childhood allergy prevention (ECAP). Research has shown that preventive counselling by health professionals can be effective in improving patients' health literacy (HL) and health behaviour. Providing effective advice relies on two factors. First, health professionals need be up-to-date with research evidence on ECAP, to consider popular misconceptions and fears and to translate this knowledge into clear recommendations for parents (knowledge translation). Second, they need to know and apply counselling techniques and create a practice setting which accommodates parental HL needs (health literacy-responsive care). The objective of this study is to explore and assess how German health professionals take up and translate ECAP evidence into appropriate recommendations for parents, how they consider HL in counselling and practice organisation and what barriers and enablers they find in their performance of HL-responsive ECAP., Methods and Analysis: The study has a sequential mixed-method design, in two phases. In the first phase, qualitative semi-structured expert interviews will be conducted with health professionals (paediatricians, GPs and midwives) at primary care level and professional policy level. Data collection is ongoing until January 2022. In the second phase, based on the qualitative results, a standardised questionnaire will be developed, and pilot-tested in a wider population of German health professionals. The findings of both phases will be integrated., Ethics and Dissemination: The study has received ethical approval from the Ethics Committee of the University of Regensburg (18-1205-101). The results will be published in international peer-reviewed open access journals and via presentations at scientific conferences. The results will also be shared with German health professionals, decision-makers and potential funders of interventions., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Our aim was to gain insight into the experiences of women suffering from the urinary component of the Genitourinary Syndrome of Menopause (GSM) and to understand the impact of urinary complaints as part of GSM on the lives of affected women., Design: Qualitative study., Setting: Online, primary care., Participants and Methods: Postmenopausal women aged from 46 to 85 years reporting vaginal and urinary complaints were recruited to participate in either online or face-to-face focus groups to share their experiences with urinary complaints as part of GSM. Transcripts of sessions were analysed using qualitative content analysis., Results: One online focus group, one face-to-face focus group and one online-interview were conducted, involving 11 women. Five a priori assumed main themes related to the impact of urogenital symptoms were identified: daily life, emotional well-being, sexual functioning, self-concept and body image, and interpersonal relations and communication. Additionally, two further themes associated with GMS as a clinical condition were inductively found: unmet healthcare needs, including expectations of affected women regarding menopausal symptoms and a lack of adequate health education, and aspects on the personal dealing with the complaints, including personal coping strategies and medical treatment., Conclusions: This study showed that urinary complaints as part of GSM have, similar to vaginal complaints, negative impacts on the daily life, the emotional well-being, the sexual functioning, the self-concept and body impact as well as interpersonal relations and communication of affected women. We further identified several unmet healthcare needs that should trigger improvements in healthcare., (© 2021. The Author(s).)

Background: Syrian migrants represent the third-largest group of foreigners in Germany and are therefore potential users of health promotion initiatives, including nutrition programs. It is little known how (healthy) nutrition is understood and implemented by this group and which factors influence their experiences related to food and eating in the host country. Thus, this study aimed to explore the importance of (healthy) nutrition, facilitators, and barriers of a preferred diet; nutritional changes in relation to the country of origin; and how nutrition may change with increasing length of stay., Methods: Thirty semi-structured qualitative interviews with Syrian migrants (male = 16, female = 14, 18-35 years, length of stay 10-68 months) were conducted in 2018. Seventeen migrants could be followed-up after 12 months and were interviewed in 2019 again and were asked for changes in their nutritional behavior. Interviews were conducted in German, English, or Arabic, transcribed and translated into English if necessary. For analysis, an abbreviated version of the Grounded Theory was used., Results: We identified six overarching themes that described influencing factors on a favored diet in Germany over the course of stay: (1) managing everyday life; (2) intercultural contact with local residents; (3) social context of cooking and eating; (4) ambiguity toward Arabic food; (5) mistrust toward certain types of food; and (6) influence of postmigration stressors. In general, the importance of nutrition is high among Syrian migrants. However, daily stressors, the lack of practical knowledge of how to cook favored dishes, and food insecurity in the new food environment make it difficult to obtain a preferred diet. With increasing stay, many developed a higher awareness of healthy eating, mainly due to a new independence or influences from the social environment in Germany., Conclusion: Results highlight the need for health promotion interventions to be more responsive to the specific needs of Syrian migrants, including nutrition. Syrian migrants differ in their capabilities, needs, and aims, and they should be addressed differently by health professionals, social services or migrant specific services. Future research should continue to focus on the living conditions of Syrian migrants and its influence on nutrition.

Background: In early childhood allergy prevention (ECAP), parents act on behalf of their children. Parental health literacy and the availability of high-quality information, both online and offline, are crucial for effective ECAP. Recent research highlights three main points. First, parents need sufficient health literacy to discriminate between high-quality and low-quality information. Second, ECAP information behaviors may vary between phases of childhood development and according to individual circumstances. Third, to strengthen user-centeredness of available services, a better overview of parents' information practices and needs and how they handle uncertainties is required., Objective: This study aims to explore why, how, and when parents search for and apply ECAP-specific health information and which individual (eg, understanding of advice) and organizational challenges (eg, information services, information complexity, and changing recommendations) they perceive and how they handle them. This study also aims to assess the needs and preferences that parents express for future information formats and contents. The findings should inform the practical design of ECAP information as well as formats and channels specific to different parent groups., Methods: The above-named issues will be explored with parents in four German cities as one element in our efforts to cover the spectrum of perspectives. Based on a mixed methods design, including qualitative and quantitative assessments, the first year serves to prepare focus groups, a piloted focus group guide, a short standardized survey adapted from the European Health Literacy Project, recruitment channels, and the recruitment of participants. After conducting 20 focus groups in the second year, data will be analyzed via a constant comparison method in the third year. Based on this, practice implications on channels (ie, Where?), formats (ie, How?), and contents (ie, What?) of ECAP-specific information will be derived and discussed with parents and associated project partners before its dissemination to relevant ECAP actors (eg, childcare institutions and pediatricians)., Results: The study began with preselection of recruitment channels, drafting of recruitment and study information for potential participants, and agreement on a first full version of the guideline. Then, a detailed contact list was compiled of health professionals, administrative and social institutions, and relevant social media channels (N=386) to be approached for assistance in contacting parents. The recruitment was postponed due to COVID-19 and will start in January 2021., Conclusions: ECAP is a relevant example for assessing how users (ie, parents) handle not only health information but the various and continuous changes, uncertainties, and controversies attached to it. So far, it is unclear how parents implement the respective scientific recommendations and expert advice, which is why this study aims to inform those who communicate with parents about ECAP information., International Registered Report Identifier (irrid): PRR1-10.2196/25474., (©Jonas Lander, Janina Curbach, Julia von Sommoggy, Eva Maria Bitzer, Marie-Luise Dierks. Originally published in JMIR Research Protocols (http://www.researchprotocols.org), 20.01.2021.)

Background: Sedentary time is high among university students. Prolonged sitting time and reduced physical activity is linked to a number of health risks, therefore interventions to increase options for physical activity on campuses are of high public health relevance. Evidence about the influence of the campus environment on movement and sedentary behavior of students is scarce. This study explores how the structural and social environment of two University campuses are related to students' everyday physical activity. Methods: We used the photovoice method to get a thorough insight into students' daily life on campus. We recruited a total of 46 University students in two German cities (University 1: n = 22, University 2: n = 24). They were asked to take ≥15 photos of places and situations on their respective campus that facilitate or hinder them to be physically active. The pictures were discussed with the participants in 10 focus groups. Focus group discussions were audio-recorded, transcribed and analyzed using content analysis. Results: Both universities do not exploit their potential of fostering daily physical activity on campus, according to the photos and discussions of the participating students. The vast green spaces offer no cues for movement: easily accessible equipment for sports (fixed or mobile) is lacking, walkways are partially hidden, and the facilities discourage from cycling to and on campus. Social norms induce participants to keep sitting during lectures and learning time. It was also pointed out that indoor hallways and foyers could be put to better use with regard to physical activity. The Photovoice project raised the participants' awareness of how the context influences their movement behavior, and helped them come up with solutions to make physical activity easier for students of their respective universities. Conclusion: The studied campuses discouraged students from being physically active by missing out on opportunities-indoors and outdoors-for fostering movement, such as designating the greens for games or walks, or providing sufficient lockers for biking gear. The results can serve as a basis to plan custom-made public health interventions., (Copyright © 2020 von Sommoggy, Rueter, Curbach, Helten, Tittlbach and Loss.)

Background: Due to the civil war in Syria, many Syrian citizens have had to flee their country during recent years, among them many physicians. Germany is among the preferred immigration countries. Immigrant Syrian physicians could help overcome the prevailing shortage of medical specialists in Germany. This study explores the experiences and perceptions of Syrian physicians of the licensure process and job application. The study aims at understanding barriers in integrating Syrian doctors into the German health care system., Methods: We conducted 20 semi standardized interviews with Syrian doctors (n = 17 m; n = 3 f) living in different federal states in Germany. The interviews dealt with the procedure of the accreditation process, its speed and challenges, the interactions with authorities, and the job application process; they were transcribed verbatim. A detailed content analysis was performed., Results: All interviewees described the licensure process as a complex, lengthy, ever-changing and non-transparent procedure, which is perceived as a partly unfair, sometimes arbitrary bureaucracy. They often feel at mercy of Government employees and report experiences with reviewers who ask for absurd and impossible accomplishments, refuse to give information, and act at random. As a consequence, the interviewees describe themselves as depressed, irritated and/or in despair. According to the interviews, informational and practical support from official institutions was scarce. Instead, the Syrian doctors relied on peers or, in some cases, German friends to understand the requirements and seek information about the licensure process. To find a job placement, it was very helpful, if not essential, to have a German acquaintance establishing contact with possible employers. All three interviewed female doctors reported that their wearing a Hijab led to episodes of discrimination in their job search., Conclusions: The study points towards the necessity to establish an official information source which provides immigrant doctors with accurate and detailed information about the licensure process, e.g. required documents, estimated waiting times, regulation for courses and exams, criteria regarding credentials, sources of help, etc. Additionally, it seems advisable to consider providing help with regard to the job search and sensitize hospital management for cultural and religious diversity to avoid discrimination.