The study, led by Kristin Sofie Waldum-Grevbo and colleagues including Solveig Holen, Tore Wentzel-Larsen and Åse Sagatun, surveyed 1,425 thirteen-year-olds recruited from 48 lower secondary schools across 19 municipalities in Southeast and Central Norway. The sample deliberately spanned urban and rural communities ranging from villages of roughly 1,000 residents to cities of 700,000, and achieved a 71 percent response rate among invited students. Girls made up 50.3 percent of participants, and the vast majority reported Norwegian as their home language, lived with both parents, and perceived their family’s economic situation as ordinary. The data were drawn from the baseline of the GuideMe intervention study, collected in two waves during the 2022/23 and 2023/24 school years, making this one of the more robust population snapshots of early adolescence available in the Nordic region.

At the heart of the research is a concept known as health-related quality of life, or HRQoL — a measure that captures how health shapes physical, psychological and social functioning, and an explicit target of the United Nations’ Sustainable Development Goal 3. The researchers measured it using the Norwegian version of KIDSCREEN-27, a widely validated questionnaire covering five dimensions: physical well-being, psychological well-being, autonomy and parent relations, peer and social support, and school environment. Health literacy was assessed with the ten-item Health Literacy Among School-Aged Children instrument, which operationalizes the OECD-aligned definition — the knowledge, motivation and skills to access, understand, evaluate and apply health information — across five dimensions: theoretical knowledge, practical knowledge, critical thinking, self-awareness and citizenship. Self-efficacy was captured with the Norwegian five-item General Self-Efficacy Scale, rooted in Albert Bandura’s social-cognitive theory. All three instruments showed strong internal consistency, with Cronbach’s alpha values ranging from 0.81 to 0.90.

The descriptive results confirmed patterns that have haunted adolescent health research for years. Boys scored significantly higher than girls on health literacy, self-efficacy, and every single HRQoL subscale. Girls’ mean T-scores on KIDSCREEN ranged from 43.99 to 49.77, while boys’ ranged from 48.98 to 52.33, with the widest gaps in physical and psychological well-being. Compared with normative data spanning ages 8 to 18, the girls in this sample reported substantially lower physical and psychological well-being — a discrepancy the authors attribute in part to the narrow age range and in part to the timing of data collection shortly after the COVID-19 pandemic, whose documented toll on adolescent girls’ mental health may linger well beyond lockdowns.

But the study’s central question was not simply who scores higher. The researchers wanted to know whether self-efficacy mediates — statistically explains — the association between health literacy and quality of life. Using a causal mediation framework implemented in the R statistical environment, they modeled what would happen with a hypothetical 10 percentage-point increase in health literacy on a 0-to-100 scale, an increment grounded in reality: a recent European comparative study found health literacy levels vary by 13.5 percentage points across participating countries. The hypothetical bump produced significant increases across all five KIDSCREEN subscales for both sexes. The largest total effect appeared for school environment, with estimated T-score increases of 2.47 for girls and 1.86 for boys — roughly a quarter and a fifth of a standard deviation, respectively, which is notable for a modest, population-level shift in a single determinant.

The mediation results were striking. The proportion of the effect channeled through self-efficacy was significant for every subscale in both sexes, ranging from 30 percent for physical well-being among girls to 76 percent for peer and social support among boys — though the latter estimate came with a wide confidence interval and deserves caution. For psychological well-being, self-efficacy accounted for about 45 percent of the association in girls and 63 percent in boys. In other words, a substantial share of the benefit that comes with understanding health information appears to flow through the confidence to use it. The pattern fits neatly with Bandura’s theory: mastery experiences, social support and role models build self-efficacy, and self-efficacy determines whether knowledge and skills are actually translated into action and coping. An adolescent who believes she can successfully apply what she knows may be better equipped to engage in health-promoting behaviors and weather health-related challenges — and that, in turn, may be reflected in how well she feels and functions.

Why would the school environment subscale show the strongest total effect? The authors offer a plausible mechanism: health literacy overlaps conceptually with the competencies that drive learning. Students who can access, evaluate and apply information may engage more effectively with schoolwork and perceive their school environment more positively. Notably, the total effect estimates tended to be larger for girls than boys across all subscales, possibly because thirteen-year-old girls typically show higher emotional awareness and psychological distress and may be more receptive to health information. The confidence intervals for boys and girls overlapped, however, so the authors urge restraint in interpreting that pattern — it is a hypothesis generator, not a conclusion.

The team was careful about the limits of its design. Because the data are cross-sectional, the temporal assumptions underpinning causal mediation cannot be verified; the authors explicitly label the findings exploratory. Sensitivity analyses probed how much unmeasured confounding would be needed to overturn the results, and the direct effect estimates proved largely robust across subscales in both sexes, with one exception — peer and social support among boys — showing greater vulnerability. School-level clustering, measured by intra-class correlation coefficients between 0.003 and 0.03, was deemed negligible. All measures were self-reported, leaving room for social desirability bias, and item-level correlations between the health literacy and self-efficacy instruments (Spearman coefficients of 0.14 to 0.35) confirmed the two constructs, while related, are conceptually distinct.

The implications, if the associations hold causally, are considerable. Global health policy documents, European frameworks and Norway’s national strategy all emphasize strengthening population health literacy, and the education sector is the natural arena — it reaches nearly all children across socioeconomic backgrounds. Finland, whose children rank among Europe’s health literacy leaders, credits a standardized framework of health literacy learning objectives woven through the entire school program. Norway’s national guideline for school health services already mandates individual health-promoting consultations with all thirteen-year-olds, precisely to build health literacy, encourage positive behaviors and bolster self-efficacy, while identifying students who need follow-up. Evidence from German school nursing, where health literacy was measured before and after nurse-led health education, suggests schools and school health services jointly hold real potential to lift students’ literacy. Yet effectiveness studies of these strategies remain scarce.

What makes this study resonate beyond Norway is its population-level arithmetic. As Geoffrey Rose famously argued, even modest individual-level shifts in a health determinant can yield substantial benefits when applied across an entire population. If a ten-percentage-point improvement in adolescent health literacy is associated with measurable gains in physical, psychological and social well-being — with self-efficacy carrying a third to three-quarters of that association — then school-based literacy interventions become not just educational policy but mental and physical health infrastructure. The authors conclude that longitudinal studies are now needed to pin down the temporal ordering and causal nature of these relationships. Until then, the message for educators, school nurses and policymakers is tantalizingly concrete: teaching teenagers to understand health information may matter most when it also teaches them to believe they can act on it.

Subject of Research: The mediating role of self-efficacy in the association between adolescent health literacy and health-related quality of life.

Article Title: Adolescents’ health literacy and health-related quality of life: The mediating role of self-efficacy

Article References: Waldum-Grevbo, K. S., Holen, S., Wentzel-Larsen, T., & Sagatun, Å. (2026). Adolescents’ health literacy and health-related quality of life: The mediating role of self-efficacy. Public Health in Practice, 12, Article 100849. https://doi.org/10.1016/j.puhip.2026.100849

Image Credits: AI Generated

DOI: 10.1016/j.puhip.2026.100849

Keywords: adolescent health, health literacy, self-efficacy, health-related quality of life, KIDSCREEN, school health services, public health, Norway, mediation analysis, well-being, social-cognitive theory, health promotion

Adolescents today encounter a myriad of health challenges, ranging from mental health issues to substance abuse and nutritional deficiencies. The rise in health misinformation, exacerbated by social media and other digital platforms, underscores the need for effective health communication and educational outreach. Public health nurses are strategically positioned to bridge the gap between complex health information and the understanding of young individuals, yet their experiences in doing so have not been extensively documented until now.

In their study, Schuur and Mikkelsen utilized a qualitative approach, interviewing public health nurses who have been actively involved in initiatives aimed at improving health literacy among adolescents. This methodology allowed them to capture the nuanced perspectives of these professionals, providing rich narratives that reflect the realities of their work. Through extensive analysis of the interviews, the study identifies common themes that reveal both the challenges faced by nurses and the innovative strategies they have developed to overcome these obstacles.

One of the most striking findings from the research is the acknowledgment by public health nurses of the unique developmental stage of adolescence, characterized by increased autonomy and the often tumultuous journey toward adulthood. This period is critical for establishing lifelong health behaviors, and nurses understand that engaging adolescents requires a tailored approach that respects their independence while also providing them with essential knowledge. The nurses reported needing to build trust and rapport with adolescents, recognizing that conventional health education methods may not resonate with this demographic.

Another prominent theme emerging from the study is the importance of collaboration and partnership. Public health nurses frequently work alongside schools, community organizations, and families to create a network of support for adolescents. This collaborative approach not only enhances the reach of health initiatives but also fosters a shared responsibility for educating young people about health matters. The nurses emphasized the necessity of tailoring messages and materials to fit the specific cultural and social contexts of the communities they serve, which further enhances the effectiveness of their work.

The study also highlights the use of innovative technology as a tool for enhancing health literacy. Public health nurses have increasingly integrated digital platforms into their educational initiatives, using social media, apps, and interactive websites to engage adolescents in conversations about their health. This adaptation demonstrates an understanding of the preferred modes of communication for young people and positions health education in a contemporary context. Such strategies not only capture the interest of adolescents but also empower them to seek out credible health information independently.

Despite the promising strategies employed, the research reveals several challenges faced by public health nurses in their quest to boost health literacy among adolescents. Time constraints, inadequate training, and institutional barriers often hinder the effectiveness of their initiatives. Many nurses expressed feeling overwhelmed by the breadth of health issues they are expected to address, which can lead to burnout and decreased job satisfaction. The study underscores the importance of providing adequate support and resources to public health nurses to ensure their well-being and maximize their impact on adolescent health literacy.

Furthermore, the findings suggest a need for comprehensive training programs that equip public health nurses with the skills necessary to effectively engage adolescents. This includes not only communication techniques but also an understanding of adolescent developmental psychology and current trends in youth culture. Investing in the professional development of public health nurses will ultimately enhance their capacity to deliver impactful health education and foster a generation of informed young individuals.

The role of the family in supporting health literacy was another focal point in the study. Public health nurses recognized the influential position of parents and guardians in shaping adolescents’ attitudes toward health and wellbeing. By involving families in educational initiatives, nurses can create a more holistic approach to health literacy that extends beyond individual sessions with adolescents. The interplay between familial support and health education underscores the necessity of addressing health literacy as a communal effort rather than solely an individual responsibility.

As the landscape of health continues to evolve, the insights gained from this study are critical for informing future health initiatives targeting adolescents. The qualitative data presented by Schuur and Mikkelsen not only encapsulate the lived experiences of public health nurses but also serve as a foundational resource for enhancing educational practices. By understanding the successes and challenges outlined by nurses, policymakers and health organizations can better design interventions that address the needs of both healthcare providers and the adolescent population.

In conclusion, Schuur and Mikkelsen’s qualitative study on public health nurses’ experiences offers a significant contribution to the field of public health and adolescent health literacy. By capturing the diverse strategies, challenges, and collaborative efforts of these crucial healthcare professionals, the research provides a roadmap for enhancing health literacy initiatives geared toward adolescents in the future. As young individuals navigate an increasingly complex health landscape, the insights gleaned from this study will continue to resonate, shaping the ways in which public health professionals communicate and engage with the next generation.

The findings from this research have implications extending well beyond public health nursing. They will inform the development of curricula for aspiring nurses, serve as a reference for policymakers advocating for adolescent health, and encourage community stakeholders to invest in health literacy programs. As the need for adolescent health literacy continues to rise, the experiences and insights documented in this study will be invaluable in fostering a healthier, more informed generation.

In essence, the qualitative research performed by Schuur and Mikkelsen truly encapsulates the mission of public health: to promote health, prevent disease, and ensure that all populations—especially vulnerable ones, such as adolescents—have access to the knowledge they need to lead healthy lives. Through the work of public health nurses, we are reminded of the profound impact that targeted health education can have on individual lives and the collective wellbeing of society as a whole.

Subject of Research: Public health nurses’ experiences with work aimed at increasing adolescents’ health literacy.

Article Title: Public health nurses’ experiences with work aimed at increasing adolescents’ health literacy: a qualitative study.

Article References:

Schuur, E., Mikkelsen, H. Public health nurses’ experiences with work aimed at increasing adolescents’ health literacy: a qualitative study.
BMC Nurs 24, 1333 (2025). https://doi.org/10.1186/s12912-025-03976-z

Image Credits: AI Generated

DOI: 10.1186/s12912-025-03976-z

Keywords: Public health nurses, health literacy, adolescents, qualitative study, health education, collaboration.