Realist evaluation of a participatory, school-based health literacy intervention among young Danes

Abstract Background Health literacy is a key determinant of health but is rarely addressed in youth-targeted interventions. Socioeconomically disadvantaged youths face structural and individual barriers that limit their engagement in health-promoting activities. This study examines how a participatory, school-based intervention can foster health literacy development among vulnerable youths and under what conditions functional, interactive, and critical health literacy may be supported. Methods A realist evaluation was conducted in two Danish educational settings: a Vocational Education and Training school and a Preparatory Basic Education. The intervention was co-created with teachers through workshops and integrated into students’ daily schedules. Data included baseline questionnaires (n = 145), focus groups, individual interviews, and field notes. Analyses focused on context-mechanism-outcome configurations and individual, interpersonal, institutional, and infrastructural context layers. Results Structural flexibility, relational trust, and teacher autonomy facilitated the development of tailored intervention activities. Competing tasks and misalignment with the curriculum hindered implementation. Students’ participation was challenged by economic hardship, low self-efficacy, and negative prior experiences. Engagement improved in environments characterized by emotional safety and where activities aligned with vocational identities. Functional and interactive health literacy were achievable. Critical health literacy development emerged when students were supported to reflect on and act upon health information in meaningful contexts. Conclusions Interventions integrating students’ needs and wishes show potential for strengthening health literacy and reducing inequalities. Early involvement of teachers and school leaders in the development of school-based interventions facilitates implementation. Key messages • Participatory, equity-focused interventions can strengthen youth health literacy beyond functional skills. • Critical health literacy requires environments that prioritize critical reflection in meaningful contexts.