Abstract
<title>Abstract</title> <p> Background Health Literacy (HL) is a key determinant of health throughout life and plays an important role in shaping health-related behaviors in childhood. Previous studies have demonstrated associations between both parental HL and children’s health and school-related HL and children’s health. However, empirical evidence on the combined contribution of parental and school-related HL on health outcomes in primary school-aged children remains limited. Methods Secondary cross-sectional data from the fit4future prevention initiative in Germany were used. The sample included 104 participating primary schools and 1,365 parents of children, attending these schools. Key variables examined in this study were parental HL, school-related HL, family health climate (FHC), health promoting school (HPS) practice, children’s health behaviors (physical activity, media use, and dietary behavior), and children’s health-related quality of life (HRQOL). Multilevel path analyses were conducted to account for the clustered data structure (children nested within schools). Results At the within-level, the analyses showed small positive associations between parental HL and FHC (β = 0.15; <italic>p</italic> < 0.001). FHC showed a moderate negative association with children’s media use (β = -0.26; <italic>p</italic> < 0.001) and a small positive association with physical activity (β = 0.07; <italic>p</italic> = 0.03). Further, a small positive association between children’s physical activity and children’s HRQOL was observed (β = 0.07; <italic>p</italic> = 0.02). At the between-level, school-related HL was positively linked to HPS practice (β = 0.67; <italic>p</italic> < 0.001) implementation and to children’s HRQOL (β = 0.38; <italic>p</italic> = 0.002). However, no significant association was observed between HPS practice and children’s health behaviors or outcomes. Conclusion The findings highlight the relevance of parental and school-related HL for fostering healthier family and school environments and promoting positive health outcomes in children. The results underscore the importance of integrating HL into school curricula, teacher training and school health policies. Future longitudinal and intervention studies are needed to better understand causal pathways and guide the development of effective school- and family-based HL promotion strategies. </p>