Health Literacy in Germany: Findings of a Representative Follow-up Survey
Findings of a representative follow-up survey
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Background: Studies have shown that the health literacy of the German population is low. The aim of this article is to analyze current developments in health literacy on the basis of recent data.
Methods: The Health Literacy Survey Germany 2 (HLS-GER 2) is a representative quantitative survey of the German-speaking resident population of Germany aged 18 and above. It was carried out in December 2019 and January 2020 by paper-assisted personal oral interview (PAPI). Data on health literacy and sociodemographic characteristics were acquired with an internationally coordinated questionnaire. The instrument for measuring general health literacy consisted of 47 questions that reflect an individual’s ability to access, understand, appraise, and apply health-related information. The associations between general health literacy and sociodemographic factors were analyzed using bivariate and multivariate statistical tests.
Results: 58.8% of the participants had low health literacy, characterized by rating at least one-third of the questions as “difficult” or “very difficult.” Many respondents stated that they had difficulties accessing (48.3%), understanding (47.7%), and applying (53.5%) information, and even more of them (74.7%) reported difficulties appraising information. The correlation coefficients reveal that health literacy is weakly associated with the following variables: age, sex, social status, literacy, level of education, financial deprivation, migration background, and the presence of one or more chronic diseases.
Conclusion: The findings of the HLS-GER 2 highlight the need for action in promoting health literacy in the healthcare system. As the explanation of variance is low, there are presumably other important determinants of health literacy that were not taken into account. Further studies should be performed to investigate societal conditions of supplying health information, for example, or social and personal characteristics.
Which competencies do people need to have today in order to cope with health problems and diseases—or, even better, to prevent these conditions and to deal with the information required to do this? For about ten years, this question has been discussed under the keyword “general health literacy“. This refers to the ability of people to access, understand, appraise, and apply various types of health information in order to make judgments and take decisions in everyday life concerning coping with disease/health care, disease prevention and health promotion (1, 2).
Previous studies have shown that the health literacy of the German population is low (3, 4, 5, 6). Follow-up surveys are needed to reveal the underlying factors responsible for this finding and to evaluate health literacy over time. Thus, six years after the first survey—the Health Literacy Survey Germany 1 (HLS-GER 1 )—, another health literacy survey—the Health Literacy Survey Germany 2 (HLS-GER 2)—was carried out, using advanced methods (8). So far, follow-up health literacy surveys have only been conducted in few countries. By repeating such surveys, trends in the changes can be identified which is increasingly important given the developments in the healthcare system and, above all, the dynamics in the field of information (9, 10). Since the first surveys on health literacy, digitalization has not only led to a surge in the number of information resources, but also to a vast expansion of the amount of health-related information available. At the same time, the amount of interest-driven, manipulated and false information has surged, as demonstrated by the current topic of COVID-19 (11). Along with this development, the so-called “infodemic” (12, 13), the requirements for dealing with health-related information and for the communication between doctors and patients have significantly increased.
The aim of this article is to analyze how health literacy has developed in the population in Germany, with a special focus on the challenges associated with the processing of information.
The questions are:
- What is the current status of health literacy?
- What are the challenges associated with information processing?
- What demographic and socioeconomic factors influence health literacy and the various steps of information processing?
This study is based on a representative quantitative survey of 2151 persons of the German-speaking resident population of Germany aged 18 and above (Table 1).
The survey was carried out in December 2019 and January 2020, using the paper-assisted personal oral interview (PAPI) method. The study’s design and methods build on the HLS-GER 1. The study is part of the Health Literacy Survey 2019 (HLS19) of the Action Network on Measuring Population and Organizational Health Literacy (M-POHL) of the World Health Organization Europe, which is currently being conducted in 17 countries (14).
Health literacy measurement is based on the European Health Literacy Survey Questionnaire with 47 questions (HLS-EU-Q47), which was revised and refined for the new survey (8). With this instrument (HLS19-Q47-DE), a person’s self-assessed difficulties accessing, understanding, appraising, and applying health-related information was measured, using various information tasks.
In their responses to each of the 47 questions, the respondents could choose between the options “very easy“, “easy“, “difficult“ and “very difficult”. From their answers, score values were calculated. For the descriptive reporting of health literacy, the scores were categorized in four levels:
- Excellent (>83.3–100)
- Sufficient (>66.6–83.3)
- Problematic (>50–66.6)
- Inadequate (0–50).
Combined, the levels “problematic“ and “inadequate“ were referred to as “low health literacy“. In addition, several sociodemographic data were obtained. The International Standard Classification of Education 2011 (ISCED-11) was used to determine the level of education. Social status was assessed based on the perceived position in society, using the image of a ladder with ten rungs. Financial deprivation was determined based on three questions, addressing perceived difficulties in paying for medications, medical treatments, and monthly bills. Migration background was defined as own or parental birth outside Germany. Chronic disease was identified by asking whether one or more chronic diseases (health problems persisting for more than six months) were present. Literacy skills were determined using an objective test, the Newest Vital Sign (NVS) (15).
Detailed information is provided in the eMethods section.
Overall, 58.8% of the respondents (Table 2) had low health literacy (8). Significant differences were found between the various steps of information processing. For example, about half of the respondents had a low health literacy in terms of assessing (48.3%), understanding (47.7%) and applying information (53.5%). When it comes to appraising information, a particularly large proportion of the respondents (74.7%) have low health literacy (Table 2).
Determinants of health literacy
Health literacy is correlated with social status (r = 0.172–0.243, p<0.001), level of education (r = 0.123–0.243, p<0.001), financial deprivation (r = –0.156 to –0.213, p<0.001), and literacy (r = 0.115–0.238, p<0.001) (Table 3). Health literacy increases with higher social status and level of education as well as a higher level of literacy; it decreases with increasing financial deprivation.
Old age (76 years and older) is also associated with lower health literacy (general health literacy compared to 30–45-year-olds: r = 0.239, p<0.001; eTable 1).
Looking at the correlation between health literacy and chronic disease, it can be seen that especially the presence of multiple chronic diseases is associated with low health literacy (general health literacy: r = –0.1, p<0.001) (Table 3, eTable 2).
The broad multivariate analysis (eTable 3) confirmed these effects. Social status, literacy and financial deprivation are related to health literacy, both overall and in each of the four steps after adjustment for other variables in the model; however, the strength of the effects is sometimes weak and shows wide variation. The higher the social status (β = 0.08–0.129, p<0.005), the higher the health literacy (β = 0.081–0.162, p<0.001) and the lower the financial deprivation (β = −0.088 to −0.109, p<0.001), the better the health literacy. Likewise, the level of education is related to health literacy in each of the steps, except for the application of information, (β = 0.078–0.134, p<0.001): Health literacy increases with increasing level of education. Age is related to health literacy in that it affects how well respondents access (p = 0.042) and appraise information (p = 0.009). Older persons report more difficulties with these steps (eTable3). In the presence of multiple chronic diseases, age is only negatively related to health literacy in the information application step (B = −6.309, p<0.001). The same applies to migration background (B = −2.962, p = 0.039).
The HLS-GER 2 carried out another representative survey of health literacy of the population in Germany, as often called for (10, 14). The results show that, with 58.8%, health literacy had declined compared to previous surveys (eTable 4). Comparability with earlier studies is limited because some of them used different methodologies and different questionnaire versions. Yet, it is evident that over the course of the last few years, the proportion of the population with a low level of health literacy has tended to increase. Thus, promotion of health literacy continues to be an important task of society and here the medical community has an important role to play.
It also became apparent that appraising information is particularly challenging. While this dimension already stood out in previous national (3, 5, 6, 7) and international (4, 16, 17) studies as the most difficult step in dealing with information, the gap to the other steps (accessing, understanding and applying) has significantly increased in the meantime. Current COVID-19-related studies have also shown that appraising information is the most challenging step (11).
This development is likely to be largely attributable to the expansion of health-related information and especially misinformation and interest-driven information which has increased to such an extent and at such a pace that internationally the term “information obesity” (18) has been adopted. Furthermore, information is often limited to mere factual information and it is left to the recipients to appraise it and apply it to their personal circumstances. Both can be overwhelming and unsettling; in addition, it impedes the application of information, which causes difficulties more often than in the past. In promoting health literacy, these increased demands on information processing should be given more intense attention in the future. The aim should be to ensure that information can be adequately received and used so that the variety of information does not abruptly turn into information aversion or produces other undesirable effects. This can, for example, be done by improving the quality of written information, but also by ensuring that physicians spend more time on communication and information dissemination and explain health-related content in detail and in an actionable form. Appropriate framework conditions should be created for this purpose.
Our analysis has once again underlined the importance of social determinants in processing health-related information: Low social status, low educational attainment, financial deprivation, and low literacy correlate with low health literacy. It should be noted, however, that the methods used in this study do not allow for conclusions about causality (17, 19, 20). Especially deprived population groups cannot or only with difficulty cope with the increased requirements for accessing, understanding, appraising, and applying information (3, 8, 21). Consequently, this, and the elimination of social inequality in general, continue to require considerable attention—and this is true for promoting health literacy as well. Furthermore, this also applies to everyday clinical practice, especially since doctors are still the most important source of information (22, 23) and they are often consulted when it cannot be determined how high the quality and reliability of information disseminated by the media is, especially of digital information. Here, trustworthy, easy-to-understand information with as few as possible technical terms, the use of conversational techniques, such as Teach-Back (Box), and sufficient time for communication and explanation are crucial.
In addition, our study provides new, more detailed insights into the relevance of the various determinants of health literacy. For instance, previously chronic disease was generally considered to be an indicator of low health literacy (4, 7, 24). The new data now show that it is primarily the presence of multiple chronic diseases which is associated with low health literacy. Especially with the growing complexity of disease processes as the result of multimorbidity, the challenges of dealing with health-related information are also growing. This is true specifically for the application of information. It also has an impact on daily clinical practice, as it highlights the importance of discussing in detail with patients which measures should be taken as the result of (factual) information. This is of particular importance for patients with multiple chronic diseases, especially since they are often confronted with diverse and sometimes conflicting information which does not adequately take the interactions between their conditions or symptoms into consideration, making it difficult to assess how relevant the information is for practical application.
Similarly, this study provides new insights into the association between age and health literacy. In previous studies, old age was usually summarized as a general age of 65 years or older, an approach which does not do justice to the differentiation of the old-age stage of life (25, 26). Our new data allow an age-differentiated approach and confirm the assumption that low health literacy poses a challenge primarily to those aged 76 and older. In this age group, the risk of chronic diseases and multimorbidity also increases, making health literacy a top priority. This, and the difficulties in accessing and appraising information, which are particularly noticeable in this stage of life, should be considered more intensely when health literacy is being promoted. This can be accomplished, for instance, through target group-specific promotional activities and guidance on where to find and how to identify reliable information, e.g. by reference to www.gesundheitsinformation.de.
But even younger people are facing considerable difficulties when it comes to dealing with health-related information. This may be attributable to the fact that, due to their age, they have only been confronted with comparatively few health problems and related information so far. Thus, these results underscore the relevance of tailoring information and information strategies to the target age group.
The finding of this study that migration background is not generally associated with low health literacy—data from earlier studies pointed to such an association—also warrants discussion (27, 28). For this subgroup too, a more differentiated approach is required, as new data show that health literacy is particularly influenced by personal migration experiences and limited German language skills (29).
Summarizing, it becomes clear how important differentiated, in-depth analyses of health literacy and the various steps of information processing as well as associated factors are. This aspect has not been addressed adequately in previous studies. Our analysis helps to fill this gap in the research, thus making a valuable contribution not only in terms of new knowledge, but also in terms of promoting health literacy in everyday clinical practice.
For a few years now, there have internationally been calls for follow-up measurements of health literacy to enable insights into trends; however, such surveys have rarely been carried out so far—here, the HLS-GER 2 Germany is an exception. The same applies to the (further) development of measuring instruments; HLS19 has also addressed this aspect (8). However, health literacy was primarily measured based on the self-assessed difficulty in dealing with health-related information. Although this approach has now been widely adopted in Europe and Asia, explanatory power is restricted. Therefore, the self-assessment tool was complemented by the NVS test to also measure functional literacy (15). By using the two instruments in combination, it was possible to achieve a comprehensive view of health literacy in the population in Germany.
Other limiting factors include that the survey was conducted in German and that the number of respondents with migration background was not particularly high (n = 397, 13.8%) and analyzed combined in two categories (migration background: yes or no). This may explain why almost no differences in relation to migration background were found. Thus, there is a need for separate, migration-specific studies (31).
Overall, the included variables explain approximately 6% to 13% of the variance. With regard to appraising and applying health-related information, the considered variables contributed the least to explaining health literacy variance; the coefficient of determination R² was the lowest for these two steps. Thus, only small effects were identified. This suggests that important determinants of health literacy, such as social conditions that shape the information available, or social and additional personal characteristics (e.g. social support), have not yet been analyzed in this paper. The results of further data analyses planned as part of this study therefore remain to be seen.
The findings of this study highlight the need for action in promoting health literacy which exists both on a socio-political level and in the healthcare system. In fact, health literacy has long been a key skill that is considered essential to cope with disease, regain and maintain health, but also to deal with the infodemic, as it is highlighted in the National Action Plan Health Literacy in Germany (Nationaler Aktionsplan Gesundheitskompetenz) (33) and several documents of the World Health Organization (12, 13). While this is a task for society as a whole, in which actors from all areas of society should be involved, the healthcare professions, and especially the medical profession, play a particularly important role. Doctors remain the population’s main point of contact for questions regarding health (information) (22, 23). This makes it all the more important that they intensify their commitment to this task and, in doing so, help to improve health literacy in Germany. Because if the healthcare professions and institutions do not get more involved in this, then: “[...] the market will respond as an advisor“ (34) and there is an increased risk of incorrect and misinformation being spread.
Conflict of interest statement
The authors declare that no conflict of interest exists.
Manuscript received on 17 May 2021; revised version accepted on 2 August 2021
Translated from the original German by Ralf Thoene, MD.
Prof. Dr. phil. Doris Schaeffer
Interdisziplinäres Zentrum für Gesundheitskompetenzforschung
Cite this as:
Schaeffer D, Berens EM, Vogt D, Gille S, Griese L, Klinger J, Hurrelmann K: Health literacy in Germany—findings of a representative follow-up survey. Dtsch Arztebl Int 2021; 118: 723–9. DOI: 10.3238/arztebl.m2021.0310
Institute of Sociology and Social Psychology (ISS), University of Cologne, Cologne, Germany:: Julia Klinger, MSc.
Hertie School – University of Governance, Berlin, Germany: Prof. Dr. rer. pol. Klaus Hurrelmann
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