Psychometric evaluation of the Persian version of the European Health Literacy Instrument (P-HLS-EU-Q47).

Health literacy is one of the most critical determinants of health for effectively improving health services and reducing health inequalities. The importance of accurate measurement cannot be overstated. The European 47-item Health Literacy Questionnaire (HLS-EU-Q47) can provide precise measurements of health literacy. Therefore, this study aimed to evaluate the psychometric properties of the European Health Literacy Instrument in Iranian society (HLS-PV-Q47) for its Persian version. This cross-sectional study was conducted using a convenient sampling of 560 people referred to comprehensive healthcare centers. The construct validity was assessed by exploratory (280 people) and confirmatory factor (with 280 people). The internal consistency was calculated using Cronbach's alpha coefficients. Based on the exploratory factor analysis, three factors of healthcare, disease prevention, and health promotion explained 48.9% of the total variance of health literacy. Cronbach's alpha was 0.96 for the whole instrument. The Persian version of the European Health Literacy Instrument (P-HLS-EU-Q47) had good validity and reliability, which can be used in future studies due to its good psychometric properties.

Measuring Comprehensive, General Health Literacy in the General Adult Population: The Development and Validation of the HLS19-Q12 Instrument in Seventeen Countries.

BACKGROUND: For improving health literacy (HL) by national and international public health policy, measuring population HL by a comprehensive instrument is needed. A short instrument, the HLS19-Q12 based on the HLS-EU-Q47, was developed, translated, applied, and validated in 17 countries in the WHO European Region. METHODS: For factorial validity/dimensionality, Cronbach alphas, confirmatory factor analysis (CFA), Rasch model (RM), and Partial Credit Model (PCM) were used. For discriminant validity, correlation analysis, and for concurrent predictive validity, linear regression analysis were carried out. RESULTS: The Cronbach alpha coefficients are above 0.7. The fit indices for the single-factor CFAs indicate a good model fit. Some items show differential item functioning in certain country data sets. The regression analyses demonstrate an association of the HLS19-Q12 score with social determinants and selected consequences of HL. The HLS19-Q12 score correlates sufficiently highly (r ≥ 0.897) with the equivalent score for the HLS19-Q47 long form. CONCLUSIONS: The HLS19-Q12, based on a comprehensive understanding of HL, shows acceptable psychometric and validity characteristics for different languages, country contexts, and methods of data collection, and is suitable for measuring HL in general, national, adult populations. There are also indications for further improvement of the instrument.

HLS19-NAV-Validation of a New Instrument Measuring Navigational Health Literacy in Eight European Countries.

To manoeuvre a complex and fragmented health care system, people need sufficient navigational health literacy (NAV-HL). The objective of this study was to validate the HLS19-NAV measurement scale applied in the European Health Literacy Population Survey 2019-2021 (HLS19). From December 2019 to January 2021, data on NAV-HL was collected in eight European countries. The HLS19-NAV was translated into seven languages and successfully applied in and validated for eight countries, where language and survey method differed. The psychometric properties of the scale were assessed using confirmatory factor analysis (CFA) and Rasch modelling. The tested CFA models sufficiently well described the observed correlation structures. In most countries, the NAV-HL data displayed acceptable fit to the unidimensional Rasch partial credit model (PCM). For some countries, some items showed poor data-model fit when tested against the PCM, and some items displayed differential item functioning for selected person factors. The HLS19-NAV demonstrated high internal consistency. To ensure content validity, the HLS19-NAV was developed based on a conceptual framework. As an estimate of discriminant validity, the Pearson correlations between the NAV-HL and general health literacy (GEN-HL) scales were computed. Concurrent predictive validity was estimated by testing whether the HLS19-NAV, like general HL measures, follows a social gradient and whether it forms a predictor of general health status as a health-related outcome of general HL. In some countries, adjustments at the item level may be beneficial.

The HLS19-COM-P, a New Instrument for Measuring Communicative Health Literacy in Interaction with Physicians: Development and Validation in Nine European Countries.

BACKGROUND: Sufficient communicative health literacy (COM-HL) is important for patients actively participating in dialogue with physicians, expressing their needs and desires for treatment, and asking clarifying questions. There is a lack of instruments combining communication and HL proficiency. Hence, the aim was to establish an instrument with sufficient psychometric properties for measuring COM-HL. METHODS: The HLS19-COM-P instrument was developed based on a conceptual framework integrating HL with central communicative tasks. Data were collected using different data collection modes in nine countries from December 2019 to January 2021 (n = 18,674). Psychometric properties were assessed using Rasch analysis and confirmatory factor analysis. Cronbach's alpha and Person separation index were considered for reliability. RESULTS: The 11-item version (HLS19-COM-P-Q11) and its short version of six items (HLS19-COM-P-Q6) fit sufficiently the unidimensional partial credit Rasch model, obtained acceptable goodness-of-fit indices and high reliability. Two items tend to under-discriminate. Few items displayed differential item functioning (DIF) across person factors, and there was no consistent pattern in DIF across countries. All items had ordered response categories. CONCLUSIONS: The HLS19-COM-P instrument was well accepted in nine countries, in different data collection modes, and could be used to measure COM-HL.

Organizational Health Literacy in Schools: Concept Development for Health-Literate Schools.

(1) Background: Health literacy is considered a personal asset, important for meeting health-related challenges of the 21st century. Measures for assisting students' health literacy development and improving health outcomes can be implemented in the school setting. First, this is achieved by providing students with learning opportunities to foster their personal health literacy, thus supporting behavior change. Second, it is achieved by measures at the organizational level promoting social change within the proximal and distal environment and supporting the school in becoming more health-literate. The latter approach is rooted in the concept of organizational health literacy, which comprises a settings-based approach aiming at changing organizational conditions to enhance health literacy of relevant stakeholders. The HeLit-Schools project aims to develop the concept of health-literate schools, describing aspects that need to be addressed for a school to become a health-literate organization. (2) Method: The concept development builds on existing concepts of organizational health literacy and its adaptation to the school setting. (3) Results: The adaptation results in the HeLit-Schools concept describing a health-literate school with eight standards. Each standard depicts an area within the school organization that can be developed for fostering health literacy of school-related persons. (4) Conclusions: The HeLit-Schools concept offers an approach to organizational development for sustainably strengthening health literacy.

Adaptation of the Health Literacy Survey Questionnaire (HLS19-Q) for Russian-Speaking Populations-International Collaboration across Germany, Israel, Kazakhstan, Russia, and the USA.

The Russian language is the eighth most spoken language in the world. Russian speakers reside in Russia, across the former Soviet Union republics, and comprise one of the largest populations of international migrants. However, little is known about their health literacy (HL) and there is limited research on HL instruments in the Russian language. The purpose of this study was to adapt the Health Literacy Questionnaire (HLS19-Q) developed within the Health Literacy Survey 2019-2021 (HLS19) to the Russian language to study HL in Russian-speaking populations in Germany, Israel, Kazakhstan, Russia, and the USA. The HLS19-Q was translated either from English or from a national language to Russian in four countries first and then critically reviewed by three Russian-speaking experts for consensus. The HLS19 protocol and "team approach" method were used for linguistic and cultural adaptation. The most challenging was the adaptation of HLS19-Q questions to each country's healthcare system while general HL questions were flexible and adaptable to specific contexts across all countries. This study provides recommendations for the linguistic and cultural adaptation of HLS19-Q into different languages and can serve as an example of international collaboration towards this end.

The effect of self-efficacy on health literacy in the German population.

Concerning the determinants of health literacy (HL) mostly socio-demographic or -economic factors have been considered, much less so psychological factors such as self-efficacy. To date, it has mostly been considered to explain the relationship of HL and health outcomes. However, self-efficacy could also be an important determinant for HL. This study therefore examines the effect of self-efficacy on comprehensive HL within the general population in Germany. Data from the German HL Survey (HLS-GER), a cross-sectional, computer-assisted personal interview study among 2000 respondents aged 15+ years in 2014 were used. Self-efficacy was measured using the German version of general self-efficacy short scale (ASKU), comprehensive HL was measured using the German version of the European Health Literacy Survey Questionnaire (HLS-EU-Q47). Correlation and multi-variate linear regression analyses were performed to analyze independent effects of socio-demographic factors-age, gender, social status, educational level and migration background-functional HL and self-efficacy on comprehensive HL. Self-efficacy and comprehensive HL are statistically significantly correlated (Spearman's Rho = 0.405; p < 0.01), respondents with better self-efficacy had better HL scores. Both concepts are significantly associated with most socio-demographic factors and functional HL. Self-efficacy showed the strongest association with HL in the multivariate analyses (model 2: ß =0.310, p < 0.001). The effect size of the other predictors decreased, when adding self-efficacy into the equation, but remained statistically significant. Self-efficacy is a rather strong predictor of comprehensive HL. Future research and measures to improve HL should therefore take self-efficacy adequately into account.

To Adapt or Not to Adapt: The Association between Implementation Fidelity and the Effectiveness of Diabetes Self-Management Education.

Self-management education (SME) is a key determinant of diabetes treatment outcomes. While SME programs are often adapted for implementation, the impact of adaptations on diabetes SME effectiveness is not well documented. This study evaluated the impact of the implementation fidelity of diabetes SME programs on program effectiveness, exploring which factors influence implementation fidelity. Data from 33 type 2 diabetes SME program providers and 166 patients were collected in 8 countries (Austria, Belgium, Germany, Ireland, UK, Israel, Taiwan and USA). Program providers completed a questionnaire assessing their adherence to the program protocol and factors that influenced the implementation. Patients answered a pre-post questionnaire assessing their diabetes-related health literacy, self-care behavior, general health and well-being. Associations between implementation fidelity and outcomes were estimated through logistic regressions and repeated measures MANOVA, controlling for potential confounders. Adaptations of the program protocol regarding content, duration, frequency and/or coverage were reported by 39% of the providers and were associated with better, not worse, outcomes than strict adherence. None of the factors related to the participants, facilitating strategies, provider or context systematically influenced the implementation fidelity. Future research should focus on individual and contextual factors that may influence decisions to adapt SME programs for diabetes.

Challenges in Navigating the Health Care System: Development of an Instrument Measuring Navigation Health Literacy.

Due to their rapid expansion and complexity, it is increasingly difficult for patients to orient themselves in health care systems. Therefore, patients require a high degree of health literacy, or more precisely, navigation health literacy (HL-NAV). The actual extent of HL-NAV of patients and citizens is still largely unknown due to the lack of adequate measurement instruments. Thus, within the new international Health Literacy Population Survey 2019 (HLS19), one aim was to develop a suitable instrument for measuring HL-NAV in the HLS19 the HL-NAV-HLS19. The item development was conducted by an international working group within the HLS19 Consortium led by the first and last authors. Methodologically, it is based on a scoping literature review, development of a conceptual framework for HL-NAV, and first item formation, as well as an evaluation by experts, stakeholders, focus groups, pre-test interviews, and continuously feedback from the HLS19 Consortium. HL-NAV was defined as the ability to access, understand, appraise, and apply information on navigational issues, drawing on ten selected publications and the health literacy definition of the HLS-EU Consortium. Main tasks of HL-NAV at the system, organization, and interaction level were identified, to which first related items were assigned. Based on the feedback from experts, the focus group discussions, and the HLS19 Consortium, the instrument was slightly revised. Finally, twelve items proved to be feasible in the pre-test. The instrument will be used for the first time in the HLS19 survey and will provide first data on HL-NAV in general populations for the countries participating in HLS19. It is suited for cross-country comparisons and monitoring, as well as for intervention development. However, the instrument should be translated into and validated in further languages and countries for population samples.

[DNVF Memorandum Health Literacy (Part 1) - Background, Relevance, Research Topics and Questions in Health Services Research]. / DNVF Memorandum Gesundheitskompetenz (Teil 1) ­ Hintergrund, Relevanz, Gegenstand und Fragestellungen in der Versorgungsforschung.

More than half of the German population has difficulties in dealing with health information. It is an important task of health services research to examine how healthcare professionals and health care organizations can meet this challenge. The DNVF Memorandum Health Literacy (Part 1) defines the terms of individual and organizational health literacy, presents the national and international state of research and ethical aspects of health literacy research in health care settings. The relevance of health literacy research is worked out in different phases of life, for different target groups and in different healthcare contexts. Central research topics and future research desiderata are derived.

[DNVF Memorandum Health Literacy (Part 1) - Background, Relevance, Research Topics and Questions in Health Services Research: Short Version]. / DNVF Memorandum Gesundheitskompetenz (Teil 1) ­ Hintergrund, Relevanz, Gegenstand und Fragestellungen in der Versorgungsforschung: Kurzfassung.

More than half of the German population has difficulties in dealing with health information. It is an important task of health services research to examine how healthcare professionals and health care organizations can meet this challenge. This short version of the DNVF Memorandum Health Literacy (Part 1) defines the terms of individual and organizational health literacy, presents the national and international state of research and ethical aspects of health literacy research in health care settings. Central research topics and future research desiderata are derived.

Health Literacy Measurement in General and Other Populations: Further Initiatives and Lessons Learned in Europe (and Beyond).

This chapter provides an overview of health literacy measurement initiatives with a focus on the European Health Literacy Survey (HLS-EU) - describing where measuring population health literacy started, where it currently is, and providing an outlook to the upcoming European HL survey. In the first part of the chapter, the methodology and the main results of the initial HLS-EU study from 2011 will be introduced. In the second part the worldwide impact of the HLS-EU study will be mapped. Many publications and studies used the HLS-EU instruments in the original or few in an adapted way to measure comprehensive health literacy - in many different settings and in diverse countries. Finally, the chapter ends with an outlook to the M-POHL and HLS19 initiatives of WHO-Europe which are intended to advance HLS-EU as well as the measurement of population and organizational health literacy in a more coordinated, standardized, and institutionalized manner.

Health Literacy in Austria: Interventions and Research.

This report provides an overview of Austria's approaches to improve population health literacy (HL). The report suggests: a) research can trigger health policy responses to improve HL; b) linking HL improvement to other reform agendas can boost effectiveness, and c) coordination is required for continuously and systematically working towards better HL. Examples of strategic thematic approaches and interventions - especially in the fields of communication in healthcare, health information products, and organizational HL responsiveness - are provided, and Austria's role in preparing the next European HL survey, HLS19, is briefly described.

Associations of health literacy with socioeconomic position, health risk behavior, and health status: a large national population-based survey among Danish adults.

BACKGROUND: Health literacy concerns the ability of citizens to meet the complex demands of health in modern society. Data on the distribution of health literacy in general populations and how health literacy impacts health behavior and general health remains scarce. The present study aims to investigate the prevalence of health literacy levels and associations of health literacy with socioeconomic position, health risk behavior, and health status at a population level. METHODS: A nationwide cross-sectional survey linked to administrative registry data was applied to a randomly selected sample of 15,728 Danish individuals aged ≥25 years. By the short form HLS-EU-Q16 health literacy was measured for the domains of healthcare, disease prevention, and health promotion. Adjusted multinomial logistic regression analyses were used to estimate associations of health literacy with demographic and socioeconomic characteristics, health risk behavior (physical activity, smoking, alcohol consumption, body weight), and health status (sickness benefits, self-assessed health). RESULTS: Overall, 9007 (57.3%) individuals responded to the survey. Nearly 4 in 10 respondents faced difficulties in accessing, understanding, appraising, and applying health information. Notably, 8.18% presented with inadequate health literacy and 30.94% with problematic health literacy. Adjusted for potential confounders, regression analyses showed that males, younger individuals, immigrants, individuals with basic education or income below the national average, and individuals receiving social benefits had substantially higher odds of inadequate health literacy. Among health behavior factors (smoking, high alcohol consumption, and inactivity), only physical behavior [sedentary: OR: 2.31 (95% CI: 1.81; 2.95)] was associated with inadequate health literacy in the adjusted models. The long-term health risk indicator body-weight showed that individuals with obesity [OR: 1.78 (95% CI: 1.39; 2.28)] had significantly higher odds of lower health literacy scores. Poor self-assessed health [OR: 4.03 (95% CI: 3.26; 5.00)] and payments of sickness absence compensation benefits [OR: 1.74 (95% CI: 1.35; 2.23)] were associated with lower health literacy scores. CONCLUSIONS: Despite a relatively highly educated population, the prevalence of inadequate health literacy is high. Inadequate health literacy is strongly associated with a low socioeconomic position, poor health status, inactivity, and overweight, but to a lesser extent with health behavior factors such as smoking and high alcohol consumption.

Development and Validation of a Self-Assessment Tool for an Integrative Model of Health Promotion in Hospitals: Taiwan's Experience.

The Health Promotion Administration of Taiwan launched an integrative certification initiative in 2016 to streamline a plural system of certifications of health promotion in hospitals. It endeavored to replace original certifications, thereby establishing the proposal of a self-assessment instrument to aid in this integration. This study aimed to verify the robustness of this self-assessment tool by conducting exploratory factor analyses through stratification, reliability tests, content and construct validity tests, and specialist evaluations, which were convened to judge the comprehensibility, applicability, and importance of the standards and measures of this tool. A stratified random sampling of 46 hospitals was performed to confirm the validity of this tool. The tool rendered a floor effect of 0% and a ceiling effect of 13%. A valid factor structure and internal consistency (α ranged from 0.88 to 0.96) in each standard were verified. Hospitals with previous certificates or with 300+ beds achieved high compliance scores. A majority of experts agreed that the sub-standards were comprehensible (≥80%), applicable (≥70%), and important (≥70%). Finally, we conclude that the self-assessment tool is valid and can serve as a reference for other countries with hospitals committed to health promotion in hospital settings.

Health literacy as a determinant, mediator and/or moderator of health: empirical models using the European Health Literacy Survey dataset.

BACKGROUND/RESEARCH QUESTION:: In the health literacy (HL) discourse there is debate about the ways by which HL is impacting health. Three different, logically non-exclusive hypotheses are proposed: (a) HL as a specific, direct, social determinant of health; (b) HL as a mediator between other determinants and health; and (c) HL as a moderator of the effect of other determinants on health. Only few examples of empirically testing the mediator or moderator hypothesis exist. The data of the European Health Literacy Survey allow testing of the three hypotheses comparatively in parallel for functional and comprehensive HL. METHODS:: Data collection was based on multistage random samples of about 1000 European Union citizens aged 15 or older with Computer Assisted Personal Interviewing or Paper Assisted Personal Interviewing methodology in 2011 in eight Member States of the EU. Demographic and socio-economic indicators, a comprehensive (European Health Literacy Survey Q47) and a functional (Newest Vital Sign Test) health literacy measure and one self-assessed health variable were surveyed. Correlation analysis, multiple regression analysis and path analysis were performed. RESULTS:: Comprehensive HL (and to a much lesser degree functional HL) is a relevant predictor for self-assessed health. Also, comprehensive HL is only to a limited degree mediating the effects of other determinants on self-assessed health and only for age does HL partly moderate the effect on health. Explained variance and strength of effects vary considerably by national context. CONCLUSIONS/IMPLICATIONS:: Comprehensive HL is a critical, direct determinant of health. Therefore comprehensive HL has a considerable potential for health promotion to improve population health and tackle the health gap. But comprehensive HL measurement should be standardised in every country to allow for designing adequate measures for the specific situation of the country and also for benchmarking. For better understanding of the causal structure of the impact of HL on health, longitudinal studies will be needed.

Strengthening patient and family engagement in healthcare - The New Haven Recommendations.

OBJECTIVE: Present and discuss the development and basic structure of a multilevel approach to strengthen patient and family engaged care, "The New Haven Recommendations on partnering with patients, families and citizens to enhance performance and quality in health promoting hospitals and health services". METHODS: A generic literature review was conducted followed by a Delphi procedure to prepare the New Haven Recommendations. From systems theory perspective, three conceptual levels are used to map action areas to enhance patient and family engaged care. RESULTS: The recommendations propose a multilevel approach to enable patient, family, (and citizen representatives') involvement (a) within direct service provision; (b) among hospitals and health services; (c) in planning healthcare delivery systems and policy. CONCLUSION: The New Haven Recommendations provide a strategic tool and practical recommendations, which can be used for reflection on current practices or generating new ways of thinking about patient and family engaged care. They support the development of patient and family engaged care as core aspect of high quality healthcare, and can contribute to achieving the Ottawa Charter's claim of reorienting health services. PRACTICE IMPLICATIONS: The potential benefit of the multilevel approach is to reorient the basic culture of healthcare towards patient- and health-centered care.

Generic health literacy measurement instruments for children and adolescents: a systematic review of the literature.

BACKGROUND: Health literacy is an important health promotion concern and recently children and adolescents have been the focus of increased academic attention. To assess the health literacy of this population, researchers have been focussing on developing instruments to measure their health literacy. Compared to the wider availability of instruments for adults, only a few tools are known for younger age groups. The objective of this study is to systematically review the field of generic child and adolescent health literacy measurement instruments that are currently available. METHOD: A systematic literature search was undertaken in five databases (PubMed, CINAHL, PsycNET, ERIC, and FIS) on articles published between January 1990 and July 2015, addressing children and adolescents ≤18 years old. Eligible articles were analysed, data was extracted, and synthesised according to review objectives. RESULTS: Fifteen generic health literacy measurement instruments for children and adolescents were identified. All, except two, are self-administered instruments. Seven are objective measures (performance-based tests), seven are subjective measures (self-reporting), and one uses a mixed-method measurement. Most instruments applied a broad and multidimensional understanding of health literacy. The instruments were developed in eight different countries, with most tools originating in the United States (n = 6). Among the instruments, 31 different components related to health literacy were identified. Accordingly, the studies exhibit a variety of implicit or explicit conceptual and operational definitions, and most instruments have been used in schools and other educational contexts. While the youngest age group studied was 7-year-old children within a parent-child study, there is only one instrument specifically designed for primary school children and none for early years. CONCLUSIONS: Despite the reported paucity of health literacy research involving children and adolescents, an unexpected number of health literacy measurement studies in children's populations was found. Most instruments tend to measure their own specific understanding of health literacy and not all provide sufficient conceptual information. To advance health literacy instruments, a much more standardised approach is necessary including improved reporting on the development and validation processes. Further research is required to improve health literacy instruments for children and adolescents and to provide knowledge to inform effective interventions.

Health-related behaviors moderate the association between age and self-reported health literacy among Taiwanese women.

The role of health-related behaviors in the association between age and health literacy has not been well-elucidated. The present cross-sectional study evaluated the interactions between age and health-related behaviors in 942 women in Taiwan between February and October 2013. Women aged 18-78 years were randomly sampled and recruited from the national administrative system. Self-reported health literacy was measured by the European Health Literacy Survey Questionnaire (HLS-EU-Q47) in Mandarin, asking about sociodemographics and essential health-related behaviors (watching health-related television, community involvement). The interviews were conducted confidentially by well-trained interviewers after having participants' consent. In multiple linear regression models adjusted for education attainment, self-perceived social status, ability to pay for medication, and health-related behaviors, health literacy was significantly negatively related to age (unstandardized regression coefficient, B = -0.04; 95% confidence interval [CI] = (-0.07; 0.00); p = .03). The lower health literacy among older women was significantly modified by watching health-related television programs (from "rarely/not-at-all", B = -0.08 (-0.12, -0.04), p < .001 to "often"; B = 0.10 (0.07, 0.12); p < .001) and community involvement (from "rarely/not-at-all", B = -0.06 (-0.10, -0.03); p = .001 to "often", B = 0.06 (0.03, 0.08); p < .001). Specific health behaviors were protective of older women's health literacy and likely their health.

Health Literacy and Health Service Use in Germany.

BACKGROUND: Health literacy (HL) is defined as the ability to process health-related information to make decisions to maintain health and improve quality of life. A growing number of studies demonstrate that people with lower HL are less likely to use preventive services but more likely to use curative, emergency, or hospital care. OBJECTIVE: This study investigated the relationship between HL and the use of different types of health services in a sample of the general German population, as we expected that the effect of HL on the frequency of use differs by type of health service. METHODS: A nationally representative sample of 2,000 people in Germany was interviewed in person in 2014. Analyses of the data included frequencies of contacts with doctors, other health professionals, hospitals, and emergency services. Analysis also included a HL measure (European Health Literacy Survey Questionnaire), as well as sociodemographic and health status indicators. To test whether and how HL is related to the frequency of use of the different types of curative health services, regression analyses were performed. KEY RESULTS: Respondents with lower HL scores reported more frequent use of all four included types of curative health services. Although multiple regression analysis showed a direct significant effect of HL only on doctor (ß = -.066) and other health professionals visits (ß = -.103), no significant direct effect of HL on hospital and emergency services use was found when sociodemographic and health-related factors were controlled for. CONCLUSIONS: Health professionals should be aware that their patients are likely to have difficulties in understanding and processing health-related information. Interventions to strengthen HL should aim at improving health care literacy and, moreover, not only address individuals but also consider demands related to the health care system and health professionals' communication skills. PLAIN LANGUAGE SUMMARY: This study investigates the relationship between health literacy and health service use in Germany. The results show that health services are used more often by individuals with low health literacy. Thus, health professionals need to take low health literacy into account in their communication with patients. [HLRP: Health Literacy Research and Practice. 2018;2(2):e115-e122.].