Quality of life and mental health in children and adolescents during the first year of the COVID-19 pandemic: results of a two-wave nationwide population-based study.

BACKGROUND: The COVID-19 pandemic has disrupted the lives of children and adolescents worldwide. The German COPSY study is among the first population-based longitudinal studies to examine the mental health impact of the pandemic. The objective of the study was to assess changes in health-related quality of life (HRQoL) and mental health in children and adolescents and to identify the associated risk and resource factors during the pandemic. METHODS: A nationwide longitudinal survey was conducted with two waves during the pandemic (May/June 2020 and December 2020/January 2021). In total, n = 1923 children and adolescents aged 7 to 17 years and their parents participated (retention rate from wave 1 to wave 2: 85%). The self-report and parent-proxy surveys assessed HRQoL (KIDSCREEN-10), mental health problems (SDQ with the subscales emotional problems, conduct problems, hyperactivity, and peer problems), anxiety (SCARED), depressive symptoms (CES-DC, PHQ-2) and psychosomatic complaints (HBSC-SCL). Mixed model panel regression analyses were conducted to examine longitudinal changes in mental health and to identify risk and resource factors. RESULTS: The HRQoL of children and adolescents decreased during the pandemic, and emotional problems, peer-related mental health problems, anxiety, depressive and psychosomatic symptoms increased over time, however the change in global mental health problems from wave 1 to wave 2 was not significant, and some changes were negligible. Socially disadvantaged children and children of mentally burdened parents were at particular risk of impaired mental health, while female gender and older age were associated with fewer mental health problems. A positive family climate and social support supported the mental health of children and adolescents during the pandemic. DISCUSSION: Health promotion, prevention and intervention strategies could support children and adolescents in coping with the pandemic and protect and maintain their mental health.

[Comparison of Health Literacy of the Population in Germany between 2014 and 2020]. / Gesundheitskompetenz der Bevölkerung in Deutschland im Zeitvergleich der Jahre 2014 und 2020.

AIM: This article compares the results of two health literacy (HL) surveys of the population in Germany over time. The first survey was conducted in 2014, the second in 2020. The changes in GK, measured by the degree of subjectively assessed difficulties in individual information tasks in the three areas of health care, prevention, health promotion, in the total population and in subgroups are examined. METHODOLOGY: The analyses were based on population-representative cross-sectional data collected in 2014 and 2020. An internationally coordinated questionnaire (HLS-EU-Q47) was used to measure GK. Changes in the population groups were analysed uni- and bivariately as well as multivariately in a trend analysis. RESULTS: The HL of the German population has worsened statistically significantly within six years. This can be observed in all three overall domains. This effect was particularly evident among people with low social status and financial deprivation. CONCLUSION: Over time, dealing with health and disease-related information has become more difficult. As this development is mainly driven by socioeconomically disadvantaged population groups, it has apparently increased social inequality in the health sector. Promoting HL - as this and other studies show - is more important for the society than ever and should be given special attention in relation to the above-mentioned population groups.

[Digital Health Literacy of the Population in Germany: Results of the HLS-GER 2]. / Digitale Gesundheitskompetenz der Bevölkerung in Deutschland: Ergebnisse des HLS-GER 2.

AIM: While the availability and variety of digital information on health offers a range of opportunities, they also pose a number of challenges, because the need for digital health literacy (DHL) is increasing along with the growing range of information possibilities. The aim of this study was to analyze the extent of DHL in the German population, key determinants, and consequences for the use of digital health information resources. METHODOLOGY: The analysis was based on data from the Second Health Literacy Survey Germany (HLS-GER 2), consisting of a representative sample of n=2,151. A questionnaire developed as part of the international comparative study HLS19 was used to measure DHL, its determinants, and the use of digital health information resources. Bivariate and multivariate analyses were conducted. RESULTS: Overall, 75.8% of the population had low DHL. In particular, low literacy skills, older age, a lower level of education and social status were associated with low DHL. Multivariate analysis also indicated a strong association between DHL and general health literacy (HL). Low DHL led to lower use of digital health information resources. CONCLUSION: The results underscore the importance of promoting DHL in the general population and especially among groups with low DHL. Efforts in this area should include general HL, as it is closely related to DHL. Strengthening DHL is also a socially important task in order to increase the still low use of digital health information resources in Germany and, in general, to meet the increasing digitalization of the health care system.

[Health Literacy in Germany before and during the COVID-19 Pandemic]. / Gesundheitskompetenz in Deutschland vor und während der Corona-Pandemie.

AIM: The aim of this study was to compare the general and digital health literacy (HL) of the German population before the outbreak of the COVID-19 pandemic and during its persistence and to investigate different changes in population groups. METHODOLOGY: The analyses are based on population representative cross-sectional data collected in 2019/2020 before and 2020 during the pandemic. An internationally coordinated questionnaire (HLS19) was used. Changes in groups were analyzed bivariate. RESULTS: The results showed that the HL of the population in Germany tended to improve during the pandemic. This effect was especially evident with regard to the evaluation of health information and in the area of digital HL. Women, people with low or medium education, younger people and those with a migration background appeared to have benefited to a more than average extent. For older people, there was no change, and for those with multiple chronic conditions, the results even indicated a worsening. CONCLUSION: The systematic exposure to clearly structured and continuously repeated health information during the COVID-19 pandemic seems to have improved the ability to process health-related information in the German population. In particular, there has been an increase in competence in dealing with digital information media, which are being increasingly used to communicate health information. However, there are some large differences between different population groups.

[Mental health and psychological burden of children and adolescents during the first wave of the COVID-19 pandemic-results of the COPSY study]. / Seelische Gesundheit und psychische Belastungen von Kindern und Jugendlichen in der ersten Welle der COVID-19-Pandemie ­ Ergebnisse der COPSY-Studie.

BACKGROUND: The drastic changes during the COVID-19 pandemic may have a negative impact on the psychological wellbeing of children and adolescents. OBJECTIVES: COPSY is the first national, representative German study to examine mental health and quality of life of children and adolescents during the pandemic. Results are compared with data of the representative longitudinal BELLA study conducted before the pandemic. MATERIALS AND METHODS: Internationally established instruments for measuring health-related quality of life and mental health (including anxiety and depressive symptoms) were administered to n = 1586 parents with 7­ to 17-year-old children and adolescents, of whom n = 1040 11- to 17-year-olds also provided self-reports, from 26 May to 10 June 2020. Data were analyzed using descriptive statistics and bivariate tests. RESULTS: Seventy-one percent of the children and adolescents and 75% of the parents felt burdened by the first wave of the COVID-19 pandemic. Compared to the time before the pandemic, the children and adolescents reported a lower health-related quality of life, the percentage of children and adolescents with mental health problems almost doubled, and their health behavior worsened. Socially disadvantaged children felt particularly burdened by the COVID-19 pandemic. Two-thirds of the parents would like to receive support in coping with their child during the pandemic. CONCLUSIONS: The COVID-19 pandemic poses a mental health risk to children and adolescents. Schools, doctors, and society are called to react by providing low-threshold and target-group-specific prevention and mental health promotion programs.

[National Action Plan Health Literacy: Need, Objective and Content]. / Der Nationale Aktionsplan Gesundheitskompetenz ­ Notwendigkeit, Ziel und Inhalt.

In recent years, studies on health literacy of the population have been conducted in many countries. Most of them show that health literacy levels are worse than expected and that large parts of the population have low health literacy levels. National strategies and action plans to promote health literacy have been developed in many countries to address these results. Following these examples, a National Action Plan on Health Literacy was also developed for Germany. A panel of 15 experts was involved in the 2-year development process. Based on an analysis of available literature on health literacy and existing action plans, the concept, objectives and priorities of the action plan were defined, and recommendations were developed. The National Action Plan on Health Literacy formulates recommendations in the fields of living environments, the healthcare system, chronic illness, and research.

Is being a "small fish in a big pond" bad for students´ psychosomatic health? A multilevel study on the role of class-level school performance.

BACKGROUND: Features of schools and classes are closely related to students´ health and wellbeing. However, class composition (e.g. in terms of school performance) has rarely been examined in relation to students´ health and wellbeing. This study focuses on the so called Big-Fish-Little-Pond-Effect (BFLPE), by investigating whether the level of high-performing students in classroom is negatively associated with psychosomatic complaints of students who perceive themselves as poor performers. METHODS: Data were derived from the German sample of the WHO-Collaborative "Health Behaviour in School-aged Children (HBSC)" study 2013/2014. The sample included 5226 11-, 13- and 15-year-old students. Individual perceived school performance (PSP) was included (very good/good vs. average/below average PSP) at the individual student-level. At the class-level, school performance in class was generated by aggregating the share (in percentage) of students who report a very good/good PSP to the class-level, indicating the percentage of students with good/very good PSP in classroom. Using multilevel regression models, the association between class-level school performance (in percentage of students with very good/good PSP) and individual psychosomatic complaints were analyzed, stratified by students´ individual PSP. RESULTS: Students who report average/below average PSP showed higher likelihoods of psychosomatic complaints (Odds Ratio: 1.75; 95% Confidence Interval: 1.52-2.03) compared to counterparts with very good/good PSP. The aggregated class-level PSP was not significantly associated with psychosomatic complaints. However, in line with the BFLPE, results further revealed that students with average/below average PSP, who attend classes with a higher percentage of students who report very good/good PSP, had higher likelihoods of psychosomatic complaints (Odds Ratio: 1.91; 95% Confidence Interval: 1.01-4.01) compared to classmates with very good/good PSP. CONCLUSIONS: This study revealed that class composition in terms of PSP was differentially associated with students´ psychosomatic complaints, depending on their individual PSP. Findings highlight the vulnerability of students with poor PSP placed in classes with a higher percentage of students with good PSP. Results of this study therefore indicate a need for initiatives for low performing students from teachers and school staff in class.

Perceived school climate, academic well-being and school-aged children's self-rated health: a mediator analysis.

Background: Schools are crucial settings for young people's development. Rare studies have examined the impact of perceived school-climate and academic well-being on young people's self-rated health in joint analyses. This study focuses on the role of perceived school-climate and academic well-being for young people's self-rated health and examines whether school climate is mediated by indicators of academic well-being. Methods: Data were obtained from the German National Educational Panel Study, including seventh grade students (n = 6838) aged 11-12, nested in 710 classes within 277 schools. Indicators of school climate (teacher control, demands, autonomy, interaction, goal setting and orientation, teaching quality) and academic well-being (satisfaction with school, helplessness in major school subjects) were reported from students. Multilevel modelling was used to analyze the relative importance of perceived school-climate and academic well-being on school-aged children's self-rated health. Results: Results showed that academic well-being is strongly related to self-rated health. The better students perceive their academic well-being, the lower the likelihood of poor self-rated health. In contrast, indicators of perceived school climate are only indirectly related to self-rated health, mediated by academic well-being or are not at all associated with self-rated health. Conclusions: This study suggests that school climate is important for academic well-being but not as important for students' self-rated health as academic well-being. Health promotion initiatives in schools have to ensure that school climate serves to enhance students' academic well-being to avoid health problems in the long-run.

Health literacy in old age: results of a German cross-sectional study.

Health literacy is especially important for older people to maintain or enhance remaining health resources and self-management skills. The aim of the study was to determine the level of health literacy and the association between health literacy, demographic and socio-economic factors in German older adults aged 65 years and above stratified by age group. Health literacy was assessed via computer-assisted personal interviews using HLS-EU-Q47 on a representative sample of the German-speaking population. Descriptive statistics, bivariate analyses and logistic regression modelling stratified by age group were conducted to assess health literacy of 475 respondents aged 65 years and above. Overall, 66.3% of all respondents aged 65 years and above had limited health literacy. Limited health literacy was especially prevalent among respondents above 76 years of age (80.6%). Limited health literacy was associated with financial deprivation (OR: 3.05; 95% CI: 1.99-4.67) and limited functional health literacy (OR: 2.16; 95% CI: 1.29-3.61). Financial deprivation was strongest predictor for limited health literacy in the total sample and stratified by age group. Limited health literacy is a frequent phenomenon in German adults aged 65 years and above. Research on health literacy in old age and the role in health disparities is urgently needed.

[Class Climate, Academic Well-Being and Self-Rated Health Among School Children in Germany: Findings of the National Educational Panel Study (NEPS)]. / Klassenklima, schulisches Wohlbefinden und Gesundheit von Schülerinnen und Schülern in Deutschland: Ergebnisse des Nationalen Bildungspanels (NEPS).

OBJECTIVES: The aim of this study was to examine the associations between features of class climate and school wellbeing, based on self-rated health and reports of absence from school due to illness among adolescents in secondary schools, by using data from the German National Educational Panel Study (NEPS). METHODS: Data was obtained from the National Educational Panel Study (NEPS). The sample includes (n=7,348) seventh grade students in regular schools (Starting Cohort 3, Wave 3, 2012). Measures of class climate comprise indicators about demands, control and orientation, autonomy and interaction among students as well as teaching quality in German language class. School wellbeing was measured by satisfaction with school and helplessness in main school subjects. Bivariate and logistic multilevel logistic regression techniques are applied, by controlling for student age, gender and school type attended. RESULTS: Multilevel results showed that particularly among students with higher school satisfaction, there was a higher likelihood of self-rated health and less school absence due to illness. In contrast, perceived helplessness in major subjects and learning orientation were negatively associated with both outcomes. Further, students attending low track schools had a higher risk of school absence than students in high track schools. CONCLUSION: The results highlight the fact that particularly students' school wellbeing in terms of school satisfaction and perceived helplessness in the subjects German and mathematics are associated with self-rated poorer health and school absence due to illness. Therefore, health promotion initiatives should particularly focus on students' school wellbeing as well as on students attending low track schools.

The Great Recession, Adolescent Smoking, and Smoking Inequalities: What Role Does Youth Unemployment Play in 24 European Countries?

INTRODUCTION: Conflicting evidence has been reported on smoking behavior among adults during times of economic downturn. No study has yet investigated young people's smoking and inequalities in smoking during economic recessions. This study examines the association between country-level youth unemployment due to the economic recession and adolescent smoking and smoking inequalities in Europe. METHODS: The WHO collaborative "Health Behaviour in School-aged Children" study in 2009/2010 included 15-year-old adolescents from 24 European countries (N = 43 093). Socioeconomic position (SEP) was measured by the Family Affluence Scale. Logistic multilevel models were conducted. The absolute rate of youth unemployment in 2010 (during the recession) and the relative change rate in youth unemployment (2005/2006-2009/2010) were regressed on smoking and SEP inequalities in smoking in 2010, respectively. RESULTS: Youth unemployment rates were not significantly associated with overall smoking in adolescents. A higher absolute youth unemployment rate in 2010 related to lower likelihoods of smoking among middle (OR: 0.99; 95% CI: 0.98-0.99) and low affluent adolescents (OR: 0.99; 95% CI: 0.98-0.99) compared to high affluent adolescents. In contrast, an increase in youth unemployment (2005/2006-2009/2010) was not associated with overall likelihoods of smoking and inequalities in smoking. CONCLUSIONS: Our findings indicate that an increase in youth unemployment was not related to smoking and smoking inequalities. However, higher absolute levels of youth unemployment are related to lower likelihoods of smoking in lower SEP adolescents. Thus, smoking among vulnerable groups is more linked to the overall insecure circumstances and the affordability of cigarettes rather than to the economic recession itself. IMPLICATIONS: Economic recessions have often led to increases in adult and youth unemployment rates. Conflicting evidence has been reported on smoking behavior among adults during times of economic downturn. This study examines for the first time the impact of the economic recession on young people's smoking and socioeconomic inequalities in smoking. Findings highlight that rather than an increase in youth unemployment, the overall country-level youth unemployment rate is related to young people's tobacco use and particularly to lower odds in smoking among less affluent adolescents across Europe, a finding which is likely to be linked to the affordability of tobacco use.

Health literacy among different age groups in Germany: results of a cross-sectional survey.

BACKGROUND: Health literacy is of increasing importance in public health research. It is a necessary pre-condition for the involvement in decisions about health and health care and related to health outcomes. Knowledge about limited health literacy in different age groups is crucial to better target public health interventions for subgroups of the population. However, little is known about health literacy in Germany. The study therefore assesses the prevalence of limited health literacy and associated factors among different age groups. METHODS: The Health Literacy Survey Germany is a cross-sectional study with 2,000 participants aged 15 years or older in private households. Perceived health literacy was assessed via computer-assisted personal interviews using the HLS-EU-Q-47 questionnaire. Descriptive analyses, chi-square tests and odds ratios were performed stratified for different age groups. RESULTS: The population affected by limited perceived health literacy increases by age. Of the respondents aged 15-29 years, 47.3 % had limited perceived health literacy and 47.2 % of those aged 30-45 years, whereas 55.2 % of the respondents aged 46-64 years and 66.4 % aged 65 years and older showed limited perceived health literacy. In all age groups, limited perceived health literacy was associated with limited functional health literacy, low social status, and a high frequency of doctor visits. CONCLUSIONS: The results suggest a need to further investigate perceived health literacy in all phases of the life-course. Particular attention should be devoted to persons with lower social status, limited functional health literacy and/or a high number of doctor visits in all age groups.

Adolescents' psychological health during the economic recession: does public spending buffer health inequalities among young people?

BACKGROUND: Many OECD countries have replied to economic recessions with an adaption in public spending on social benefits for families and young people in need. So far, no study has examined the impact of public social spending during the recent economic recession on health, and social inequalities in health among young people. This study investigates whether an increase in public spending relates to a lower prevalence in health complaints and buffers health inequalities among adolescents. METHODS: Data were obtained from the 2009/2010 "Health Behaviour in School-aged Children (HBSC)" study comprising 11 - 15-year-old adolescents from 27 European countries (N = 144,754). Socioeconomic position was measured by the Family Affluence Scale (FAS). Logistic multilevel models were conducted for the association between the absolute rate of public spending on family benefits per capita in 2010 and the relative change rate in family benefits (2006-2010) in relation to adolescent psychological health complaints in 2009/2010. RESULTS: The absolute rate of public spending on family benefits in 2010 did not show a significant association with adolescents' psychological health complaints. Relative change rates of public spending on family benefits (2006-2010) were related to better health. Greater socioeconomic inequalities in psychological health complaints were found for countries with higher change rates in public spending on family benefits (2006-2010). CONCLUSIONS: The results partially support our hypothesis and highlight that policy initiatives in terms of an increase in family benefits might partially benefit adolescent health, but tend to widen social inequalities in adolescent health during the recent recession.

Is educational differentiation associated with smoking and smoking inequalities in adolescence? A multilevel analysis across 27 European and North American countries.

This study aims to determine whether educational differentiation (i.e. early and long tracking to different school types) relate to socioeconomic inequalities in adolescent smoking. Data were collected from the WHO-Collaborative 'Health Behaviour in School-aged Children (HBSC)' study 2005/2006, which included 48,025 15-year-old students (Nboys = 23,008, Ngirls = 25,017) from 27 European and North American countries. Socioeconomic position was measured using the HBSC family affluence scale. Educational differentiation was determined by the number of different school types, age of selection, and length of differentiated curriculum at the country-level. We used multilevel logistic regression to assess the association of daily smoking and early smoking initiation predicted by family affluence, educational differentiation, and their interactions. Socioeconomic inequalities in both smoking outcomes were larger in countries that are characterised by a lower degree of educational differentiation (e.g. Canada, Scandinavia and the United Kingdom) than in countries with higher levels of educational differentiation (e.g. Austria, Belgium, Hungary and The Netherlands). This study found that high educational differentiation does not relate to greater relative inequalities in smoking. Features of educational systems are important to consider as they are related to overall prevalence in smoking and smoking inequalities in adolescence.

Three years into the pandemic: results of the longitudinal German COPSY study on youth mental health and health-related quality of life.

Purpose: For the past three years, the German longitudinal COPSY (COVID-19 and PSYchological Health) study has monitored changes in health-related quality of life (HRQoL) and the mental health of children and adolescents during the COVID-19 pandemic. Methods: A nationwide, population-based survey was conducted in May-June 2020 (W1), December 2020-January 2021 (W2), September-October 2021 (W3), February 2022 (W4), and September-October 2022 (W5). In total, n = 2,471 children and adolescents aged 7-17 years (n = 1,673 aged 11-17 years with self-reports) were assessed using internationally established and validated measures of HRQoL (KIDSCREEN-10), mental health problems (SDQ), anxiety (SCARED), depressive symptoms (CES-DC, PHQ-2), psychosomatic complaints (HBSC-SCL), and fear about the future (DFS-K). Findings were compared to prepandemic population-based data. Results: While the prevalence of low HRQoL increased from 15% prepandemic to 48% at W2, it improved to 27% at W5. Similarly, overall mental health problems rose from 18% prepandemic to W1 through W2 (30-31%), and since then slowly declined (W3: 27%, W4: 29%, W5: 23%). Anxiety doubled from 15% prepandemic to 30% in W2 and declined to 25% (W5) since then. Depressive symptoms increased from 15%/10% (CES-DC/PHQ-2) prepandemic to 24%/15% in W2, and slowly decreased to 14%/9% in W5. Psychosomatic complaints are across all waves still on the rise. 32-44% of the youth expressed fears related to other current crises. Conclusion: Mental health of the youth improved in year 3 of the pandemic, but is still lower than before the pandemic.

Welfare state regimes, health and health inequalities in adolescence: a multilevel study in 32 countries.

Comparative research on health and health inequalities has recently started to establish a welfare regime perspective. The objective of this study was to determine whether different welfare regimes are associated with health and health inequalities among adolescents. Data were collected from the 'Health Behaviour in School-aged Children' study in 2006, including 11- to 15-year-old students from 32 countries (N = 141,091). Prevalence rates and multilevel logistic regression models were calculated for self-rated health (SRH) and health complaints. The results show that between 4 per cent and 7 per cent of the variation in both health outcomes is attributable to differences between countries. Compared to the Scandinavian regime, the Southern regime had lower odds ratios for SRH, while for health complaints the Southern and Eastern regime showed high odds ratios. The association between subjective health and welfare regime was largely unaffected by adjusting for individual socioeconomic position. After adjustment for the welfare regime typology, the country-level variations were reduced to 4.6 per cent for SRH and to 2.9 per cent for health complaints. Regarding cross-level interaction effects between welfare regimes and socioeconomic position, no clear regime-specific pattern was found. Consistent with research on adults this study shows that welfare regimes are important in explaining variations in adolescent health across countries.

Child and Adolescent Mental Health During the COVID-19 Pandemic: Results of the Three-Wave Longitudinal COPSY Study.

PURPOSE: The German population-based longitudinal COVID-19 andPsychological Health study monitors changes in health-related quality of life (HRQoL) and mental health of children and adolescents during the COVID-19 pandemic and identifies vulnerable groups. METHODS: A nationwide, population-based survey was conducted in May 2020 to June 2020 (Wave 1), December 2020 to January 2021 (Wave 2), and September 2021 to October 2021 (Wave 3). In total, n = 2,097 children and adolescents aged 7-17 years were investigated using measures to assess HRQoL (KIDSCREEN-10), mental health problems (SDQ), anxiety (SCARED), depressive symptoms(PHQ-2), and psychosomatic complaints(HBSC-SCL). RESULTS: The prevalence of low HRQoL increased from 15% prepandemic to 40% and 48% in Waves 1 and 2 and improved slightly to 35% in Wave 3 (all differences significant). Similarly, overall mental health problems increased from 18% prepandemic to 29% in Wave 1 and 31% in Wave 2 to 28% in Wave 3 (all differences significant, except Wave 3 vs. 2), anxiety increased from 15% prepandemic to 24% and 30% in Waves 1 and 2 and was still 27% in Wave 3. Depressive symptoms increased from 10% prepandemic to 11% and 15% in Waves 1 and 2 and were 11% in Wave 3. A group with low parental education, restricted living conditions, migration background, and parental mental health problems was at significantly increased risk of HRQoL and mental health impairments. DISCUSSION: The prevalence of low HRQoL, mental health problems, and anxiety has been elevated throughout the pandemic. Thus, mental health promotion, prevention, and intervention strategies need to be implemented to support adolescents-particularly those at risk.

Health Literacy in Germany - Findings of a Representative Follow-up Survey.

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 socio - demographic 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 pro - moting 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.