[Digital health literacy in Germany: current status, concepts, and challenges]. / Digitale Gesundheitskompetenz der Bevölkerung in Deutschland: Aktueller Stand, Konzepte und Herausforderungen.

A key prerequisite for the successful digital transformation of the healthcare system is a well-developed level of digital health literacy (DHL) among the population. DHL is the ability to deal with health-relevant digital information and information options with the aim of promoting and maintaining health and well-being for oneself and one's environment. This article examines the discussions about digital health literacy, the existing studies and measurement tools used in them, the data situation in Germany, and current challenges.DHL consists of various sub-competencies that reflect current digital information behavior, opportunities, and risks. The data situation is very heterogeneous due to different study designs and instruments, which limits the informative value. Two representative studies, HLS-Ger­2 by Bielefeld University and the study by AOK Rheinland/Hamburg and the Leibniz-WissenschaftsCampus, both indicate a high proportion of people with low DHL despite different methods. Both nationally and internationally, DHL is subject to a social gradient and is associated with educational level, social status, financial deprivation, and age.According to the current empirical data, the acquisition of DHL in Germany is still insufficient, so there is a great need for action. The necessary legal framework conditions have been established, but there is still a lack of reliable and financial resources, as well as a solid data basis on DHL at population level. This is essential to identify vulnerability factors and to prepare and evaluate the implementation of measures. In addition, there is a need for an in-depth conceptual discussion on DHL that builds on the established health literacy concept and addresses the emerging health-related infodemic and its consequences for DHL.

[Professional health literacy among nurses in Germany: Results of a quantitative, cross-sectional survey]. / Professionelle Gesundheitskompetenz bei Pflegenden in Deutschland.

Professional health literacy among nurses in Germany: Results of a quantitative, cross-sectional survey Abstract. Background: Little is known about the professional health literacy (HL) of nurses, i.e., how well they are able to promote patients' HL. Existing studies have focused on personal HL, which does not entirely align with professional HL. Therefore, a new concept and questionnaire for professional HL have been developed and implemented for the first time. The results obtained for nurses in Germany are analysed with this article. Research question: It is asked how professional health literacy (HL) is distributed among nurses and which factors are associated with it. Methods: Data were collected through an online survey where nurses were asked about the difficulties they encounter in managing tasks in four dimensions: (1) information and knowledge management, (2) explaining and conveying information, (3) patient-centered communication, and (4) professional digital health literacy. Descriptive and multivariate, linear regression methods were used for analysis. Results: The 624 respondents rated the fourth dimension as the most difficult. The first and second dimensions were rated as similarly difficult, while the third dimension was considered least difficult. Higher professional HL is linked to better self-assessed training and framework conditions. Conclusion: Despite a relatively positive self-assessment, the results indicate areas that require improvement and should be addressed urgently.

[Navigational health literacy of the population in Germany]. / Navigationale Gesundheitskompetenz der Bevölkerung in Deutschland.

AIM: Many health care systems are characterized by their high complexity and intransparency. Finding one's way through the multitude of services and finding the right place requires high navigational health literacy (NHL). NHL is defined as the ability to manoeuvre through the health care system and deal with the information required to do so. However, so far, there has been a lack of data on the population's NHL. The objective of this article is to analyse empirically the NHL in Germany and its association with socio-demographic and economic factors. METHOD: NHL was surveyed with an instrument (HLS19-NAV) newly developed by an international working group, measuring the self-assessed difficulties in relation to 12 navigation-related information tasks. The HLS19-NAV has already been used in 8 countries, including Germany. In Germany, data on NHL was collected from 2,151 adult residents in a representative cross-sectional study. The relationship between socio-demographic and economic factors, and NHL was examined by using methods of analysis of variance and multivariate linear regression analysis. RESULTS: Approximately 80% of the respondents showed low NHL with a mean score of 41.5 out of a possible 100 points. Those with low socio-economic resources, people of advanced age, people who had migrated to Germany or who were limited by health issues had a particularly low NHL. However, even people with good resources had a relatively low NHL. In contrast, the mean score was significantly higher among health professionals. CONCLUSIONS: In recent years, numerous efforts have been made to reduce navigational difficulties and to better guide patients through the German health care system. However, according to the results of the study, there is still need for further action. Above all, structural measures are required: this includes the creation of sufficient, reliable information on the health care system and its organizations as well as the implementation of navigation aids, health care pathways and the creation of a health-literate health care system including organizations and health professionals that contribute to strengthening NHL in general.

Health literacy and the role of social support in different age groups: results of a German cross-sectional survey.

BACKGROUND: Scholars demand more focus on context-related factors of health literacy as the management of health information is seen as a social practice. One prominent factor is social support that is expected to be particularly relevant for persons vulnerable for low health literacy. It was shown that health literacy can differ across the life span and especially older people have been demonstrated to be vulnerable for low health literacy. Therefore, health literacy and the relation of social support on health literacy in different age groups should be investigated. METHODS: In a German nationwide survey 2,151 adults were interviewed face-to-face. General comprehensive health literacy was measured with the HLS19-Q47 which differentiates single steps of health information management - access, understand, appraise, and apply. Social support was measured with the Oslo 3 Social Support Scale. Bivariate and multivariate analyses were performed for all respondents and for five age groups. RESULTS: Health literacy is relatively low in all age groups but particularly low among old-old people (76 + years). Also, the youngest adults (18-29 years) have slightly lower health literacy than middle-aged adults. On average, health literacy is higher among people with higher social support but this association varies between age groups. It tends to be quite strong among younger adults (18-45 years) and young-old persons (65-75 years) but is weak among older middle-aged (46-64 years) and old-old persons. The association also differs between steps of information management. It is stronger for accessing and applying information but there are differences in age groups as well. CONCLUSIONS: Social support is a relevant aspect to improve individuals' health literacy and therefore should be addressed in interventions. However, it is necessary to differentiate between age groups. While both young adults and particularly old-old persons are challenged by health information management, young adults can strongly profit from social support whereas it can barely compensate the low health literacy of old-old persons. In addition, different challenges in information management steps in different age groups need to be considered when designing health literacy interventions. Thus, target group specific services and programs are needed.

[Health Literacy of People with Former Soviet Union and Turkish Migration Background in Germany]. / Gesundheitskompetenz von Personen mit ex-sowjetischem und türkischem Migrationshintergrund in Deutschland.

AIM: So far, there are hardly any data on the health literacy of persons with a migration background in Germany. The aim of the article was to analyse the health literacy of this population group - particularly persons who originate in Turkey and the former Soviet Union (FSU). METHODOLOGY: In summer 2020, face-to-face interviews with 525 persons with FSU and 512 persons with Turkish migration background above the age of 18 were carried out across Germany. The interviews were conducted in German, Russian or Turkish. Health literacy was assessed using the internationally developed HLS19-Q47 instrument. Bivariate and multivariate analyses were carried out for each immigration group separately considering demographic, socioeconomic, linguistic and migration-specific variables. RESULTS: Overall, around half of the respondents had low health literacy, with no differences between the immigration groups. In both groups, low educational levels, socioeconomic disadvantages, limited German literacy skills, older age, multiple chronic illnesses and personal experience of immigration were linked with lower health literacy. In multivariate analyses, associations between health literacy and literacy skills, social status, financial deprivation, and chronic illness remained; however, after adjustment, no significant difference persisted by immigration generation. CONCLUSION: While a significant proportion of persons with Turkish or FSU migration background in Germany have difficulty dealing with health information, compared with existing studies, they do not have a lower health literacy than the population without a migration background. People with a migration background are therefore not to be regarded as vulnerable to low health literacy in general. Particularly socioeconomically disadvantaged subgroups display low health literacy. Interventions should therefore target these subgroups specifically and consider their living conditions. In addition, people with low literacy skills and German proficiency have greater difficulties in processing health information. This highlights the need for multilingual information, but also for multimedia materials in plain language. Structural measures are necessary for a health-literate health system and for reducing health inequalities.

[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.

Navigational health literacy among people with chronic illness.

OBJECTIVES: People with chronic illness are particularly dependent on navigating and using the health care system. This requires navigational health literacy (HL-NAV). The article aims to examine the distribution and predictors of HL-NAV in a sample of chronically ill individuals. METHODS: Data of 1,105 people with chronic illness from the general population in Germany were collected in December 2019 and January 2020. HL-NAV was assessed by 12 items (score 0-100). Bivariate and multiple linear regression analysis were performed. RESULTS: HL-NAV score was 39.1 (SD 27.3). In bivariate analyses, HL-NAV was lower among chronically ill persons aged 65 or above, with low education, limited functional health literacy, low social status, financial deprivation, poor social support, multiple chronic conditions, and an illness duration of 6-10 years. In multivariate analyses, advanced age, lower education, less functional health literacy, lower social status, and less social support remained associated with lower HL-NAV. DISCUSSION: The results underline the importance of promoting HL-NAV among people with chronic illness. Strategies should aim at strengthening individual competencies taking into account the social and situational factors but also at reducing the demands placed on chronically ill people by providing user-friendly and trustworthy information on the health care system along the illness trajectory.

[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.

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.

Differences in health literacy domains among migrants and their descendants in Germany.

Background: Health literacy (HL) is considered to be an important precondition for health. HL research often identifies migrants as vulnerable for low HL. However, in-depth data on HL among migrants especially in its domains of health care, disease prevention and health promotion and its determinants are still scarce. Objective: The aim of this study was therefore to analyse the current status of HL among migrants and their descendants from Turkey and from the former Soviet Union (FSU) in Germany and factors associated with it. This has not been studied using large-scale data and bilingual interviews. We differentiate between dimensions of HL, namely the domains of health care, disease prevention and health promotion which goes beyond many previous studies. In addition, we explore new mechanisms by testing the explanatory power of self-efficacy and interethnic contacts for migrants' HL. Methods: The study includes 825 first- and second-generation adult migrants from two of the largest immigration groups in Germany, from Turkey and FSU, who were interviewed face-to-face in German, Turkish or Russian in late summer 2020. HL was measured using the HLS19-Q47 instrument. Age, gender, educational level, social status and financial deprivation, chronic illness, health-related literacy skills, self-efficacy, interethnic contacts, migration generation, duration of stay and region of origin were considered as possible determinants. Ordinary least square regressions were estimated. Results: The average general HL score was 65.5. HL in health promotion and disease prevention was lower than in health care. Low financial deprivation, health-related literacy skills, and self-efficacy were positively correlated with each HL domain. Educational level, social status, age, gender, duration of stay and interethnic contacts were positively correlated with HL in some domains. Region of origin was only correlated with the domain of disease prevention until interethnic contact was accounted for. Conclusion: Our study contributes to the existing knowledge by analyzing different domains of HL and testing its correlations with self-efficacy and interethnic contact among migrants. We reveal that migrants cannot generally be considered as vulnerable for low HL, as oftentimes outlined. There is a need for interventions e.g. to enhance the understanding of health information among subgroups with lower HL.

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.

[DNVF Memorandum Health Literacy (Part 2) - Operationalisation and Measuring of Health Literacy from a Health Services Research Perspective]. / DNVF Memorandum Gesundheitskompetenz (Teil II) ­ Operationalisierung und Messung von Gesundheitskompetenz aus Sicht der Versorgungsforschung.

The "DNVF Memorandum Health Literacy (Part 2): Operationalization and Measurement of Health Literacy from the Perspective of Health Services Research" of the German Network for Health Services Research represents the continuation of the memorandum "DNVF Memorandum Health Literacy (Part 1): Background, Subject and Issues in Health Services Research". In addition to the general requirements for the measurement of health literacy, this memorandum also deals with the specific requirements, such as the differentiation of health literacy from related constructs, the differences between performance-based and self-assessment methods, the differences between generic and specific instruments, the use of screening instruments, and the measurement of health literacy in special populations. Furthermore, special considerations about the measurement of digital health literacy, potentials of qualitative and participatory research approaches as well as research ethics in the measurement of health literacy will be elaborated on. A special emphasis is placed on practical relevance for health services researchers. Finally, the authors will give an outlook on challenges and research desiderata in connection with the measurement of health literacy in the context of health services research.

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.

Preferences and Experiences of People with Chronic Illness in Using Different Sources of Health Information: Results of a Mixed-Methods Study.

BACKGROUND: People with chronic illness are particularly dependent on adequate health literacy (HL), but often report difficulties in accessing, understanding, appraising, and applying health information. To strengthen the HL of people with chronic illness, in-depth knowledge about how they deal with health information is crucial. METHODS: To this end, quantitative data from the Second Health Literacy Survey Germany (HLS-GER 2) and qualitative data from seven focus group discussions were used to examine the interest in health information, preferred sources of information as well as experiences and challenges with information management among people with chronic illness. RESULTS: The results show that people with chronic illness have a great interest in health information and use very different sources of health information, preferring personal information from physicians most. The results also point to several challenges in health information management that seem to be influenced by the illness duration as well as by the experiences made with the respective sources. CONCLUSIONS: Overall, the study provides important starting points for intervention development for the provision and communication of health-related information, but also to research on health information behavior and HL.

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.

[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.

[Health Literacy: Germany in the Digital Race to Catch Up Introduction of Technological Innovations is not Sufficient]. / Gesundheitskompetenz: Deutschland in der digitalen Aufholjagd Einführung technologischer Innovationen greift zu kurz.

Recently, several acts have been passed by the German Ministry of Health to drive the digital transformation of the healthcare system. These aim at far-reaching innovations to improve care and increase the efficiency of the healthcare system. At the same time, the demands on users in dealing with digital applications and information are increasing. Digital health literacy is thus becoming particularly relevant. However, available studies show that the digital health literacy of the population in Germany is often limited. This paper explores challenges, gaps, and prospects regarding the implementation of these new digital health policies, particularly in terms of the implications for improving digital health literacy and increasing user involvement and participation by providing six major aspects that should be considered.

[Health Literacy among People with Chronic Illness]. / Gesundheitskompetenz von Menschen mit chronischer Erkrankung in Deutschland.

BACKGROUND: People with chronic illnesses (Pwci) face a variety of challenges in managing their illness and using health care. Thus, their need for information and health literacy (HL) is high. While the topic has already been addressed in international research, there is a lack of studies on health literacy among Pwci in Germany. OBJECTIVES AND METHODS: The aim was to analyze HL among Pwci in Germany in more detail. For this purpose, cross-sectional data from a total of 499 Pwci of the German Health Literacy Survey (HLS-GER) were used. HL was assessed with the European Health Literacy Survey Questionnaire (HLS-EU-Q 47). Possible differences in the distribution of low HL by socio-demographic characteristics (gender, age, social status, financial resources, educational level and functional HL (assessed with the Newest Vital Sign (NVS)) and disease-related characteristics (number of diseases and disease duration) were tested using chi-square tests. To investigate the influence of these factors on low HL among Pwci, a multiple logistic regression was performed. RESULTS: Low HL was found in 72.7% of Pwci. Low HL differed greatly according the single domains healthcare, prevention and health promotion. Low social status (OR: 4.4 [1.8; 10.7]), low financial resources (OR: 2.0 [1.2; 3.1]), limited literacy skills (OR: 2.7 [1.4; 5.0]), and an intermediate-level of education (OR: 0.5 [0.3; 0.9]) were associated with low HL in multiple logistic regression. Number and duration of chronic illnesses were not significantly associated with low HL. CONCLUSION: The analysis provides initial findings for Germany that need further investigation. However, they already provide important indications for intervention development. It is necessary to develop target group-specific interventions for strengthening personal health literacy of Pwci, specifically addressing people with low social status, low financial resources and limited literacy. To avoid stigmatization, it is also important to address the information demands in the personal environment. Interventions should make it easier to search for, acquire and process information and thus contribute to reducing inequality.