Digital health literacy: How is the implementation of Section 20k SGB V?

With the introduction of the Digital Care Act (DVG) in 2019, the statutory health insurance companies (GKVn) received the legal mandate under Section 20k SGB V to provide their insured persons with “services to promote the self-determined, health-oriented use of digital or telemedical applications and procedures.” to offer. The aim of the paragraph is to impart skills that enable the use of digital or telemedical applications and procedures. Every two years, the Federal Association of Health Insurance Funds (SpiBu) reports to the Federal Ministry of Health (BMG) on how and to what extent such measures have been implemented. In the first report (deadline December 31, 2021) it became clear that only 26% of GKVs had developed or purchased such services (SpiBu 2021: 10). As early as 2018, the “National Health Literacy Action Plan” highlighted the enormous importance of promoting media literacy and the population's ability to make critical judgments when dealing with digital health information (Schaeffer et al. 2018: 53). Digital health literacy (dGK) includes the knowledge, motivation and skills of people to find, understand, evaluate and apply relevant digital health information in various forms in order to make decisions about disease management, disease prevention and health promotion (Sørensen et al. 2012: 3). Although health literacy has improved since the beginning of the Covid-19 pandemic, insured persons find it particularly difficult to assess (74.9%) and the concrete application of health information (53.7%) (Schaeffer et al. 2021: 22 ff.) . The central question is to what extent the statutory health insurance companies have implemented the legal obligation so far.

>> In order to determine the status quo (period July to mid-September 2022), the GKVn websites (n = 97, SpiBu 2022) were specifically searched for the term “digital health literacy” (dGK) using the search function and the first and second search
level taken into account. The search was confirmed by a Google check. Content that was aimed at specifically promoting the dGK was included. General information (e.g. press releases) was not included.
Since many statutory health insurance companies use social media platforms to promote skills, an additional survey was carried out via the YouTube platform in order to obtain a comprehensive insight into the existing learning content. The GKVn's main YouTube channels were taken into account here, not specific topic channels (such as “TK Press & Politics”).
In addition to the quantitative survey, a qualitative content analysis was carried out. For this purpose, rough categories were defined in order to categorize and quantify content based on online research.
Results
Due to the low number of cases, the data were evaluated descriptively. Community projects (e.g. www.gesund-digital.info) were not included in the analysis. Overall, it was possible to determine during the inventory that a total of 44 GKVn (45.5%) provide offers for the promotion of the dGK on their homepage and/or their YouTube channel.
• Internet sites: 16 of the 97 GKVn (16.5%) offer offers to increase the dGK, which can be found directly via the search functions from the perspective of the insured.
• YouTube: 41 of the 97 GKVn (42.3%) offer videos to increase dGK via their YouTube channels.

Most of the content was targeted across populations. If target group-specific offers are initiated, they focus primarily on children and young people, parents, employees and employers as well as older people and caring relatives (Fig. 1). Offers aimed at migrants are a rarity. Only one GKV offers videos on the subject of dGK in English and Ukrainian on its YouTube channel.
Only a few dGK offers can be found centrally and quickly by insured persons on the GKVn websites through a targeted search. Things look different on the YouTube channels due to the medium; here, dGK topics are relatively easy to find. A system
Thematic linking or linking of the content (YouTube videos) is rarely done in order to make sensible use of existing content in the spirit of the solidarity community's resource-saving use of funds.
With regard to the content, the websites and YouTube channels show sub-
divorce. While the YouTube channels tend to focus on digital process innovations (ePA, etc.) as well as negative side effects that digitalization can have on human health (e.g. social media addiction, media consumption among children and young people , cyberbullying, cyberchondria, body shaming), the content of the homepages concentrates more on the topics of ePA, eGK, ePrescription and digital prevention (Tab. 2).
Despite the high demand for “searching for health information on the internet” identified in the HLS-GER 2 study (Schaeffer et al. 2021), statutory health insurers seem to be neglecting this topic at the moment. On the Internet pages, such content is mainly presented in text-based form. There are also only a few explanatory videos on this important topic on the YouTube channels. Learning content that relates to the search for causes or symptoms of illness in health portals is a rarity. In addition, many topics are viewed in isolation. For example, offers for the quality-related search of health-related information on the Internet take into account the characteristics of reputable and dubious sources, but the associated advantages (patient maturity, etc.) and disadvantages (cyberchondria, etc.) are not presented in an integrated manner.
It is also noticeable that not all competence dimensions (knowledge, understanding, application, implementation) are addressed in the existing offerings. A quantitative evaluation of the didactic media is not possible because the multiple use of personalized videos would lead to severe distortions. It became clear that text-based information often dominated the websites. Interviews, podcasts and lectures are didactic media that have been used the least.
The qualitative analysis revealed which didactic elements were used for different content purposes.
• Animated explanatory videos: Animated explanatory videos were used to present complex issues, connections and processes in an easy-to-understand manner. The transfer of knowledge related in particular to the technical and associated procedural innovations in the healthcare system (e.g. eGK).
• Human explanation videos: Human explanation videos could not be clearly assigned to any subject area. The videos were made by e.g. B. GKV employees or expert testimonials (e.g. Dr. Johannes Wimmer) to increase attention and increase credibility.
• Screen recordings: Screen recordings set to music are used in particular to display websites (e.g. trustworthy health portals) and to explain the specific use of these.
• Lectures: Recorded online lectures are a rarity and are aimed more at a specialist audience. Lectures that can be booked online (e.g. DAK startklar) that are offered have the disadvantage that the insured are tied to fixed dates and must have technical equipment (e.g. microphone, camera). The advantage is that you can actively participate and ask individual questions.
• Interviews: Interviews were used in the form of a critical discussion (dealing with social media, etc.) and for experience-based information (e.g. benefits of digital health applications; DiGAs). Here, among other things, representative experiences of health laypeople are used to represent personal experiences (e.g. with the use of health apps).
• Podcasts and audio formats: If podcasts are used, then often in the form of interviews on topics related to the use or slower handling of digital media (eg digital detox). So far, audio formats have been very isolated, but could be used in the future for modular offers to introduce the subject, to present experience reports or to support explanations of visualizations (e.g. classification of content or explanation of procedures and processes). Podcasts are popular media that are used regardless of location (e.g. train, car). Such podcasts could be used in voice assistant skills (Google Assistant, Amazon Alexa, etc.).
• Text-based explanations (homepage): Text-based explanations
cannot be clearly assigned to any substantive topics and were used for general clarification. It was noticeable that texts dominated and only a few GKVs enriched them with visual elements (information graphics, illustrations, etc.) in order to enable brain-friendly learning.
Visual elements with interaction elements (or click elements), where the insured have to take action themselves, increase attention and promote motivation. Such interaction elements have rarely been used so far. In addition, visualizations are not set to music in order to make the illustrations easier to understand.

While most GKVs do not provide a central area for their skills-building content, in addition to the cooperation platform www.digital-gesund.info, four GKVs offer their own area with modular learning offerings. Two offers are aimed at the company's own insurance community (mhplus BKK: DiGi-Coach; TK: DisSK-Coach), while two offers are accessible to the general public (pronova BKK: have a say digitally; BKK mobil: digital healthcare). The learning objectives or learning outcomes are not precisely described in the existing offerings with regard to the desired skills. The personal benefit for the insured is therefore not apparent at first glance. Not all competence dimensions (knowledge, understanding, application, implementation) are addressed in the offers. The opportunity to critically reflect on the previously learned content using a learning success control is currently only offered by two statutory health insurance companies (pronova BKK, BKK mobil), where the insured can pass or fail a quiz.
These differ depending on the time at which learning success is monitored, etc.:
1 Points in time of the learning success check: With the pronova BKK offer, the learning check takes place at the end of the entire module with a wide variety of learning content, while with the BKK mobil each sub-module ends with a quiz. It is known from learning psychology that immediate (i.e. as timely as possible) feedback has a beneficial effect on the motivation of the learner (Hattie 2014: 209 f.). Therefore, more manageable and topic-related content should be checked in order to enable direct learning reflection. It makes sense to implement smaller learning success checks at the end of a sub-module. Such learning success checks should be called quizzes in a playful and low-threshold manner, as “tests” can sometimes evoke negative associations.
2 Contents of the learning success checks: It is noticeable that not all dimensions of “knowledge, understanding, application and implementation” were always checked. The questions do not always relate to the subject area of the dGK and include, among other things: querying abbreviations. Such learning success controls do not help to promote independent actions by the insured in the future through critical reflection. Learning success controls should therefore not only take all dimensions into account, but also help to promote the transfer of what has been learned into everyday practice.
3 Number and form of learning success checks: The number of learning success checks varied depending on the subject area and amounted to two to five questions. The forms of learning success checks also varied (e.g. multiple choice questions, assignment, marking, sequencing tasks, fill-in-the-blanks).
4 Feedback and feedback: From a learning psychology perspective, learning success checks should stimulate critical reflection and have an encouraging effect. Individual feedback on individual tasks as well as the overall feedback are important for the learning processes and the continuation of the learning activity. Praise is an important motivator, but the praise should not be too general (e.g. “Right!”). Generalizations can have a negative impact on motivation because relevant information about one's own actions is missing.
The learning success checks are currently partly very factual, feedback is very general and offers the insured, e.g. B. in the case of mistakes, no indications of how to improve their deficits. Merely pointing out errors does not make pedagogical sense, as a positive learning experience is only possible through encouraging, result-oriented feedback with suggestions for solutions (Jürg; Sandra 2021: 162). Feedback should be given regularly, e.g. B. after smaller learning units (Willert 2018: 5). Since the type of feedback is important, feedback should be formulated in a factual or criteria-related, understandable, benevolent, personal and not personally attacking manner (Willert 2018: 6). A positive example of result-oriented feedback is the interactive tool “CheckyourApp” from TK (tk-checkdieapp.de). In this knowledge test, young people receive supportive and encouraging feedback with result-oriented tips and justifications if test questions were not answered correctly.

To date, there are no opportunities on the GKVn websites for insured persons to assess their current level of knowledge regarding the dGK themselves in advance (subjective knowledge assessment) or/and to critically reflect on their current competence (objective knowledge reflection) in order to be able to specifically promote their competences on this basis .
Limitation
Despite the defined inclusion and exclusion criteria, the associated fluid areas between information and skills transfer and in view of the high dynamics, this snapshot can only provide a rough orientation of what is currently happening. Distortions result, for example, from the fact that many company health insurance companies (BKKn) refer to the same films (e.g. ePA), which, however, have been individualized and provided with the logo of the respective GKV. With regard to the media formats used, an additional qualitative analysis was carried out in order to gain an insight into which topics were preferably implemented with which media formats. Due to the
Despite the enormous complexity and dynamics of the topic, it is not possible to provide a precise overview, but the inventory can nevertheless be
analysis provides assistance and suggestions for optimization.
Conclusion and recommendations for action
The SpiBu has specified premises for the development, which are e.g. B. refer to the target group-specific orientation, the comprehensibility of the methodological approach and the easier use of disadvantaged groups (SpiBu 2020: 3f.), which should guide action. It can be assumed that compliance will be checked in the future, for example using a dGK traffic light system (Merz et al. 2022: 39 ff.). The questionnaire from the SpiBu report on the status of dGK funding also provides information on implementation (SpiBu, 2021: 19 ff.).
Goals and target groups should be clearly defined at the beginning. Newer pedagogical approaches advocate defining learning outcomes instead of learning goals in order to take the learners' perspective more closely and make the direct benefits visible.
While a universal approach makes sense for some topics (e.g. eGK), precise target group addressing (e.g. age, health status) makes sense for other topics. Lay and expert testimonials or vicarious experiences can also increase the experience of competence and self-efficacy through reflection on one's own experiences and sensitivities (Bandura 1997: 3 f.). The benefits and limitations in relation to your own health should be presented in layman's terms.
The comprehensibility of the methodological approach results from the desired competencies, which are to be systematically increased through the use of sub-modules that build on one another. Depending on the desired learning outcome, different media (videos, animations, etc.) should be used. Learning success checks with encouraging feedback should be based on the learning results and should be selected based on whether it concerns, for example, the knowledge testing of complex processes or the specific use of digital applications and procedures in healthcare.
For disadvantaged target groups (e.g. older people, people with a migrant background), use can be made easier by orienting the offer towards the “weakest learner” and involving the target group in the development process. Knowledge should be able to be critically reflected in certain areas (knowledge, understanding, implementation, etc.). Easy-to-understand support in accessing services can be guaranteed through practical examples. Questions of understanding could be answered using accompanying learning elements (e.g. glossary, FAQs, chatbots).
Reference works (e.g. Wikipedia) are among the best known and most common websites where health information is sought (Kolpatzik et al. 2020: 19). Chatbots as learning companions are only as good as the stored database.
Neutral references to characteristics as well as content, behavior-specific and technical limits that are associated with the z. B. concrete use of digital applications and processes (health apps, health portals, etc.) should not be limited to the presentation of negative consequences (cyberchondria, etc.), but deliberately take up positive opportunities to promote personal responsibility and self-determination.
Disclosure of the authors, editors and financiers can significantly increase the credibility and acceptance of the offer. It should be clear with whom (e.g. university, institute) and how the offer was developed. An interdisciplinary advisory board could help to critically reflect on and improve the offering once or twice a year. <<

Author's statement
Prof. Dr. Viviane Scherenberg and Melanie Preuß are employees of the APOLLON University in Bremen. The inventory and analysis was carried out as part of a third-party funded project for the Techniker Krankenkasse in Hamburg

thanksgiving
The authors would like to thank the Techniker Krankenkasse (TK) and thus Mrs. Dr. Jenny Mex and Mr. Mirko Ruchel for making the project possible. Many thanks also for the express wish of the TK to be able to make the central findings available to the general public (to improve and reflect on quality).