Health literacy in vulnerable population groups

In the healthcare system, users are increasingly required to be able to find, understand, assess and apply health information to their own situation in order to make decisions, for example, about the treatment and care of illnesses or the recovery and maintenance of health. The knowledge, motivation and skills to deal with health-related information are referred to by experts as health literacy (Sørensen et al. 2012). Health literacy is the interaction of personal abilities and the requirements and complexity of situations and systems in which people move (Schaeffer et al. 2018). But people often face difficulties in dealing with health information.

>> First of all, the correct access to information must be identified, or when searching for information on the Internet, for example, is it necessary to identify the right terms and select the appropriate one from a variety of available information. But it's not just access to information that is difficult for many people. Even when it comes to understanding health information found or received and assessing its relevance and quality, many users and
Users at their limits. This is particularly true for some population groups, as international studies have shown for many years. Groups with particular difficulties in dealing with health information include ethnic minorities, people with low levels of education, the elderly and those with chronic illnesses (Australian Bureau of Statistics 2008; Beauchamp et al. 2015; CCL 2008; Kutner et al. 2006). There are now also findings in Germany about the extent and differences in health literacy in individual population groups. Here, too, people with a low level of education, people with a migration background, people of older age and people with chronic illness are more likely to have low health literacy (Schaeffer et al. 2016, 2017, Zok 2014, Jordan/Hoebel 2015).
The National Action Plan recommends intensifying research on health literacy, particularly among vulnerable population groups such as people of older age, people with chronic illnesses and/or disabilities, people with a migrant background and also people with low levels of education. This article discusses why health literacy is so important in these groups and what challenges they face when dealing with health information. At the same time, important starting points for future health services research are pointed out.
People with chronic illnesses and/or disabilities
According to available studies, the most vulnerable groups when dealing with health information include people with chronic illnesses. This is particularly precarious because chronic diseases have become increasingly important worldwide and have long accounted for the majority of deaths in many countries. They are almost always characterized by complexity and are accompanied by numerous health, psychological, social and economic consequences for those affected and their families.
People with chronic illnesses are now often more informed and active. At the same time, they are given greater responsibility and are required to participate in partnership in dealing with the illness and the numerous treatment and care decisions that have to be made. They also have to navigate the health system, which is still not adequately adapted to chronic diseases, and also have to work to maintain their remaining health. For all of this they need strong health literacy.
However, only a minority have good or very good health literacy and find it easy to deal with health and illness-related information. On the other hand, around 73 % of the people surveyed in the HLS-GER with one or more chronic illnesses stated that they had significant problems dealing with health-relevant information and had a limited level of health literacy (Schaeffer et al. 2017). For example, almost half of those with chronic illnesses (47 %) rate it as difficult or very difficult to find information about treatments for diseases that affect them (Schaeffer et al. 2016).
The high proportion of limited health literacy and the large number of self-assessed difficulties in dealing with health information among people with chronic illnesses and/or disabilities are initially surprising. Until now, it was assumed that the accumulation of experience, as provided solely by the persistence of the illness, automatically leads to an increase in competence. But it seems to be different: Precisely because people with chronic illnesses and/or disabilities are confronted with high demands in coping with their illness and are absolutely dependent on the healthcare system, they know the difficulties and demands that come with using it and also the necessary handling with information, very accurately - better than people who do not have as frequent contact with the health system. They know from an internal perspective what it means to navigate the opaque health system, to find the right contact point in the complicated network of authorities and responsibilities, and to motivate health professionals to spend the necessary time to work with them on suitable and subjectively viable solutions To advise on strategies for coping with illness (and also maintaining health) or to communicate about the difficulties encountered in providing care.
This explains the findings, but also underlines how important it is to intervene here: both to make the care system more user-friendly and to make the promotion of health literacy an important task here. One of the four fields of action in the National Action Plan is also dedicated to the topic of “living health-competently with chronic illness” (Schaeffer et al. 2018). A total of four recommendations call for integrating health literacy into the care of people with chronic illnesses (Recommendation 11), enabling people with chronic illnesses and their consequences to be dealt with in a health-competent manner (Recommendation 12), and the ability to self-manage people with chronic illnesses and their illnesses To strengthen families (Recommendation 13) and to promote health literacy to cope with everyday life with chronic illness (Recommendation 14). However, it is also necessary to pay greater attention to the topic of “health literacy and chronic illness” in health services research, because the existing findings urgently need to be deepened.
People of older age
Older people also belong to the groups with a high proportion of limited health literacy. The social importance of this target group becomes clear when one considers that the proportion of older people has increased significantly in recent decades as a result of demographic and social change and the increase in life expectancy and will continue to increase in the coming decades. By 2060, it is expected that more than a third of Germany's population will be 65 years of age or older (Federal Statistical Office 2015). An even greater increase is expected among very old people aged 80 and over. Their share will even double in this country (Federal Statistical Office 2015). At the same time, age itself has changed extensively, because as a result of, among other things, the increase in life expectancy, the age phase of life has continued to expand and become more differentiated.
In order to be able to spend this phase of life in the greatest possible health, health literacy is therefore very important. Existing empirical findings on health literacy in older age underline this. Because they show that more than two thirds of people aged 65 and over in Germany have limited health literacy.
wise, i.e. they have difficulty dealing with health information relevant to them and using it to make well-founded health and illness-related decisions (Schaeffer et al. 2016; Vogt et al. 2017). This particularly affects people aged 76 and over: the proportion of limited health literacy among them is as high as 76 % (Vogt et al. 2017). For example, they have great difficulty weighing up the advantages and disadvantages of treatment options.
However, people of older age are – and this should be emphasized again – particularly dependent on good health literacy. It does seem to be possible to push health problems and illness further and further to the end of the life course. However, the risk of health problems and chronic illnesses increases, particularly in older and older age (Lampert et al. 2016; RKI 2015; Schaeffer 2017). In general, this phase of life is characterized by health vulnerability. The preservation and promotion of the remaining health resources is therefore of particular importance for this target group. However, as previous empirical findings show, they face major challenges when dealing with health information.
They therefore require great attention in health services research and intervention research to strengthen health literacy. What seems particularly important in this context are studies and approaches that examine how organizations, particularly in the health and care system, hinder or promote the finding, understanding, assessment and application of health information and that aim to become health-competent organizations. The sixth recommendation of the National Action Plan also refers to this. There it is called for health literacy to be anchored as a standard at all levels in the health system so that users of the health and care system - especially people of older age - can actively participate in their treatment and care and make informed decisions (Schaeffer et al. 2018 , p. 38).
People with a migration background

Another vulnerable group in terms of health literacy are people with a migration background. Almost a quarter of the population in Germany now has a migrant background and it can be assumed that the proportion will continue to increase in the future (Federal Statistical Office 2018). However, they are not only a group to be taken into account because of their growing share of the population. Their health resources and disease risks also differ significantly from the general population. (Razum et al. 2008). People with a migrant background are disadvantaged in terms of health because they often have problems finding the right access to the healthcare system, do not know the healthcare system particularly well and face numerous barriers when looking for the right provider and also when using healthcare services .
In order to be able to adequately use the care system and work to maintain their own health, this population group in particular needs good health literacy. The ability to search/find, understand, assess and use health information can reduce possible barriers and navigation problems caused by financial, legal, linguistic or social aspects.
However, a high proportion of people with a migrant background have limited health literacy (71 %) and face major challenges in dealing with health information (Schaeffer et al. 2016, Quenzel & Schaeffer 2016, Messer et al. 2017). 55 % of people with a migration background find it difficult or very difficult to judge whether information about an illness in the media is trustworthy. In addition, almost 50 % of people with a migration background state that they have difficulties understanding the package inserts for medications (Schaeffer et al. 2016).
These findings indicate how important it is to pay more attention to the health literacy of people with a migrant background in the future. A central principle of the National Action Plan is that greater attention to the health literacy of people with a migrant background can help reduce social inequality in health care. In addition to individual health literacy, structural aspects of information provision and communication must be taken into account. Adapting existing information to the level of education, language skills, preferred information channels and the living situation of people with a migration background is important in order to reduce existing information deficits and thus make communication and navigation through the care system easier. It seems equally important to raise awareness among health professionals about the information and communication requirements of people with a migrant background. It is particularly important to note that the group of people with a migration background is very heterogeneous and shows great cultural, linguistic and social diversity.
Health services research should therefore pay greater attention to the health literacy of people with a migrant background and examine in more detail what difficulties they face on their way through the health system and what role the handling of health information plays in this. To date, there has been a lack of differentiated, in-depth and reliable knowledge on this, as well as on the health literacy of people with a migration background. However, they are essential to developing effective, evidence-based interventions to promote health literacy among this diverse group.
People with low levels of education
But it's not just people with a migrant background who are often disadvantaged socially and health-wise. Education is also – as many studies have now shown – an important influencing factor on health, illness and mortality. People with a low level of education suffer more often from chronic illnesses and functional limitations, smoke much more often, exercise less and tend to have poorer eating habits than people with higher educational qualifications (Mackenbach et al. 2003, 2008; Marmot et al. 2012; Richter and Hurrelmann 2009, Mensink et al. 2017). Educational differences are also evident in the use of care: people with low levels of education have greater difficulty navigating the health care system and use the care system more intensively than people with higher educational qualifications (Prütz & Rommel 2017).
Health literacy also differs based on educational level. According to the HLS-GER, more than 60 % of people with a low level of education have inadequate or problematic health literacy (Schaeffer et al. 2016). Among young people who have completed at most secondary school, three quarters (74 %) have an inadequate or problematic level of health literacy (Quenzel & Schaeffer 2016). Particular problems arise, among other things, when deciding when to get a second opinion from another doctor. Here, 46 % of people with a low level of education stated that they had great or very great difficulties (Schaeffer et al. 2016).
This shows, by way of example, that people with low levels of education belong to the vulnerable groups. In order to counteract the increase in health inequalities and strengthen the ability to act and make decisions that support a healthy life, the management of illnesses and the navigation through the care system, the promotion of health literacy could make an important contribution (WHO 2016; Schaeffer et al. 2018 ). However, people with a low level of education belong to the 'hard to reach groups' and require interventions that are specifically tailored to their everyday and structural conditions and their social situation. At the same time, the acquisition of health literacy is closely linked to basic resources such as self-efficacy, future orientation or social support. One implementation principle of the National Action Plan is therefore to change both individual and structural conditions in order to increase personal skills but also basic resources (Schaeffer et al. 2018).
However, even for people with a low level of education, there is still a lack of sufficient empirical data on which information-related barriers or disadvantages make it difficult to make appropriate use of the medical and nursing care system and how people with a low level of education can be better addressed. Particular attention should be paid to information, advice and instructions.
Consequences
In summary, it should be noted that population groups in particular, which are already considered vulnerable from a public health and health care research perspective in Germany and are at risk of social and health inequality, also require special attention from the perspective of health literacy. They have greater difficulty dealing with health information, acquiring necessary information and using it constructively to maintain their own health or to use health care. Although initial studies provide important information, there are still extensive research gaps due to the delayed start of the discussion about health literacy in Germany, as is also emphasized in the National Action Plan for Health Literacy.
It is therefore important to address and work on the topic of health literacy more intensively in health services research in the future. This is particularly true for the health literacy of vulnerable population groups. It is necessary to gain differentiated empirical knowledge about how health literacy presents itself in these groups and with which factors it is associated. It is also important to identify other potential vulnerable groups and to examine their health literacy in more detail (including caring relatives, people with disabilities, people with cognitive limitations). Findings like these are necessary in order to be able to develop interventions that are based on the special characteristics, preferences and living conditions of these target groups (Schaeffer et al. 2018). But conceptual and methodological aspects of health literacy research should also be addressed and worked on in depth, with a particular focus on vulnerable groups.
The German Network for Health Care Research has also recognized the importance of the topic and the challenges it poses for the realization of patient-centered, needs-based care and is dedicating a memorandum currently being drawn up to the care-related relevance of health literacy - also with a view to individual vulnerable groups. <<