Health Literacy of People with Substitutive Private Health Insurance in Germany and Their Assessment of the Health System Performance According to Health Literacy Levels: Results from a Survey
Abstract
:1. Introduction
2. Materials and Methods
2.1. Sample
2.2. Survey Items
2.3. Analysis
2.4. Health Literacy Score
3. Results
3.1. Sample Characteristics
3.2. Results of the HLS-EU-Q16 Items
3.3. Health Literacy Levels and Subgroup Differences by Socioeconomic and Health Characteristics
3.4. Health System Performance Assessment according to Health Literacy Levels
4. Discussion
5. Limitations
6. Conclusions
Author Contributions
Funding
Institutional Review Board Statement
Informed Consent Statement
Data Availability Statement
Acknowledgments
Conflicts of Interest
References
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Health Literacy Score Available a | ||||||
---|---|---|---|---|---|---|
Total | Yes | No | ||||
n | % | n | % | n | % | |
Total | 3601 | 100 | 2801 | 77.8 | 800 | 22.2 |
Gender (n = 3589) | ||||||
Male | 2323 | 64.7 | 1806 | 64.7 | 517 | 64.9 |
Female | 1266 | 35.3 | 986 | 35.3 | 280 | 35.1 |
Age (years) (n = 3588) | ||||||
Mean (SD) b | 58.5 (14.6) | 57.8 (14.3) | 60.0 (15.6) | |||
18–34 | 307 | 8.6 | 243 | 8.7 | 64 | 8.0 |
35–49 | 637 | 17.8 | 509 | 18.2 | 128 | 16.1 |
50–64 | 1220 | 34.0 | 999 | 35.8 | 221 | 27.8 |
65–74 | 928 | 25.9 | 717 | 25.7 | 211 | 26.5 |
75+ | 496 | 13.8 | 324 | 11.6 | 172 | 21.6 |
Educational level (n = 3572) | ||||||
Low (ISCED 0–1) | 57 | 1.6 | 39 | 1.4 | 18 | 2.3 |
Medium (ISCED 2–4) | 641 | 17.9 | 481 | 17.3 | 160 | 20.3 |
High (ISCED 5–8) | 2874 | 80.5 | 2264 | 81.3 | 610 | 77.4 |
Work status (n = 3560) | ||||||
Full-time | 1578 | 44.3 | 1274 | 45.8 | 304 | 39.1 |
Part-time | 315 | 8.8 | 257 | 9.2 | 58 | 7.5 |
Retired | 1431 | 40.2 | 1068 | 38.4 | 363 | 46.7 |
Other (student, parental leave, unemployed, etc.) | 236 | 6.6 | 183 | 6.6 | 53 | 6.8 |
Monthly net equivalent income c (n = 3399) | ||||||
Up to €1136 | 81 | 2.4 | 62 | 2.3 | 19 | 2.6 |
€1137–€1893 | 374 | 11.0 | 277 | 10.4 | 97 | 13.3 |
€1894–€2839 | 1418 | 41.7 | 1084 | 40.6 | 334 | 45.7 |
€2840+ | 1526 | 44.9 | 1245 | 46.7 | 281 | 38.4 |
Subjective social status (n = 3514) | ||||||
Lower middle class | 150 | 4.3 | 113 | 4.1 | 37 | 4.9 |
Middle class | 1616 | 46.0 | 1247 | 45.3 | 369 | 48.6 |
Upper middle class | 1512 | 43.0 | 1222 | 44.4 | 290 | 38.2 |
Upper class | 137 | 3.9 | 103 | 3.7 | 34 | 4.5 |
None of those | 99 | 2.8 | 69 | 2.5 | 30 | 3.9 |
Self-rated health (n = 3582) | ||||||
(Very) bad | 119 | 3.3 | 93 | 3.3 | 26 | 3.3 |
Moderate | 890 | 24.8 | 710 | 25.5 | 180 | 22.7 |
Good | 2098 | 58.6 | 1646 | 59.0 | 452 | 56.9 |
Very good | 475 | 13.3 | 339 | 12.2 | 136 | 17.1 |
Chronic diseases (n = 3584) | ||||||
None | 1475 | 41.2 | 1079 | 38.6 | 396 | 50.0 |
Yes, one | 1247 | 34.8 | 998 | 35.7 | 249 | 31.4 |
Yes, several | 862 | 24.1 | 715 | 25.6 | 147 | 18.6 |
Taking care of own health (n = 3589) | ||||||
Less/not at all | 93 | 2.6 | 56 | 2.0 | 37 | 4.7 |
Moderate | 1213 | 33.8 | 912 | 32.6 | 301 | 38.0 |
(Very) much | 2283 | 63.6 | 1829 | 65.4 | 454 | 57.3 |
Health Literacy Levels | n | % | 95%-CI |
---|---|---|---|
Inadequate (score 0–8) | 263 | 9.4 | 8.4–10.5 |
Problematic (score 9–12) | 1032 | 36.8 | 35.1–38.6 |
Sufficient (score 13–16) | 1506 | 53.8 | 51.9–55.6 |
Health Literacy Level | |||||
---|---|---|---|---|---|
Low (Inadequate/Problematic) | High (Sufficient) | ||||
n | % | n | % | p-Value | |
Total | 1295 | 46.2 | 1506 | 53.8 | |
Gender (n = 2792) | 0.023 | ||||
Male | 863 | 47.8 | 943 | 52.2 | |
Female | 427 | 43.3 | 559 | 56.7 | |
Age (years) (n = 2792) | <0.001 | ||||
18–34 | 131 | 53.9 | 112 | 46.1 | |
35–49 | 269 | 52.8 | 240 | 47.2 | |
50–64 | 482 | 48.2 | 517 | 51.8 | |
65–74 | 275 | 38.4 | 442 | 61.6 | |
75+ | 132 | 40.7 | 192 | 59.3 | |
Educational level (n = 2784) | 0.735 | ||||
Low (ISCED 0–1) | 16 | 41.0 | 23 | 59.0 | |
Medium (ISCED 2–4) | 227 | 47.2 | 254 | 52.8 | |
High (ISCED 5–8) | 1044 | 46.1 | 1220 | 53.9 | |
Work status (n = 2782) | <0.001 | ||||
Full-time | 644 | 50.5 | 630 | 49.5 | |
Part-time | 117 | 45.5 | 140 | 54.5 | |
Retired | 434 | 40.6 | 634 | 59.4 | |
Other (student, parental leave, unemployed, etc.) | 88 | 48.1 | 95 | 51.9 | |
Monthly net equivalent income a (n = 2668) | <0.001 | ||||
Up to €1136 | 37 | 59.7 | 25 | 40.3 | |
€1137–€1893 | 154 | 55.6 | 123 | 44.4 | |
€1894–€2839 | 505 | 46.6 | 579 | 53.4 | |
€2840+ | 532 | 42.7 | 713 | 57.3 | |
Subjective social status (n = 2754) | <0.001 | ||||
Lower middle class | 68 | 60.2 | 45 | 39.8 | |
Middle class | 622 | 49.9 | 625 | 50.1 | |
Upper middle class | 514 | 42.1 | 708 | 57.9 | |
Upper class | 40 | 38.8 | 63 | 61.2 | |
None of those | 30 | 43.5 | 39 | 56.5 | |
Self-rated health (n = 2788) | <0.001 | ||||
(Very) bad | 57 | 61.3 | 36 | 38.7 | |
Moderate | 366 | 51.5 | 344 | 48.5 | |
Good | 747 | 45.4 | 899 | 54.6 | |
Very good | 121 | 35.7 | 218 | 64.3 | |
Chronic diseases (n = 2792) | 0.040 | ||||
None | 473 | 43.8 | 606 | 56.2 | |
Yes, one | 460 | 46.1 | 538 | 53.9 | |
Yes, several | 357 | 49.9 | 358 | 50.1 | |
Taking care of own health (n = 2797) | 0.001 | ||||
Less/not at all | 33 | 58.9 | 23 | 41.1 | |
Moderate | 458 | 50.2 | 454 | 49.8 | |
(Very) much | 802 | 43.8 | 1027 | 56.2 |
Health Literacy Level | |||||||
---|---|---|---|---|---|---|---|
Total n = 2801 | Low (Inadequate/Problematic) n = 1295 | High (Sufficient) n = 1506 | |||||
n | % | n | % [95%-CI] | n | % [95%-CI] | p-Value | |
Satisfaction | |||||||
Overall satisfaction with the health system (n = 2718) | <0.001 | ||||||
(Very) dissatisfied | 127 | 4.7 | 81 | 6.4 [5.2–7.9] | 46 | 3.2 [2.4–4.2] | |
Neither satisfied nor dissatisfied | 768 | 28.3 | 423 | 33.5 [31.0–36.2] | 345 | 23.7 [21.5–25.9] | |
(Very) satisfied | 1823 | 67.1 | 757 | 60.0 [57.3–62.7] | 1066 | 73.2 [70.8–75.4] | |
Access | |||||||
Accessing after-hours medical care (n = 2796) | <0.001 | ||||||
Very/somewhat difficult | 1588 | 56.8 | 839 | 64.9 [62.3–67.5] | 749 | 49.8 [47.3–52.3] | |
Very/somewhat easy | 593 | 21.2 | 208 | 16.1 [14.2–18.2] | 385 | 25.6 [23.4–27.8] | |
Never needed after-hours medical care | 615 | 22.0 | 245 | 19.0 [16.9–21.2] | 370 | 24.6 [22.5–26.8] | |
Unmet needs due to a | |||||||
Waiting time (n = 2580) | 207 | 8.0 | 136 | 11.5 [9.8–13.4] | 71 | 5.1 [4.0–6.3] | <0.001 |
Distance (n = 2551) | 90 | 3.5 | 61 | 5.2 [4.1–6.6] | 29 | 2.1 [1.4–3.0] | <0.001 |
Financial reasons (n = 2622) | 199 | 7.6 | 135 | 11.0 [9.4–12.9] | 64 | 4.6 [3.6–5.8] | <0.001 |
Coverage | |||||||
Out-of-pocket health spending in the past year b (n = 2671) | |||||||
Medical products (pharmaceuti-cals and medical aids) | 2043 | 76.5 | 976 | 78.7 [76.4–80.9] | 1067 | 74.6 [72.3–76.8] | 0.012 |
Deductible | 1202 | 45.0 | 603 | 48.6 [45.9–51.4] | 599 | 41.9 [39.3–44.4] | <0.001 |
Services (inpatient/ambulatory care by physicians/allied health professionals) | 659 | 24.7 | 351 | 28.3 [25.9–30.9] | 308 | 21.5 [19.5–23.7] | <0.001 |
Dental care | 661 | 24.7 | 354 | 28.5 [26.1–31.1] | 307 | 21.5 [19.4–23.6] | <0.001 |
Other services | 529 | 19.8 | 275 | 22.2 [19.9–24.6] | 254 | 17.7 [15.8–19.8] | 0.004 |
No out-of-pocket spending | 351 | 13.1 | 131 | 10.4 [8.8–12.2] | 220 | 15.2 [13.4–17.1] | <0.001 |
Quality | |||||||
Reasons for hospital choice b (n = 2562) | |||||||
Reputation | 2028 | 79,2 | 922 | 78.0 [75.6–80.3] | 1106 | 80.1 [78.0–82.2] | 0.183 |
Medical quality | 1596 | 62.3 | 739 | 62.5 [59.7–65.2] | 857 | 62.1 [59.5–64.6] | 0.827 |
Amenities | 583 | 22.8 | 291 | 24.6 [22.2–27.1] | 292 | 21.2 [19.1–23.4] | 0.037 |
Quality differences between hospitals (n = 2746) | <0.001 | ||||||
No/some differences | 645 | 23.5 | 240 | 18.9 [16.8–21.2] | 405 | 27.4 [25.2–29.7] | |
Notable differences | 2101 | 76.5 | 1028 | 81.1 [78.8–83.2] | 1073 | 72.6 [70.3–74.8] | |
Knowledge about information sources regarding hospital quality a | |||||||
Hospital websites (n = 2758) | 2350 | 85.2 | 1088 | 85.1 [83.0–86.9] | 1262 | 85.3 [83.5–87.1] | 0.847 |
Hospital quality reports (n = 2702) | 1216 | 45.0 | 497 | 39.4 [36.7–42.1] | 719 | 49.9 [47.3–52.5] | <0.001 |
Other sources (n = 2730) | 1541 | 56.4 | 709 | 55.8 [53.0–58.5] | 832 | 57.0 [54.5–59.5] | 0.514 |
Safety | |||||||
Experiences in the past two years a | |||||||
Received wrong medication/dose (n = 2533) | 188 | 7.4 | 118 | 10.1 [8.5–11.9] | 70 | 5.1 [4.0–6.4] | <0.001 |
Suspected medical error in treat-ment/care (n = 2525) | 396 | 15.7 | 234 | 20.2 [18.0–22.6] | 162 | 11.8 [10.2–13.6] | <0.001 |
Was told that a medical error had been made (n = 2623) | 123 | 4.7 | 57 | 4.6 [3.6–5.9] | 66 | 4.7 [3.7–5.9] | 0.914 |
Received wrong results of medical/laboratory tests (n = 2400) | 107 | 4.5 | 69 | 6.3 [5.0–7.9] | 38 | 2.9 [2.1–3.9] | <0.001 |
Improved health | |||||||
Perceived health (VAS from 0 [worst] to 100 [best health]), mean (95%-CI) c (n = 2788) | 75.7 | 1291 | 73.9 [73.0–74.7] | 1497 | 77.3 [76.6–78.1] | <0.001 | |
Responsiveness | |||||||
Very good/good rating of the last physician’s visit (GP or SP) (vs. moderate/bad/very bad) | |||||||
Waiting time until the appointment (n = 2611) | 2177 | 83.4 | 936 | 77.5 [75.1–79.8] | 1241 | 88.5 [86.7–90.0] | <0.001 |
Waiting time in medical practice (n = 2643) | 1969 | 74.5 | 844 | 68.7 [66.0–71.2] | 1125 | 79.6 [77.4–81.6] | <0.001 |
Free choice of physician/practice (n = 2607) | 2405 | 92.3 | 1066 | 88.3 [86.4–90.0] | 1339 | 95.6 [94.5–96.6] | <0.001 |
Respectful treatment (n = 2643) | 2478 | 93.8 | 1121 | 91.2 [89.5–92.7] | 1357 | 96.0 [94.8–96.9] | <0.001 |
Comprehensible explanations (n = 2642) | 2376 | 89.9 | 1029 | 83.7 [81.6–85.7] | 1347 | 95.3 [94.1–96.3] | <0.001 |
Participation in shared decision-making (n = 2615) | 2262 | 86.5 | 949 | 78.4 [76.0–80.7] | 1313 | 93.5 [92.1–94.7] | <0.001 |
Talk confidentially (n = 2616) | 2452 | 93.7 | 1102 | 90.3 [88.6–91.9] | 1350 | 96.7 [95.7–97.5] | <0.001 |
Coordination of care among different physicians (n = 1953) | 1162 | 59.5 | 418 | 46.1 [42.9–49.3] | 744 | 71.1 [68.3–73.8] | <0.001 |
Trust that treatment solely serves for well-being (and not other interests) (n = 2602) | 2103 | 80.8 | 880 | 73.4 [70.8–75.8] | 1223 | 87.2 [85.3–88.8] | <0.001 |
Discrimination experiences in health care in the past year a (n = 2675) | 220 | 8.2 | 156 | 12.6 [10.8–14.5] | 64 | 4.5 [3.5–5.6] | <0.001 |
High need for reforms in Germany (vs. low/no need) | |||||||
Coordination between physicians and hospitals (n = 2405) | 1153 | 47.9 | 613 | 55.0 [52.0–57.9] | 540 | 41.9 [39.2–44.6] | <0.001 |
Coordination between physicians (n = 2557) | 1217 | 47.6 | 665 | 55.1 [52.3–57.9] | 552 | 40.9 [38.3–43.5] | <0.001 |
Amount of money spent out-of-pocket (n = 2536) | 975 | 38.4 | 511 | 43.5 [40.7–46.4] | 464 | 34.1 [31.6–36.6] | <0.001 |
Availability of SPs (n = 2762) | 641 | 23.2 | 375 | 29.3 [26.9–31.9] | 266 | 17.9 [16.0–19.9] | <0.001 |
Quality of care (n = 2669) | 584 | 21.9 | 323 | 26.1 [23.7–28.6] | 261 | 18.2 [16.3–20.3] | <0.001 |
Availability of home care services (n = 1877) | 413 | 22.0 | 238 | 27.9 [24.9–30.9] | 175 | 17.1 [14.9–19.5] | <0.001 |
Availability of GPs (n = 2728) | 571 | 20.9 | 311 | 24.6 [22.3–27.0] | 260 | 17.8 [15.9–19.8] | <0.001 |
Availability of hospitals (n = 2745) | 168 | 6.1 | 99 | 7.8 [6.4–9.4] | 69 | 4.7 [3.7–5.8] | 0.001 |
Social and financial risk protection | |||||||
Households with out-of-pocket spending ≥500€ in the past year (vs. <500€) (n = 2312) | 789 | 34.1 | 398 | 36.1 [33.3–39.0] | 391 | 32.3 [29.7–35.0] | 0.058 |
Very strong/strong financial burden by out-of-pocket spending (vs. fair/less strong/not at all) (n = 2348) | 273 | 11.6 | 168 | 15.1 [13.0–17.2] | 105 | 8.5 [7.1–10.2] | <0.001 |
Difficulties paying health insurance premium a (n = 2660) | 73 | 2.7 | 44 | 3.6 [2.7–4.7] | 29 | 2.0 [1.4–2.8] | 0.013 |
Improved efficiency | |||||||
Experiences in the past two years a | |||||||
Duplicate tests due to lack of co-ordination (n = 2462) | 572 | 23.2 | 323 | 28.7 [26.1–31.4] | 249 | 18.6 [16.6–20.8] | <0.001 |
Subjectively unnecessary services (e.g., pharmaceuticals) (n = 2432) | 624 | 25.7 | 358 | 32.4 [29.7–35.2] | 266 | 20.1 [18.0–22.3] | <0.001 |
Relation of health insurance premium to coverage (n = 2751) | 0.004 | ||||||
Low/too low | 119 | 4.3 | 65 | 5.1 [4.0–6.4] | 54 | 3.6 [2.8–4.7] | |
Fair | 1716 | 62.4 | 753 | 59.2 [56.5–61.9] | 963 | 65.1 [62.6–67.5] | |
Too high/high | 916 | 33.3 | 453 | 35.6 [33.0–38.3] | 463 | 31.3 [29.0–33.7] |
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Achstetter, K.; Köppen, J.; Haltaufderheide, M.; Hengel, P.; Blümel, M.; Busse, R. Health Literacy of People with Substitutive Private Health Insurance in Germany and Their Assessment of the Health System Performance According to Health Literacy Levels: Results from a Survey. Int. J. Environ. Res. Public Health 2022, 19, 16711. https://doi.org/10.3390/ijerph192416711
Achstetter K, Köppen J, Haltaufderheide M, Hengel P, Blümel M, Busse R. Health Literacy of People with Substitutive Private Health Insurance in Germany and Their Assessment of the Health System Performance According to Health Literacy Levels: Results from a Survey. International Journal of Environmental Research and Public Health. 2022; 19(24):16711. https://doi.org/10.3390/ijerph192416711
Chicago/Turabian StyleAchstetter, Katharina, Julia Köppen, Matthias Haltaufderheide, Philipp Hengel, Miriam Blümel, and Reinhard Busse. 2022. "Health Literacy of People with Substitutive Private Health Insurance in Germany and Their Assessment of the Health System Performance According to Health Literacy Levels: Results from a Survey" International Journal of Environmental Research and Public Health 19, no. 24: 16711. https://doi.org/10.3390/ijerph192416711