Eva-Maria Berens

Health Literacy in the German Population: Results of a Representative Survey

BACKGROUND Persons with low health literacy have difficulty dealing with the health care system and understanding health-related information. Studies from multiple countries have shown that low health literacy negatively affects health, health-related and illness-related behavior, and the utilization of health care resources. The data available till now on health literacy in Germany have been sparse. The goal of this study is to acquire representative data on the health literacy of the German population. METHODS In a cross-sectional study, we collected data from a representative group of 2000 persons over age 15 in Germany by means of computer-assisted personal interviews (CAPI) that were based on the long version of the questionnaire used in the European Health Literacy Survey (HLS-EU-Q47). Sociodemographic data were also collected. RESULTS The respondents were a representative sample of the German population. 54.3% of them were found to have limited health literacy. Multiple logistic regression revealed associations of limited health literacy with advanced age (odds ratio [OR] 1.83, 95% confidence interval [CI] [1.36; 2.48]), an immigrant background (OR 1.87 [1.27; 2.75]), low self-assessed social status (OR 5.25 [3.57; 7.72]), and low functional literacy (OR 1.94 [1.49; 2.52]). CONCLUSION The low health literacy of many Germans can impair communication between doctors and patients and exacerbate existing problems in health policy. In the future, greater effort will have to be made to foster health literacy, make health-related information for patients easier to understand, and intensify research in the field of health literacy.

A cross-sectional study on informed choice in the mammography screening programme in Germany (InEMa): a study protocol

Introduction Breast cancer is the most prevalent cancer among women. In Germany, women are invited to a population-based mammography screening programme for the first time at the age of 50. Since it is still discussed whether the benefits of mammography screening outweigh its harms, the concept of informed choice has gained importance. The objective of this cross-sectional study is to assess the proportion of informed choices in the mammography screening programme. A special focus is on the examination of the impact of Turkish migration background and educational level on informed choices. Methods and analysis The proportion of informed choices is evaluated in a cross-sectional study with 3-month follow-up for behavioural implementation of the screening intention. A randomly selected sample of 17 000 women aged 50 years living in Westphalia-Lippe, a region in the Federal State of North-Rhine Westphalia, is invited to participate in this study. To reach adequate numbers of Turkish women, all possibly Turkish women in the sample are identified through a name algorithm and contacted. The sample is drawn from women registered in the study area for which the registration offices consented to supply data for the study (88% of all towns/cities in the study region). Women identified through the Turkish name algorithm received all materials in German and Turkish. The primary outcome is informed choice. Data are collected on informed choice components (knowledge, attitude, decision/implementation) as well as on its possible determinants (eg, health behaviour, perceived behavioural control, subjective norms, invitation status, migration background and other demographic variables). Data are collected before the screening appointment and at 3 months follow-up. Ethics and dissemination The study was approved by the ethical committee of the Medical Faculty of Muenster University. Results will be published in a relevant scientific journal and communicated to respondents and relevant institutions.

Determinants of mammography screening participation among Turkish immigrant women in Germany – a qualitative study reflecting key informants' and women's perspectives

Mammography screening programmes aiming to reduce mortality from breast cancer are implemented in most European countries. Immigrant women are less likely to participate than women of the respective autochthonous populations in several European countries but not in Germany. Qualitative, semi-structured interviews were conducted with 16 key informants and 10 Turkish immigrant women aged 50-69 years to analyse the factors influencing their screening participation in Germany. Interviews were analysed using summarising content analysis. The Theory of Planned Behaviour was used for structuring the results. Key informants stated poor German language skills and insufficient knowledge about breast cancer and screening as factors influencing screening participation. Immigrant women demonstrated basic knowledge about screening, but their attitudes towards screening varied. Information from the invitation letter of the screening programme was often filtered by family members. Key informants tended to emphasise barriers and system-related factors while the Turkish women focused more on factors on the individual level. Contrasting both perspectives is helpful for health professionals to critically assess their own views. Measures to improve screening participation need to address not only barriers but also take womens attitudes and norms into account, thus helping women to make an informed decision.

Informed Choice in the German Mammography Screening Program by Education and Migrant Status: Survey among First-Time Invitees

Breast cancer is the most prevalent cancer among women and mammography screening programs are seen as a key strategy to reduce breast cancer mortality. In Germany, women are invited to the population-based mammography screening program between ages 50 to 69. It is still discussed whether the benefits of mammography screening outweigh its harms. Therefore, the concept of informed choice comprising knowledge, attitude and intention has gained importance. The objective of this observational study was to assess the proportion of informed choices among women invited to the German mammography screening program for the first time. A representative sample of 17,349 women aged 50 years from a sub-region of North Rhine Westphalia was invited to participate in a postal survey. Turkish immigrant women were oversampled. The effects of education level and migration status on informed choice and its components were assessed. 5,847 (33.7%) women responded to the postal questionnaire of which 4,113 were used for analyses. 31.5% of the women had sufficient knowledge. The proportion of sufficient knowledge was lower among immigrants and among women with low education levels. The proportion of women making informed choices was low (27.1%), with similar associations with education level and migration status. Women of low (OR 2.75; 95% CI 2.18–3.46) and medium education level (OR 1.49; 95% CI 1.27–1.75) were more likely to make an uninformed choice than women of high education level. Turkish immigrant women had the greatest odds for making an uninformed choice (OR 5.30, 95% CI 1.92–14.66) compared to non-immigrant women. Other immigrant women only had slightly greater odds for making an uninformed choice than non-immigrant women. As immigrant populations and women with low education level have been shown to have poor knowledge, they need special attention in measures to increase knowledge and thus informed choices.

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.

Postalische Befragung von Frauen mit türkischem Migrationshintergrund – Identifizierung, Stichprobenbereinigung und Response im Rahmen der InEMa-Studie

AIM OF THE STUDY Migrants are an important target group for mailed surveys but also difficult to reach. For planning these surveys and invitational health measures, we assessed response figures for women with and without Turkish migration background. METHODS Women aged 50 years living in Westphalia-Lippe were invited to a postal survey at 2 time points about mammography screening. Turkish migrant women were identified in the contact database by a name-based algorithm. Possible differences in sample revision and response among women with and without Turkish migration background were assessed. RESULTS Women with Turkish migration background had unknown addresses significantly more often (4.6 vs. 1.7%) and responded to the questionnaires less often (first questionnaire: 14.3 vs. 35.9%; second questionnaire: 70.7 vs. 85.6%). CONCLUSIONS For postal invitation to participate in healthcare measures, or recruitment of Turkish migrants for studies, differences in current address and readiness to respond must be taken into consideration.

Uptake of Gynecological Cancer Screening and Performance of Breast Self-Examination Among 50-Year-Old Migrant and Non-migrant Women in Germany: Results of a Cross-Sectional Study (InEMa)

Our aim was to provide data regarding uptake of gynecological early detection measures and performance of breast self-examinations among migrant women in Germany. Cross-sectional self-reported data were collected using paper-and-pencil questionnaires. Descriptive analyses, Chi square-tests, and logistic regression were applied. Results were adjusted for educational level. Of 5387 women, 89.9% were autochthonous, 4.1% German resettlers, 2.8% Turkish, 3.1% other migrants. Participation rates regarding cancer screening differed significantly, with the lowest proportion in Turkish migrants (65.0%), resettlers (67.8%), other migrants (68.2%) and autochthonous population (78.2%). No differences in performance of breast self-examinations were detected. When adjusted for education, results indicated only slight changes in the odds to participate in screening irregularly or not at all. Results support existing evidence by showing lower participation rates in cancer screening among migrant women, but there were no differences regarding breast self-examinations. Migrant women form a potential high-risk group for late-stage diagnosis of cervical or breast cancer.