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

Abstract

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.

Full text

TYPE Original Research
PUBLISHED 23 September 2022
DOI 10.3389/fpubh.2022.988782
OPEN ACCESS
EDITED BY
Susanne Jordan,
Robert Koch Institute (RKI), Germany
REVIEWED BY
Stefanie Harsch,
University of Education
Freiburg, Germany
Bernhard Wernly,
Paracelsus Medical University, Austria
Uwe H. Bittlingmayer,
University of Education
Freiburg, Germany
René Rüegg,
Bern University of Applied
Sciences, Switzerland
*CORRESPONDENCE
Eva-Maria Berens
eva-maria.berens@uni-bielefeld.de
SPECIALTY SECTION
This article was submitted to
Public Health Education and
Promotion,
a section of the journal
Frontiers in Public Health
RECEIVED 07 July 2022
ACCEPTED 25 August 2022
PUBLISHED 23 September 2022
CITATION
Berens E-M, Klinger J, Carol S and
Schaeer D (2022) Dierences in
health literacy domains among
migrants and their descendants in
Germany.
Front. Public Health 10:988782.
doi: 10.3389/fpubh.2022.988782
COPYRIGHT
©2022 Berens, Klinger, Carol and
Schaeer. This is an open-access
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publication in this journal is cited, in
accordance with accepted academic
practice. No use, distribution or
reproduction is permitted which does
not comply with these terms.
Dierences in health literacy
domains among migrants and
their descendants in Germany
Eva-Maria Berens1*, Julia Klinger1,2, Sarah Carol3and
Doris Schaeer1
1Interdisc. Cen. for Health Literacy Research, Bielefeld University, Bielefeld, Germany, 2Institute for
Sociology and Social Psychology, University of Cologne, Köln, Germany, 3School of Sociology,
University College Dublin, Dublin, Ireland
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
dierentiate 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-ecacy 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-ecacy, 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-ecacy 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
dierent domains of HL and testing its correlations with self-ecacy and
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Berens et al. 10.3389/fpubh.2022.988782
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.
KEYWORDS
health literacy, determinants and correlates, immigration and migration, Turkey,
former Soviet Union (FSU), Russian-speaking, self-ecacy, interethnic contact
Introduction
Health literacy, understood as the ability to find, understand,
assess and apply health-related information to make appropriate
health decisions and take action in everyday life concerning
health care, disease prevention and health promotion (1),
has become an increasingly important topic in public health
research and policy (2). It has widely been shown to be associated
with poor health behavior, poor health outcomes, lower use of
preventive measures, and increased use of several health services
[ex. (3–6)], leading to additional annual health care costs (7).
The concept of health literacy is relational; thus a person’s health
literacy depends on both the individual skills and abilities as well
as situational demands (1). In other words, the need and the
quality of individual skills and abilities depend on organizational
structures and access to reliable health information presented in
an understandable, assessable and applicable manner.
Recent surveys have shown that large proportions of adult
populations, including adults from Germany, have limited
health literacy (5,6,8,9). Studies have also highlighted that
health literacy is unequally distributed. Several groups, such
as, for instance, persons with lower socioeconomic status, have
particularly low health literacy [ex. (6)] meaning that it is
more difficult for them to deal with health-related information.
It has also been indicated that migrant populations have
particularly low health literacy. The term “migrant” in this paper
generally refers to persons who migrated themselves across
international borders and their descendants born in the country
of residence who are labeled as second generation without any
limitations regarding reasons for moving, duration of staying
and residence status. Research in the United States, Canada
and Australia mostly shows large proportions of low health
literacy among ethnic minorities or migrants, including Asians,
Latin Americans, former Soviet Union migrants and other
ethnic groups (10–14). In Europe, this includes, for instance,
migrants with refugee status and Arabic-speaking migrants in
Sweden (15,16), women from Somalia and different migration
groups in Norway (17,18), Russian-speaking migrants in Israel
(19), Turkish, Portuguese and former Yugoslavian migrants in
Switzerland and Austria (20,21). To the best of our knowledge,
research on migrants in Germany is scarce. Existing datasets
include only a small number of migrants, which does not allow
for detailed analyses [ex. (8,22,23)]. Our aim is to fill this
research gap.
The factors associated with low health literacy among
migrant and non-migrant populations are manifold, especially
when a broad socio-ecological and relational concept of health
literacy is considered. Literacy skills in general, sometimes
framed as functional health literacy and included as a basic
prerequisite in many health literacy definitions [ex. (1,24)],
are strongly associated with health literacy [ex. (8,22,25,26)].
Furthermore, lower socioeconomic or social status and lower
levels of formal education are associated with low health literacy
(4–6,8,9,12,13,19,22,27–32). Several studies also indicate
that health literacy mostly declines with increasing age, is
sometimes associated with gender without a consistent pattern,
and in some cases lower among persons with chronic diseases
(4,6,8,29,33). More recently, psychological aspects gained
attention in health literacy research. For example, self-efficacy,
defined as ‘beliefs in one’s capabilities to organize and execute
the courses of action required to produce given attainments’
(34), was found to be linked to health literacy in the general
population (35–37). This seems plausible as dealing with health
information might be complicated and self-efficacy in other
words is the subjective certainty of being able to cope with new
and difficult situations. In addition, psychological characteristics
can affect competences more directly than sociodemographic
and -economic factors. Thus, this might be a relevant aspect
for health literacy interventions. In addition, scholars demand
more focus on the system and social-ecological context in which
health information is provided instead of individual skills (38).
In this regard, individuals’ social ties are expected to be related
to health literacy (30,39). Among migrants, especially social ties
with persons that are familiar with the national health system
and thus social integration in form of interethnic contacts might
be relevant for their health literacy. Interethnic friendships
are a common indicator of social integration (40). Qualitative
studies support the relevance of these aspects (41–43). To the
best of our knowledge, there are no quantitative studies on
the association of self-efficacy and interethnic contacts with
health literacy among migrants so far. Our study attempts to fill
this gap. We consider it to be important to investigate health
literacy more holistically by identifying factors that lie within
the migrants’ environment and network, as well as individual
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characteristics such as self-efficacy, which imply that migrants
are also self-determined actors.
Additionally, migrant-specific aspects, such as low
proficiency in the receiving country’s language and a shorter
duration of stay have been identified as factors associated with
low health literacy (12,15,16,18,21,32,44–46). Research
considering second generation migrants is scarce (21). Several
studies also indicate differences in health literacy by migrant’s
region or country of origin. For example, in Switzerland, Austria
and Norway, migrants from Turkey had lower health literacy
than other immigration groups (18,20,21). In a sample of
older migrants in a federal state in Germany (North Rhine
Westphalia), migrants form Turkey and Poland had lower
health literacy in the domain of health care than migrants from
Italy and Greece (32).
Another gap in the literature concerns a differentiation
between domains of health literacy to enable conclusions for
specific contexts of health information. Although the general
health literacy measurement (HLS-EU-Q47) used in many
European studies (47) would allow for domain-specific analyses,
there are only a few studies reporting health literacy of the
general population in its domains of health care, disease
prevention and health promotion. They show differences in
health literacy between the domains. In most studies, health
literacy in the domain of health promotion was lowest (5,20,
48,49). Comparing health care and disease prevention domains
did not reveal a consistent pattern (5,20,33,49,50). Detailed
information on health literacy in different domains among
migrants is rare and so far only considered in national reports.
In Switzerland, Portuguese and Turkish migrants showed the
lowest health literacy in the domain of disease prevention
and health promotion (20). In Norway, differences across
domains were very small among immigration groups (18).
In a small diverse migrant sample in Portugal, health care
and disease prevention literacy were similarly pronounced but
health promotion literacy was substantially lower (51). Studies
comparing determinants of health literacy across domains,
especially among migrants, are scarce (18,33,52). We address
this research gap in our study.
It is crucial to know more about health literacy in different
population groups and especially about health literacy in
its domains in order to be able to design interventions,
which can improve the provision of information to migrants.
The aim of this article is therefore to analyse health
literacy focusing specifically on the domains of health care,
disease prevention and health promotion among migrants in
Germany. Furthermore, we add migrant-specific, demographic,
socioeconomic and psychological variables (self-efficacy) as well
as social ties (interethnic contacts) to the equation.
In our analyses, we focus on two of the largest immigration
groups in Germany, Turkish migrants and migrants from the
former Soviet Union (FSU) and their descendants. In 2021,
around 3 million people of Turkish descent and around 3.5
million people from the former Soviet Union live in Germany
(53). Most of the Turkish migrants came as guest workers
(temporary labor migrants) following an agreement with Turkey
in 1961, followed by family reunions. Many of FSU migrants
arrived in the late 1980s from Russia but are ethnic Germans
(Aussiedler). The socioeconomic status of migrants is, on
average, lower than that of natives. However, FSU migrants have
a higher socioeconomic status than Turkish migrants (54,55),
partly due to the recognition of their degrees (56) or a linguistic
advantage among ethnic Germans.
The following questions are addressed:
•What is the current status of health literacy among
migrants (i.e., from Turkey and from FSU) in Germany
in general and in three different domains of health care,
disease prevention and health promotion?
•Which factors are associated with health literacy in general
and the three domains?
◦Are there differences in health literacy by migrant-
specific aspects, i.e., country of origin and
generation/duration of stay?
◦Which role do demographic, socioeconomic, health-
related aspects and health-related literacy skills play?
◦Which role do psychological aspects (self-efficacy) and
social ties (interethnic contacts) play?
Materials and methods
Data
Data from the survey “Health literacy survey of people with
migration background in Germany” (HLS-MIG) were used for
this article. It is related to the second health literacy survey in
Germany [HLS-GER 2 (49)]. The data were collected and stored
anonymously in compliance with ESOMAR (European Society
for Opinion and Marketing Research) standards and European
GDPR (General Data Protection Regulation).
The respondents of the quantitative cross-sectional survey
were persons at least 18 years old and who themselves or at
least one of their parents have / had a citizenship from Turkey
or a country belonging to the former Soviet Union. The survey
was conducted in August/September 2020 using paper-assisted
oral-personal interviews (PAPI). The interview was offered in
German, Turkish and Russian (57).
Multi-stage random and quota sampling was used. At
first, sampling points were selected within most of the federal
states of Germany with a probability proportional to the
targeted population size in the respective federal states. For each
selected sampling point one bilingual interviewer was recruited
who in turn recruited respondents by means of nationwide
quotas regarding age, gender and personal or parental (one- or
two-sided) migration experience, i.e., first- or second-generation
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migrants, for each immigration group based on official statistics
(53). After exclusion of 21 interviews with less than 80% of the
core questions answered as well as interviews with unusually
monotonous response behavior or unusual similarity of the
interviews of a specific interviewer, a total of 1,037 respondents
were included in the original study.
Measures
Health literacy was measured with the instrument
HLS19-Q47(-DE), which is based on the HLS-EU-Q47 that
was revised and refined for the Health Literacy Population
Survey 2019–2021 (6). Following Sorensen’s et al. (1) health
literacy definition, it contains 47 items on specific health
information tasks in the domains of health care (16 items),
disease prevention (15 items), and health promotion (16
items) and the information management steps accessing,
understanding, appraising, and applying. The respondents were
asked to assess perceived difficulties with the options “very easy,”
“easy,” “difficult,” and “very difficult”. In this article, the items
were combined into four health literacy scores, one for each
domain and one for general health literacy. In accordance with
the HLS19 procedure, each score is calculated as the percentage
of items that were answered with “very easy” or “easy” if 80 % of
the corresponding items were answered (6). Therefore, scores
range from 0 to 100 and higher values signify a higher level of
health literacy.
Two migration-specific factors were included. Region of
origin was coded into 0 “FSU” and 1 “Turkey.” Duration
of stay was combined with migration generation to include
respondents that were born in Germany in the same models:
“second generation,” “up to 5 years,” “6 to 25 years,” “26 years
and more.”
Demographic and socioeconomic factors, age, gender,
educational level, social status, and financial deprivation were
used. We took age measured in years and gender (1 “female”
and 0 “male”) into account. Educational level was categorized
according to the International Standard Classification of
Education [ISCED-11 (58)], ranging from 0 “no formal
education” to 8 “doctorate.” Due to low case numbers for the
lowest category (n=7), it was combined with ISCED level 1
(primary education). To facilitate the allocation, respondents
were asked about their school and vocational degrees, including
those that are or were possible to achieve in Turkey and FSU
countries. Social status was operationalized with a question on
the self-perceived position in society, using the image of a ladder,
ranging from 1 to 10. Respondents were asked “On the following
scale,” step ‘1’ corresponds to “the lowest level in the society”;
step ‘10’ corresponds to “the highest level in the society.” Could
you tell me on which step you would place yourself?” (59).
Financial deprivation was based on the perceived difficulty in
paying for medications with answers “very easy” =1 “none,”
“easy” =2 “low,” “difficult” and “very difficult” =3 “medium–
high,” the latter two being combined due to low case numbers
for the last category (n=28). As a health-related aspect,
chronic disease was included. A chronic disease was ascribed to
respondents with one or several chronic diseases (for at least 6
months) (0 “no,” 1 “yes”). German health-related literacy skills
were included based on the objective Newest Vital Sign test. The
test measures the ability to read and apply information from an
ice cream nutrition label and comprises six questions. The sum
score of correct answers varies from 0 to 6, with a higher value
for higher health-related literacy skills (60). The accompanying
food label was provided in German only to test German specific
literacy skills.
Self-efficacy was measured with a validated short version
instrument (ASKU) with 3 items: (i) I can rely on my own
abilities in difficult situations. (ii) I am able to solve most
problems on my own. (iii) I can usually solve even challenging
and complex tasks well. Respondents could answer on a five-
point Likert scale ranging from 1 “does not apply at all” to 5
“applies completely”. The items were combined in a mean score
ranging from 1 to 5 with a higher value for higher self-efficacy
(61). Interethnic contact was operationalized with a question on
the share of friends or acquaintances of German origin with 5
categories (1 “none/almost none,” 2 “less than half,” 3 “half,” 4
“more than half” and 5 “all or almost all”).
Statistical analyses
Ordinary least square (OLS) regressions were estimated by
health literacy domain. Overall, five models were estimated.
The null model (M1) only contains region of origin. In
Model 2, we add generation, in Model 3 demographic and
socioeconomic variables, in Model 4 self-efficacy and in the last
model interethnic contact. In addition, ANOVAs were used to
indicate statistically significant differences between subgroups,
based on the 95% confidence intervals. We calculated clustered
standard errors on the level of interviewers (n=113) to account
for interviewer effects (62). We applied listwise deletion based on
missing values of at least one of the described variables with 825
respondents remaining in the sample. There were no statistically
significant differences in health literacy scores in the full and
restricted sample.
Results
Characteristics of the study sample
As shown in Table 1, the mean age of the sample was
almost 44 years and more than half was female or had at least
one chronic disease. Around one third had high education
and around two-thirds had high health-related literacy skills.
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TABLE 1 Sample characteristics.
n%n%
Region of origin Financial deprivation
Former Soviet Union 413 50.1 None 195 23.6
Turkey 412 49.9 Low 442 53.6
Duration of stay Medium–high 188 22.8
Mean (SD), min–max 22.4 (13.8) 0–58 Chronic disease(s)
5 years and below 99 12.0 Yes 447 54.2
6–25 years 282 34.2 No 378 45.8
26 years and longer 219 26.5 Health-related literacy skills
Born in Germany 225 27.3 Mean (SD), min–max 3.9 (1.8) 1–6
Gender Low (NVS 0–1) 107 13.0
Male 380 46.1 Medium (2–3) 195 23.6
Female 445 53.9 High (4–6) 523 63.4
Age Self-efficacy
Mean (SD), min–max 43.5 (16.2) 18–91 Mean (SD), min–max 3.9 (0.8) 1–5
18–29 years 202 24.5 Low (below mean) 331 40.1
30–45 years 278 33.7 High (above mean) 494 59.9
46–64 years 242 29.3 Interethnic contacts
65 years and older 103 12.5 Mean (SD), min–max 2.8 (1.3) 1–5
Educational level None or almost none 150 18.2
Low (ISCED 0–2) 185 22.4 Less than half 232 28.1
Medium (3–4) 333 40.4 Around half 186 22.5
High (5–8) 307 37.2 More than half 175 21.2
Social Status All or almost all 82 9.9
Mean (SD), min–max 5.7 (1.7) 1–10
Low (1–4) 161 19.5
Medium (5–7) 545 66.1
High (8–10) 119 14.4
The social status was mostly perceived to be in the medium
categories and one half had low financial deprivation. Self-
efficacy in the sample was rather high. One quarter of the sample
was born in Germany and for first generation migrants the
duration of stay was on average 22 years. The majority of the
sample has interethnic contacts with persons of German origin.
There were substantial differences between FSU and Turkish
migrants regarding educational level, age, financial deprivation,
the proportion of first generation and duration of stay (see
Supplementary Table 1). Most people of the FSU sample were
born in Russia, Kazakhstan or Ukraine.
Descriptive statistics on health literacy
domains
As shown in Figure 1, the mean general health literacy
score among migrants in the sample was 65.5 out of 100
(95% CI: 64.1, 66.9). Significant differences were found between
FIGURE 1
Health literacy score means (means with range 0–100 and 95 %
confidence intervals).
the three domains of health literacy. Health literacy in the
domains of disease prevention [64.1 (62.5, 65.8)] and health
promotion [62.7 (61.1, 64.2)] were significantly lower than in
the domain of health care [69.7 (68.1, 71.2)]. This means that
more health information tasks regarding disease prevention and
health promotion were perceived as (very) difficult compared to
information regarding health care.
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Berens et al. 10.3389/fpubh.2022.988782
Bivariate analyses showed that health information was
more difficult to process for specific subgroups (Figure 2).
Overall, there were differences in health literacy scores regarding
migration-specific factors, demographic, socioeconomic, health
and literacy related, self-efficacy and interethnic contacts. FSU
migrants in our sample had a slightly lower score in the domains
of health care (p<0.05) and health promotion than migrants
from Turkey. Migrants from Turkey in turn had a slightly
lower score in disease prevention. Persons who were born
abroad had lower scores, especially in the domains of health
care (p<0.05) and health promotion. Health literacy scores
across all domains were also lower among older respondents.
Respondents with at least one chronic disease had a lower
health literacy score. This also applied to respondents with a
lower educational level or health-related literacy skills. A lower
social status and financial deprivation were reflected in a lower
health literacy score as well. Finally, those with lower self-efficacy
and those with fewer interethnic contacts had a lower health
literacy score.
Determinants of health literacy domains
Results of the ordinary least square regressions (Table 2)
showed that region of origin was only significantly associated
with health literacy in the domain of disease prevention,
with lower values for Turkish migrants when controlling for
demographic and socioeconomic factors, literacy, chronic illness
and self-efficacy (model 4). After adding interethnic contacts
(model 5), the association with region of origin decreases
and is no longer significant. Lower health literacy in the
domain of health care among FSU migrants was only present
in the null model (model 1) and the contrast disappeared
when taking duration of stay into account. No correlation
with region of origin were found for general health literacy
and in the domain of health promotion. All categories of
the duration of stay (reference second-generation migrants)
were significantly connected with health literacy in almost
all domains (model 2), thus first-generation migrants had
a lower health literacy compared to immigrant descendants.
When controlled for demographic and socioeconomic factors,
literacy and chronic illness (model 3), a shorter duration
of stay (up to 5 years) remained significantly associated
with a lower general health literacy and in the domain of
health care.
As shown in model 3, overall, a higher educational level,
higher social status and better health-related literacy skills
are linked to a higher health literacy, whereas financial
deprivation and increasing age (except for disease prevention)
are significantly associated with a lower health literacy in all
domains. Having at least one chronic disease is not associated
with health literacy in any domain in this sample. Women tend
to have a higher health literacy.
Self-efficacy (model 4) was significantly associated with
health literacy in all domains. Respondents with a higher self-
efficacy had a higher health literacy. It should be stressed
that self-efficacy considerably decreases the correlations of the
other independent variables with the dependent variables in
the model. Furthermore, adding interethnic contacts (model 5)
showed statistically significant and positive associations with
health literacy in all domains, except for disease prevention.
The full model (model 5) explained 13.2 % (disease
prevention) to 32.0 % (health care) of the total variance of health
literacy. The models with only region of origin and duration
of stay (model 1 and 2) explained around 1 to 6% of the total
variance. Including demographic and socioeconomic aspects,
health-related literacy skills and chronic disease (model 3)
explained considerably more variance, and the model including
self-efficacy (model 4) further increases explained variance.
Adding interethnic contacts does not add much explanation
of variance.
Discussion
A large proportion of the population in various countries
is experiencing substantial difficulties in dealing with health
information [ex. (6,9,47)]. Thus, improving health literacy
has become an important focus of health policies in many
countries (2), including Germany (63). In order to design
interventions that can improve health literacy, knowledge about
health literacy in potentially vulnerable population groups such
as migrants is crucial. The aim of this study was therefore to
analyze the current status of health literacy among migrants
and their descendants (i.e., from Turkey and from FSU) in
Germany and factors associated with it. Our contribution to
the current state-of-the-art is threefold: First, our study goes
beyond existing studies on migrant populations by drawing on a
newly collected, larger dataset and also include the non-German
speaking population. To date, there were only some qualitative
studies taking a deeper look into the matter (41–43,64). Existing
quantitative research on health literacy of migrants in Germany
could only analyse rather small subsets of migrants from diverse
backgrounds with good German language skills or subgroups
such as poorly educated adolescents or elderly (8,23,32,50).
Second, going beyond many previous studies, we differentiate
between dimensions of health literacy, namely the domains of
health care, disease prevention and health promotion. So far,
only few reports comprised data on domains of health literacy
including Turkish migrants but without going into details (18,
20) or used very small samples (51). Health literacy among FSU
migrants has mostly been neglected by research (65) and to
the best of our knowledge this has not yet been reported by
health literacy domains so far. Third and lastly, we explore new
mechanisms by testing the explanatory power of self-efficacy and
interethnic contacts for migrants’ health literacy.
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FIGURE 2
Health literacy score means in subgroups (means with range 0–100 and 95% confidence intervals).
Health literacy in general and in three
dierent domains
Our results indicate a rather low general health
literacy among migrants from Turkey and the former
Soviet Union. Nevertheless, it is important to note
that the average general health literacy score of this
sample is similar to recent observations of the general
population in Germany (8). Thus, migrants’ health literacy
in this sample is not as low as previous international
research on different migrant populations indicated
(10,11,13,16,17,19). However, a particularly low
health literacy is found within subgroups of the migrant
population. This is an important finding that was missing so far
for Germany.
In the next step, we took a deeper look at the three
domains of health-related information, namely health care,
disease prevention and health promotion. Health promotion
literacy was lowest in our sample. This is in line with findings for
the general population in various countries including Germany
(4,5,28,33,49,50,66). However, in our study health
promotion literacy is closely followed by disease prevention
literacy and both are substantially lower than health care literacy.
Thus, dealing with information regarding health promotion
and prevention in our sample is perceived to be more difficult
than health care. This is in contrast to German studies on the
general population (33,49), which showed a similar degree of
health care and disease prevention literacy. An Austrian report
on migrants also indicates low disease prevention and health
promotion literacy (20). The low health literacy in these domains
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Berens et al. 10.3389/fpubh.2022.988782
should have been alleviated by the ‘prevention act’ which was
passed in 2015. The law was supposed to expand on the disease
prevention and health promotion measures (67). While the
range of measures has grown strongly since then, user-friendly
information for migrants on these topics is still lacking.
Health literacy and migrant-specific
factors
To be able to design interventions, knowledge about
vulnerable groups is crucial. Therefore, associations with health
literacy in the different domains were analyzed. Our results
indicate differences between Turkish and FSU migrants in some
domains. While we do not see any ethnic contrasts for general
health literacy and health promotion health literacy there are
differences in the domains of health care literacy and disease
prevention literacy by region of origin. Migrants from Turkey
and their descendants seem to have a substantially higher health
care but lower disease prevention literacy than migrants from
former Soviet Union. While the deviation in health care literacy
between both immigration groups already disappears when
taking generation into account, Turkish migrants still have a
lower disease prevention literacy after controlling for differences
in demographic and socioeconomic factors, literacy, chronic
illness and self-efficacy. Migrants from Turkey apparently face
more challenges in dealing with disease prevention information,
including information tasks on vaccination, preventive check-
ups, medical screenings and dealing with health risks in general
than FSU migrants, who resemble the general population in
Germany in this domain (33). This difference may (partly) be
explained by differences the health care systems and attitudes
toward prevention and disease patterns in the countries of
origin. For example, the Semashko-System in the FSU already
provided a good basic care in a standardized system, open
for everyone, and included public health measures such as
prevention, hygiene and other preventive measures. This only
changed in the late 1980s and became weaker after the fall of the
FSU (68). In Turkey, preventive measures were also provided,
however, the focus is more on health care and therapy than
on preventive measures in the system (69). Turkish migrants
have been described to focus more on treating illness rather
than making use of preventive measures (70). In the German
health system, a lot of disease prevention measures, like common
vaccinations and disease-specific screenings, are financed by
the statutory health insurance and are therefore cost free for
users. Since the passing of the so-called Prevention Act in
2015, disease prevention and health promotion received more
attention (71). Experiences with preventive measures in the
country of origin seem to shape migrants’ expectations and
influence their behavior in the receiving country. The amount
of difficulties they face with information about prevention
measures might be higher if those were not common in their
country of origin. To the best of our knowledge, this has not
been studied so far. Further research is needed to investigate
the relevance of country of origin and differences in health care
systems and attitudes for health literacy in different domains.
Previous studies also reported lower health literacy for the
first migration generation (12,21,52) and those with a shorter
duration of stay [ex. (15,16,32,45,46)]. Our two groups of study
have different migration histories. The Turkish immigration
group has been in Germany for many decades and is thus
composed of different migration generations, while most FSU
migrants belong to the first generation (53). We found strong
evidence that descendants of migrants, i.e., persons that were
born in Germany, have substantially higher health literacy in all
domains than first generation migrants. However, generational
differences can largely be explained by demographic and
socioeconomic variables except for respondents with a short
duration of stay (up to 5 years) who have a significantly
lower general health literacy and health care literacy compared
to second-generation migrants. No effect of duration of stay
was found for disease prevention and health promotion when
taking demographic aspects into account. This indicates that
recent immigrants including refugees are more vulnerable when
dealing with information about diseases, their management and
the interaction with medical professionals and the health care
system. This seems plausible as their knowledge of the health
care system is rather limited shortly after they arrive and grows
with a longer stay in the receiving country. This also means that
there is a need for the provision of information on health care
for migrants who recently migrated to reduce the disparities in
difficulties dealing with health care related information tasks.
Health literacy and demography and
socioeconomy
Besides country of origin and duration of stay,
socioeconomic variables contributed toward explaining
health literacy. In sum, low educational level, low social status
and financial deprivation were negatively correlated with health
literacy. This is in line with German and international health
literacy research in general [ex. (4,6,8,9,22,28,29)] and in
migrant populations (12,32,45). It is also noteworthy that
adding demographic and socioeconomic determinants to the
model considerably decreases differences by region of origin.
In Germany, migrants tend to have a lower socioeconomic
position [ex. (72)] and thus part of the variation in health
literacy is due to socioeconomic disadvantages. Interventions
need to focus on socioeconomically disadvantaged groups
and create measures to make information more accessible,
understandable and applicable for persons with poor education,
financial deprivation and low social status. However, the
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TABLE 2 Factors associated with health literacy—stepwise ordinary least square (OLS) regression results.
General health literacy Health care literacy Disease prevention literacy Health promotion literacy
M1 M2 M3 M4 M5 M1 M2 M3 M4 M5 M1 M2 M3 M4 M5 M1 M2 M3 M4 M5
Constant 64.74 72.50 60.12 36.92 32.35 67.47 79.01 67.847 40.24 35.87 65.68 70.81 53.92 34.50 30.68 61.12 67.59 58.40 36.15 30.26
1.383 2.308 5.076 7.042 7.392 1.567 2.34 5.139 7.035 7.522 1.577 2.851 6.203 8.183 8.586 1.558 2.646 6.573 8.292 8.372
Region of origin: Turkey 1.546 −1.669 −1.482 −1.248 −0.260 4.363* −0.834 −0.960 −0.681 0.264 −3.084 −5.407** −4.729* −4.533* −3.678 3.059 0.979 1.014 1.239 2.329
(ref. former Soviet Union) 2.055 2.402 2.141 2.113 2.130 2.247 2.530 2.128 2.094 2.101 2.361 2.657 2.498 2.497 2.562 2.204 2.677 2.552 2.512 2.519
Duration: up to 5 years∧
−9.79*** −5.355** −5.074 −3.264 −15.90*** −10.97*** −10.64*** −8.905** −5.740* −1.876 −1.641 −0.11 −7.51** −3.034 −2.764 −1.353
3.139 2.923 3.028 3.143 3.816 3.302 3.432 3.491 3.456 3.549 3.617 3.730 3.304 3.160 3.243 3.516
6–25 years∧
−8.26*** −1.671 −1.528 −0.631 −12.4*** −3.675* −3.504 −2.647 −6.044** −2.242 −2.121 −1.427 −6.20** 0.848 0.985 1.763
2.267 2.170 2.103 2.049 2.412 2.171 2.127 2.133 2.753 2.738 2.739 2.715 2.627 2.625 2.499 2.441
26 years and more∧
−8.13*** 1.356 −0.008 0.122 −10.5*** 2.582 0.959 1.084 −4.554 0.249 −0.893 −0.821 −9.07*** 1.194 −0.113 0.017
2.647 2.363 2.309 2.291 2.706 2.420 2.373 2.355 3.185 3.162 3.101 3.094 2.691 2.605 2.570 2.574
Females 2.264 2.982** 2.922** 1.318 2.173 2.116 2.971* 3.572** 3.530** 2.53 3.219** 2.999*
(ref. males) 1.378 1.393 1.373 1.519 1.543 1.525 1.724 1.766 1.739 1.548 1.531 1.521
Age −0.171** −0.119* −0.107 −0.305*** −0.243*** −0.232*** 0.008 0.052 0.063 −0.206*** −0.156** −0.131
0.069 0.068 0.070 0.077 0.074 0.075 0.081 0.081 0.082 0.076 0.077 0.079
Educational level 1.456*** 0.963** 0.907** 1.694*** 1.108** 1.054** 1.127* 0.714 0.672 1.536*** 1.063** 0.948**
0.429 0.394 0.392 0.493 0.446 0.439 0.494 0.464 0.465 0.457 0.445 0.446
Social status 1.630*** 1.148** 1.086** 1.993*** 1.419*** 1.360** 1.418* 1.014 0.962 1.450*** 0.988* 0.939*
0.486 0.494 0.496 0.525 0.533 0.544 0.644 0.697 0.696 0.539 0.507 0.500
Financial deprivation −4.921*** −3.897*** −3.649*** −4.791*** −3.572*** −3.335*** −4.760*** −3.903** −3.682** −5.211*** −4.229** −3.822**
1.275 1.263 1.275 1.279 1.233 1.228 1.507 1.532 1.552 1.640 1.624 1.635
Chronic disease(s) −0.337 −0.095 0.012 −0.179 0.108 0.211 −0.368 −0.166 −0.038 −0.477 −0.245 −0.212
(ref. none) 1.477 1.501 1.499 1.582 1.592 1.594 1.933 1.976 1.961 1.767 1.767 1.745
Health–related literacy skills 2.059*** 1.836*** 1.768*** 2.098*** 1.834*** 1.768*** 2.205*** 2.018*** 1.942*** 1.867*** 1.653*** 1.642***
0.498 0.473 0.469 0.543 0.500 0.501 0.601 0.586 0.584 0.571 0.559 0.551
Self–efficacy 6.231*** 6.115*** 7.415*** 7.303*** 5.217*** 5.077*** 5.975*** 5.835***
1.022 1.010 1.154 1.140 1.229 1.218 1.073 1.055
Interethnic contacts 1.358** 1.299* 1.180 1.572**
0.559 0.669 0.748 0.628
Corrected. R² 0.0002 0.025 0.215 0.266 0.271 0.008 0.054 0.256 0.315 0.318 0.003 0.008 0.105 0.129 0.131 0.003 0.020 0.163 0.199 0.205
N=825; bold numbers: B-coefficients; italic numbers: standard errors; ***p <0.01, **p <0.05, *p <0.1; ∧reference (ref.): born in Germany; M: Model.
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Berens et al. 10.3389/fpubh.2022.988782
socioeconomic disadvantage is not the only explanation for low
health literacy.
In addition, we have shown that age is a relevant predictor
of health care literacy and health promotion literacy. In
contrast, we could not observe an association in the domain
of disease prevention. This resembles findings for the general
population sample in Germany (33). Results from other
countries investigating the association of age and general health
literacy have been inconsistent [ex. (25)]. We conclude, that
it is necessary to differentiate by domains and that this focus
might lead to more consistent findings. Our results imply
that there is a need to focus on older people in health
care information interventions but not in disease prevention
information interventions in Germany. As in the general
population in Germany (33), gender differences were found for
general health literacy, disease prevention literacy and health
promotion literacy, and were higher among female migrants.
This is plausible as migrant women sometimes manage health
matters for family members (64). No substantial deviation
from male migrants was found for health care literacy when
controlling for other characteristics. However, it has to be noted
that gender does only account for small variations of health
literacy in our study. Age and gender should be considered
when designing interventions. Strategies to design and promote
health information should be adjusted to different age-groups
and among men and women, especially in different domains.
The bivariate results also show that migrants with at least one
chronic disease face more challenges with health information in
the domains of health care and health promotion, but not in
the regression analyses. In contrast, having a chronic disease
was associated with a lower health literacy among the general
population in Germany across all domains (33). This needs
further exploration in future studies.
Low health-related literacy skills were also strongly
associated with lower health literacy across domains. The effect
of low proficiency in the receiving country’s language on health
literacy is not surprising and has been well documented for
migrants [ex. (10,12,15,16,32,44,46). Thus, there is a need for
information in a simple language. It also needs to be reflected
if information should be provided in more accessible formats
such as videos or pictures.
Our study adds to the scare literature of determinants on
health literacy in domains by showing that the associations are
mostly constant across the three domains of health literacy.
Health literacy and self-ecacy
Our results add to the state-of-knowledge on health literacy
by considering self-efficacy using a migrant sample. The results
show that migrants with higher self-efficacy had better health
literacy than migrants with lower self-efficacy in regression
models across all domains. Hence, migrants with strong beliefs
in their own capabilities “to organize and execute the courses
of action required to produce given attainments” (34) perceived
tasks in dealing with health relevant information in different
domains as less difficult. This resembles findings in the
general population and children in Germany (35,73). Thus,
strengthening self-efficacy might positively affect health literacy.
This might also prevent reverse effects if difficulties in dealing
with health information might negatively affect self-efficacy.
Health literacy and interethnic contact
Previous findings emphasized the importance of the social
context for health literacy, especially among vulnerable groups
(39,41–43,64). We included interethnic contacts as a form
of social ties and social integration. Previous research has
repeatedly emphasized the importance of interethnic ties as
generators of “bridging social capital” for ethnic minority
integration that can equip migrants with resources relevant
in the country of residence [ex. (74,75)]. For the first time,
we were able to show quantitatively that interethnic contacts
might help migrants dealing with health-related information.
In our study, we find that interethnic contacts with native
Germans are positively linked to a higher health literacy across
all domains except for disease prevention. Social ties with
persons that are familiar with the national health system seem
to be important to gain relevant information on health–related
aspects in the receiving country. These ties could also be
a resource or even compensation for the above-mentioned
possible disadvantages, like lower socioeconomic position or
literacy skills. We suspect that these ties play less of a role
for disease prevention, as the occurrence of diseases is rather
unforeseeable and therefore triggers insecurity among all parts
of the population. In the COVID-19 pandemic, it became
clear, that prevention knowledge changes at a much faster pace
compared, for instance, to knowledge about the health care
system, which is a more static entity. This in turn will affect
the degree to which it can be transmitted through personal ties;
knowledge that changes at a faster pace cannot be transmitted as
efficiently. We argue that interethnic contact is therefore more
important for all other domains of health literacy. However,
information must also be designed and provided in a better
way to meet the needs of socially less integrated migrants and,
for instance, additionally train persons from the community as
health information multipliers/mediators (76). Further research
should examine the social support within interethnic contacts.
Limitations
Limitations arise primarily in two areas: the area of sampling
and the area of measurement of health literacy. First, due to the
COVID-19 pandemic and difficulties with face-to-face surveys
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Berens et al. 10.3389/fpubh.2022.988782
in respondents’ households, we relied on community-based
sampling. This is strictly speaking not a probability sample and
therefore hampers the representativity of our sample. This is
reflected in a higher share of highly educated migrants in both
immigration groups, higher share of older persons in the FSU
sample and higher share of young persons in the Turkey sample
compared to official statistics (53,77). Due to quotas for each
immigration group, the sample consists of similar shares of
persons who migrated to Germany and descendants of migrants
as well as similar shares of males and females compared to
the target population. German citizenship was overrepresented
in the Turkey sample and underrepresented in the FSU
sample, while the share of persons with a shorter duration
of stay in Germany was higher than in the target population
in both samples. Hence, we need to be cautious with the
interpretation of descriptive statistics. However, in regression
analyses we control for education and other variables, partially
accounting for this sampling bias. Other studies could also
show that it can be beneficial to use non-probability sampling
methods especially in the immigrant population since more
vulnerable subgroups can be included in the survey (78–81).
The second limitation occurs with regard to the measurement
of our dependent variable health literacy. The scores are
based on self-rated difficulties with the different domains of
health literacy. However, perceptions can often be biased. For
instance, some respondents might underestimate difficulties,
whereas others overestimate their difficulties. Especially for
migrants, research on educational aspirations has repeatedly
shown that some immigration groups are more optimistic about
their skills than natives [ex. (82–84)]. To buffer this bias,
our models held actual health-related literacy skills constant.
Furthermore, the calculated health literacy scores following
international procedure (6) suffer from loss of information
due to the dichotomization of the four-point item answer
options. However, the scores still give a useful impression of the
individual’s health literacy in the light of the naturally superficial
limitations of quantitative studies. Health-related literacy skills
in this study were measured using the NVS test and the food
label was provided in German. Although this test measures
a small set of literacy skills related to health, i.e., nutrition,
we believe that this more objective measure reflects literacy
skills in German language better than the first language of
the respondents or self-assessed measures on German language
proficiency. Last, interethnic contact might interact with self-
efficacy. Hence, coefficients may be biased. This would need
further exploration in future studies. All in all, we believe that
our study has contributed to the existing state-of-the-art on
health literacy by (a) conducting the first study on Turkish and
FSU migrants in Germany, (b) investigating domain-specific
health literacy and (c) considering novel factors associated with
health literacy such as self-efficacy and interethnic contact.
Conclusion
Our study draws attention to the importance of migrant’s
health literacy. We show that health information on health
promotion and disease prevention are more difficult to process
than information regarding health care. Therefore, measures
addressing the provision of information (e. g. enhancing
accessibility and usability of health information) need to take
differences between the domains into account. We also reveal
that migrants in this study cannot generally be considered as
vulnerable, as often outlined, but there are subgroups of the
migrant population that have lower health literacy. There is
need for targeted interventions, especially for socioeconomically
disadvantaged, older migrants, those with poor German
language skills, and recently migrated. In addition, self-efficacy
and poor interethnic contact need to be addressed to reduce
inequalities in health literacy.
Data availability statement
The raw data supporting the conclusions of this article
will be made available by the authors upon request, without
undue reservation.
Ethics statement
The studies involving human participants were
reviewed and approved by Ethics Committee of Bielefeld
University (EUB-2019-104). Written informed consent
for participation was not required for this study
in accordance with the national legislation and the
institutional requirements.
Author contributions
DS and E-MB conceived the idea of the study. The
analyses were performed by JK and E-MB. The draft of
the manuscript was written by E-MB, JK, and SC. DS
commented and edited versions of the manuscript. All authors
contributed to the study design and questionnaire development,
interpreted the data and have read and approved the
final manuscript.
Funding
This work was funded by Robert Bosch Foundation (grant
number 01000081-001). The funders have had no influence on
the study design, data collection and analysis, interpretation
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Berens et al. 10.3389/fpubh.2022.988782
of the results, the manuscript and the decision to submit it
for publication.
Acknowledgments
We kindly thank Uliana Kostareva, Maria Lopatina, Altyn
Aringazina, Diane Levin-Zamir, and Yüce Yilmaz-Alsan for
their collegial advice on cross-country interpretation of the
results. We acknowledge the financial support of the German
Research Foundation (DFG) and the Open Access Publication
Fund of Bielefeld University for the article processing charge.
Conflict of interest
The authors declare that the research was conducted in
the absence of any commercial or financial relationships
that could be construed as a potential conflict
of interest.
Publisher’s note
All claims expressed in this article are solely those of the
authors and do not necessarily represent those of their affiliated
organizations, or those of the publisher, the editors and the
reviewers. Any product that may be evaluated in this article, or
claim that may be made by its manufacturer, is not guaranteed
or endorsed by the publisher.
Supplementary material
The Supplementary Material for this article can be found
online at: https://www.frontiersin.org/articles/10.3389/fpubh.
2022.988782/full#supplementary-material
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