The influence of living environments on subjective health literacy in fourth-graders in Germany

Abstract Background Evidence suggests that worse family affluence is related to low health literacy in children. Still, for the targeted promotion of health literacy, a more nuanced understanding is needed of how living environments affect health literacy in early life. This study explores the relationships between health literacy and indicators of living environments in the neighborhood and at home. Methods A representative sample of 4th-graders (age 8-11) was surveyed from Oct. 2022 to Feb. 2023 in North Rhine-Westphalia, Germany. We included the HLS-Child-Q15 to assess subjective health literacy, 4 items about the neighborhood (e.g., “neighborhood is a good place to play outside” or “I often see people smoking in the neighborhood”), and 4 items about home (e.g., “there’s always fruit and vegetables at home” or “it’s important to my parents that I exercise”). The tendency to answer in a socially desirable way was controlled for with a validated scale. Likert-scale items were dichotomized for use in linear regression. Results n = 1085 students are included, 50.3% are female. The mean age is 9.5 years (SD=.6). The regression model explains 17.8% of variability in health literacy (corr. R²). Significant (p<.05) predictors for high health literacy were birthplace (Germany, not Germany), agreement to the statements “I often see people exercising in my neighborhood”, “my parents can answer all my question about health”, “there’s always fruit and vegetables at home”, “it’s important to my parents that I exercise”, but also social desirability scores. Family affluence was not a significant predictor. Conclusions In this sample of 4th-graders, subjective health literacy could not adequately be explained by family affluence. Indicators of living environments seem to be better suited to explore variability in health literacy. These findings can be used to explore entry points for the promotion of health literacy early in life and to identify groups at risk for low health literacy.