The influence of health literacy on health outcomes and behaviors in fourth-graders in Germany

Abstract Background For the adult population, evidence suggests that a high level of subjective health literacy is associated with a number of favorable health outcomes and behaviors. However, for younger populations, particularly children, little evidence is available. This study investigates the relationship between subjective health literacy, health outcomes, and health behaviors in children. Methods We conducted a representative survey of 4th-grade students (age 8-11) in North Rhine-Westphalia, Germany, between Oct. 2022 and Feb. 2023. Subjective health literacy was measured with the HLS-Child-Q15 questionnaire. For mental and physical well-being, the KINDL-R was used. For health behaviors, we asked about the frequency of (1) brushing teeth, (2) eating fruit and (3) vegetables, (4) exercising, (5) consuming sweetened drinks, and (6) wearing a helmet when riding the bike. Regression analysis was used to determine the impact of health literacy on outcomes, controlling for a number of sociodemographic indicators (birthplace, home language, sex, age), as well as the tendency to give socially desirable responses. Health behaviors were rated on a Likert scale and where dichotomized for ordinal regression. Results n = 1085 students are included with a mean age of 9.5 years (SD=.6). 50.3% are female. While controlling for a number of variables, health literacy was a significant predictor (p<.05) for every indicator except the frequency of (1) brushing teeth, (4) exercising, and (5) consumption of sweetened drinks. For mental well-being, health literacy was the strongest predictor. Conclusions Our findings highlight the potentially enabling role of subjective health literacy regarding favorable health outcomes and health behaviors. However, because this is a study among younger children, further research is needed on the interplay of individual subjective health literacy, social contexts (e.g., parental health literacy and health behaviors), and children’s health outcomes and behaviors.