Health literacy and healthcare utilisation in universal healthcare systems: A systematic review

Abstract Background Low health literacy affects approximately 50% of the population in industrialised countries, limiting access to healthcare in privatised systems like the U.S. However, its impact on universal healthcare systems based on the Bismarck model, such as in Austria and other European countries, remains underexplored. This study examined how health literacy influences the utilisation of outpatient, inpatient, emergency, preventive services, and digital health navigation in these systems. Methods The study was registered (osf.io/5w4h3) and adhered to PRISMA guidelines. In May 2024, we systematically searched PubMed, CINAHL, and PsycINFO for quantitative observational studies published in the past ten years and used Google Scholar to identify grey literature. Eligible studies focused on adults (18-80 yrs), assessed general or digital health literacy with validated tools, and analysed health literacy as an independent variable. Data extraction followed a standardized sheet, and critical appraisal was conducted using the JBI checklist for cross-sectional studies. Due to substantial heterogeneity, a qualitative synthesis was performed. Results Of the 234 screened studies, 13 met the inclusion criteria (n = 590 to 24,824). Most studies used standardised self-report health literacy measures, with some linking survey data to routine social insurance records to examine the relationship between health literacy and healthcare utilisation in four Bismarck-model countries. Health literacy influenced outpatient service use, digital health access, and vaccination uptake. However, it showed no association with inpatient, surgical, or emergency services. Conclusions Evidence is inconsistent, but health literacy significantly impacts some service areas while having minimal effect on others, likely due to the overriding influence of acute healthcare needs. These findings highlight the need for targeted interventions to address access barriers in universal healthcare systems. Key messages • Low health literacy is linked to reduced use of outpatient, preventive, and digital health services in Bismarck healthcare systems. • In contrast, low health literacy has little influence on inpatient and emergency care, where acute medical needs likely dominate utilisation decisions.