Health literacy of

Slovenian adults

Results of the Slovenian

Health Literacy Survey

(HLS-SI )

19



Health literacy of Slovenian adults

Results of the Slovenian Health Literacy Survey (HLS-SI ) 19

Authors: Mitja Vrdelja, Sanja Vrbovšek, Nejc Berzelak

Published by: National Institute of Public Health, Trubarjeva 2, Ljubljana Place and year of publication: Ljubljana, 2022

Design: Nicha d.o.o.

Translation: Amidas d.o.o.

Free copy

Electronic edition

Available at: https://www.nijz.si/

The Slovenian Health Literacy Survey was conducted as part of the ‘Improving Health Literacy in Slovenia (ZaPiS)’ project, which is co-financed by the European Union (via European Social Fund) and the Slovenian government. The respective co-financing shares are 80% and 20%.

Kataložni zapis o publikaciji (CIP) pripravili v Narodni in univerzitetni knjižnici v Ljubljani COBISS.SI-ID 123429891

ISBN 978-961-6945-82-0 (PDF)

Table of contents

FIGURES AND TABLES

4





INTRODUCTION 5


CONCEPT OF HEALTH LITERACY


7

METHODOLOGY



9



Measuring health literacy

9



Implementation of the Slovenian Health Literacy Survey (HLS-SI ) 11

19

RESULTS



13



General health literacy



13



Health care

16



Disease prevention



17



Health promotion





18



Communicative health literacy



19



Navigational health literacy

22



Vaccination health literacy



25



Digital health literacy

27

CONCLUSION



31

SOURCES



33

APPENDIX 1: QUESTIONNAIRE OF THE SLOVENIAN HEALTH LITERACY SURVEY (HLS-SI ) 36

19

Figures and tables

Table 1:

Matrix of four dimensions of health literacy applied to three health domains.

10

Table 2:

Categories of health literacy level.

11

Figure 1: Number of people by final survey status.

12

Figure 2: Distribution of the number of points scored for general health literacy.

13

Figure 3: Categories for general health literacy scores.

14

Figure 4: Average number of points scored for general health literacy and its dimensions.

15

Figure 5: Assessments of the difficulty of performing tasks related to general health literacy in the domain of health care.

16

Figure 6: Assessments of the difficulty of performing tasks related to general health literacy in the domain of disease prevention.

17

Figure 7: Assessments of the difficulty of performing tasks related to general health literacy in the domain of health promotion.

18

Figure 8: Difficulty of performing tasks related to communicative health literacy.

19

Figure 9: Distribution of the number of points scored for communicative health literacy.

20

Figure 10: Categories for scores of communicative health literacy.

21

Figure 11: Difficulty of performing tasks related to navigational health literacy.

23

Figure 12: Distribution of the number of points scored for navigational health literacy.

24

Figure 13: Categories of scores for navigational health literacy.

24

Figure 14: Difficulty of performing tasks related to vaccination health literacy.

25

Figure 15: Opinions on the truth of selected statements on the undesirable consequences of vaccination.

26

Figure 16: Opinions on the safety, effectiveness and importance of vaccination.

26

Figure 17: Agreement with statements related to digital health literacy – Being smart on the net.

28

Figure 18: Agreement with statements related to digital health literacy – Awareness of sources.

28

Figure 19: Agreement with statements related to digital health literacy – Understanding information.

29

Figure 20: Agreement with statements related to digital health literacy – Recognising quality and meaning.

29

Figure 21: Agreement with statements related to digital health literacy – Validating information.

30

Figure 22: Agreement with statements related to digital health literacy – Perceived efficiency.

30

4





Introduction


The development vision set out in the Slovenian

vision of this network, which covers 28 countries, is

resolution on the national health care plan 2016–

to increase the health literacy of people living in the 2025 (‘Together for a Healthy Society’, 2016),

European region of the World Health Organization

which presents the basic starting points for the

by ensuring that high-quality and internationally

development of health care in Slovenia, includes

comparative data is available to support political

the adoption and implementation of measures to

decisions and targeted practice interventions

promote and protect health and prevent disease.

(M-POHL, 2022). The M-POHL network supports

It also highlights the need to improve the health

health literacy by strengthening cooperation

literacy of the Slovenian population. A prerequisite

between the research and policy-making spheres: in

for the planning and development of interventions

Slovenia, the former is represented by the national

that can help to improve health literacy, and

research centre for the study of health literacy at

consequently the health and quality of life of

the National Institute of Public Health and the latter the Slovenian population, is research into health

by the Public Health Directorate at the Slovenian

literacy at national level. This is made possible by

Ministry of Health.

an integrated approach that involves a study of all

the basic dimensions of health literacy (accessing,

The European Health Literacy Survey 2019 (HLS-EU

understanding, appraising and applying health

19) was conducted within the M-POHL network and

information) in the domains of health care, disease

involved 42,445 respondents from 17 countries in prevention and health promotion. In order to

the European region of the WHO: Austria, Belgium,

develop targeted interventions, it is also crucially

Bulgaria, the Czech Republic, Denmark, France,

important to study the links between health literacy

Germany, Hungary, Ireland, Israel, Italy, Norway,

and the social determinants of health, health status,

Portugal, Russia, Slovakia, Slovenia and Switzerland.

health-related behaviour and the use of health care

services. This enables us to identify the population

(sub-)groups to which particular attention should be

directed.

In order to develop targeted

interventions, it is crucially important to

In 2019 Slovenia joined the Action Network on

study the links between health literacy and

Measuring Population and Organizational Health

the social determinants of health, health

Literacy (M-POHL), which was established under

status, health-related behaviour and the

the umbrella of the WHO’s European Health

use of health care services. This enables us

Information Initiative (EHII) in accordance with the

to identify the population groups to which

recommendations set out in the ‘Health Literacy: The

particular attention should be directed.

Solid Facts’ (Kickbusch et al., 2013) publication. The 5

The survey looked at general health literacy, at determinants and consequences of health literacy.

specific types of health literacy (navigational,

This report presents the basic results of the Slovenian communicative, digital), vaccination health literacy,

Health Literacy Survey (HLS-SI ), which focuses on

19

and health literacy in relation to health care costs.

the levels of health literacy in different domains and highlights those key problems that require particular

The Slovenian Health Literacy Survey (HLS-SI ) was

attention going forward.

19

conducted in collaboration with the international

M-POHL network by researchers from the National

Institute of Public Health in 2020. The survey

obtained representative data on the health literacy

of adults in Slovenia. Using a probability sample of 3,360 people enabled particularly vulnerable

population groups in relation to health literacy

to be identified, and a study to be made of the 6



Concept of health literacy

The Ninth Global Conference on Health

the individual; rather, it is a wider, relational concept Promotion, which took place in Shanghai in 2016

that takes into consideration the individual’s

and was attended by 1,260 high-level political

level of health literacy and the complexity of the

representatives from 131 countries, resulted in

context (e.g. the health care system) in which

the Shanghai Declaration on Promoting Health

the individual operates. Health literacy therefore

(WHO, 2016), which put health and well-being at

covers the competencies of the individual, but also

the forefront of sustainable development efforts.

depends on the characteristics of the health care

It stressed that health was a universal right, a basic system and the services that enable (or hinder)

resource for everyday life, a common social goal

the application of relevant health information to

and a political priority for all countries. The three

decision-making on health. A patient’s ability to

key pillars of health promotion are good health

understand health instructions will, for example,

governance, healthy cities and health literacy.

be greater if they are capable of interpreting and

of asking for explanations when in doubt, and if

Health literacy is a key determinant, mediator and

the health worker is able to adapt their method

moderator of health. It is the basis for empowering

of communication to the patient’s needs. Health

individuals to participate actively in caring for their literacy is therefore a two-way process in which the

own health and enabling them to navigate the health

quality of interactions between individuals and the

system successfully. In everyday life, it is relevant to health system can be optimised (Dietscher et al.,

the adoption of informed decisions about health,

2019; Kickbusch et al., 2013; Moreira, 2018). Health

managing disease, understanding health messages

literacy is not determined solely by the abilities of

and communicating with health workers, and is

individuals within the population, but also by the

also related to individuals’ health outcomes and

responsiveness of health systems and services.

with the costs of health care. Health literacy is

linked to literacy and encompasses the knowledge,

motivation and competence individuals have that

enable them to access, understand, appraise and

Health literacy encompasses the

apply health information in everyday decision-

knowledge, motivation and competence

making processes concerning health promotion,

individuals have that enable them to

disease prevention and health care (Jakab, 2019; access, understand, appraise and apply

Rademakers and Heijmans, 2018; Sørensen et al.,

health information in everyday decision-

2012, 2013; Van den Broucke, 2014; WHO, 2016).

making processes concerning health

promotion, disease prevention

However, a comprehensive understanding of the

and health care.

concept of health literacy goes beyond a focus on

7



The latter is referred to as ‘organisational health

(Berkman et al., 2011; Brach et al., 2012; Dietscher

literacy’, which is a relatively new concept and one

et al., 2019; Rowsell et al., 2015; Schillinger et al., that remains unresearched in Slovenia.

2002). This also has an impact on the costs of health

care. Health economists estimate that limited health

People with a high level of health literacy make

literacy is responsible for between 3% and 5% of better health-related decisions in their everyday

health care expenditure (Eichler et al., 2009).

lives, use more preventive and fewer acute health

care services; this is because, as patients, they are

As a low level of health literacy is linked to a

better able to communicate their health problems

variety of negative health outcomes, including self-

to health staff, have a better understanding of the

assessed health, quality of life and mortality, it is

treatment options, and are able to take a more

one of the biggest health challenges of the 21st

active and competent role in treating their disease

century (Geboers et al., 2018) and one that must

themselves. People with a low level of health literacy be addressed in the future in a systematic and

have worse health outcomes, poorer health and

systemic way.

survival rates, less knowledge about health, find it

more difficult to manage their disease, and are more

likely to use health services inadequately and to

enter the health system more frequently. Research

Health literacy is not determined solely

shows that patients with chronic disease and a low

by the abilities of individuals within the

level of health literacy encounter more problems

population, but also by the responsiveness

in managing their disease, enter the health system

of health systems and services.

more frequently and have worse health outcomes

8

Methodology

Measuring health literacy

health information to manage disease and risk

factors for health and to maintain health (Pelikan

The concept of health literacy has gained in

and Straßmayr, 2021; Sørensen et al., 2015). The importance in Europe in the last 15 years, in

combination of the four dimensions of health

research, political discourse and practice. Until just information processing and the three domains is

over ten years ago, we had no information on the

shown in a matrix containing the 12 sub-dimensions

level of health literacy among the EU population, of health literacy included in the questionnaire

despite the growing importance of the topic. This gap

(Table 1).

was addressed in 2009 by the first European Health

Literacy (HLS-EU) project, which aimed to measure

The measurement instrument of the second European

and compare health literacy within the populations

Health Literacy Population Survey (HLS-EU ), which

19

of a number of selected European countries (HLS-

was conducted between 2019 and 2021 and included

EU Consortium, 2012). In order to carry out the Slovenia, is based on the HLS-EU-Q.

project, the HLS-EU consortium, comprising

nine research institutions from Austria, Bulgaria,

The Slovenian Health Literacy Survey (HLS-SI )

19

Germany, Greece, Ireland, the Netherlands, Poland

focused on measuring general, communicative

and Spain, developed the European Health Literacy

and navigational health literacy, vaccination health

Survey Questionnaire (HLS-EU-Q), which includes

literacy and digital health literacy. The general health the key dimensions of health literacy as established

literacy of the population was measured using a by the definition and conceptual model formulated by

scale of 47 items (HLS-EU-Q47), with the respondents

Kristina Sørensen and others (Pelikan and Straßmayr,

assessing the difficulty of 47 tasks across 12 sub-2021; Sørensen et al., 2012, 2013, 2015).

dimensions of health literacy presented in the form

of a matrix (Table 1). The questionnaire also included The HLS-EU-Q was developed for the purpose

31 correlates (socio-demographic information,

of measuring the health literacy of the general

general health status, health-related lifestyle, use of population and not specific patient groups. For this

health care services, search for health information).

reason, it does not focus on the clinical or medical

For the first time the HLS-EU survey also included

19

aspects, but incorporates a broader public health

the measurement of specific health literacies:

perspective. Based on a public health perspective,

communicative health literacy (assessment of the the HLS-EU-Q measures health literacy in three

difficulty of a further 11 tasks), navigational health health domains (health care, disease prevention and

literacy (assessment of the difficulty of a further 12

health promotion) and specifically with reference to

tasks) and vaccination health literacy (assessment accessing, understanding, appraising and applying

of the difficulty of four vaccination-related tasks, 9

Table 1: Matrix of four dimensions of health literacy applied to three health domains.

Source: Sørensen et al. (2012)

ACCESS/

OBTAIN

UNDERSTAND

PROCESS/

APPLY/USE

INFORMATION

INFORMATION

APPRAISE

INFORMATION

RELEVANT TO

RELEVANT TO

INFORMATION

RELEVANT TO

HEALTH

HEALTH

RELEVANT TO

HEALTH

HEALTH

Ability to access

Ability to

Ability to interpret

Ability to make

HEALTH CARE

information on

understand medical

and evaluate

informed decisions

medical or clinical

information and

medical information

on medical issues

issues

derive meaning

Ability to

Ability to interpret

Ability to make

DISEASE

Ability to access

understand

and evaluate

informed decisions

PREVENTION

information on risk

information on risk

information on risk

on risk factors for

factors for health

factors and derive

factors for health

health

meaning

Ability to

Ability to interpret

Ability to update

understand

Ability to make

and evaluate

oneself on

information on

informed decisions

HEALTH

information on

determinants

determinants

on health

PROMOTION

health determinants

of health in the

of health in the

determinants in the

in the social

social and physical

social and physical

social and physical

and physical

environment

environment and

environment

environment

derive meaning

and viewpoints on the safety, effectiveness and

of difficulty converted into an interval of between 0

importance of vaccination). As far as was possible,

and 100, where a higher number of points indicated

the instrument for measuring specific health literacies a higher level of health literacy.

employed the format used to measure general health

literacy.

In order to simplify the interpretation of health

literacy levels, individuals could be classified into The respondents rated the difficulty of the tasks on

one of four categories according to number of

a scale of 1 (‘very difficult’) to 4 (‘very easy’). The points scored. Although the boundaries were to a

number of health literacy points scored per individual certain extent arbitrary, a lower category indicated

domain was calculated as the sum of the assessments

a higher likelihood of the occurrence of difficulties in 10

Table 2: Categories of health literacy level.

Categories defined on the basis of the criteria in the literature (HLS-EU Consortium, 2012; Sørensen et al., 2015).

Number of points scored

Descriptive category of points scored

50 points or fewer

Insufficient health literacy

Over 50–66 points

Problematic health literacy

Over 66–84 points

Sufficient health literacy

Over 84–100 points

Excellent health literacy

addressing health-related tasks and situations. The

by the Statistical Office of the Republic of Slovenia

boundaries of the categories defined on the basis of

using two-stage stratified sampling from the Central

the literature (HLS-EU Consortium, 2012; Sørensen et

Population Register.

al., 2015) are shown in Table 2.

Data collection began in March 2020, but was

The Slovenian Health Literacy Survey (HLS-SI )

interrupted by the COVID-19 pandemic. It resumed

19

also addressed digital health literacy, which

between June and August 2020. The persons

was measured using an instrument developed by

selected for the sample were invited by post to

researchers at the University of Ljubljana’s Faculty of complete a web questionnaire. Computer-assisted

Social Sciences (Petrič et al., 2017) and was upgraded personal interviews (CAPI) were planned for those before being incorporated into the HLS-SI19 survey.

who did not wish to take part online. The option was

The instrument comprises 32 statements that the

also given of completing the questionnaire on paper

respondents assess using a five-point agreement

and returning it by post.

scale. The level of digital health literacy was calculated as the sum of the assessments of selected statements,

Of the 6,000 individuals selected, 415 could not be

converted into an interval of between 0 and 100. The

contacted (Figure 1). A total of 3,412 people opted to agreement scores were coded before being added

take part in the survey. However, 52 did not

up, with higher scores indicating a higher level of

complete the questionnaire to an extent

digital health literacy.

sufficient for inclusion in the final database. The response rate was 60% (5,585 eligible individuals Implementation of the Slovenian Health

were contacted and 3,360 questionnaires were

Literacy Survey (HLS-SI

completed satisfactorily). The final sample was

19)

weighted for gender, age, statistical region and The survey targeted residents of Slovenia aged 18

education.

and over. The sample of participating individuals was

selected by probability sampling, with each unit from

the population having the known probability of being

selected for the sample. Sampling was carried out

11

Figure 1: Number of people by final survey status.

Non-contacts

Insufficient

Mail survey 12

415

completions 52

Refusals

Other non-

Web survey

Face-to-face survey

1.349

participating

1.488

1.860

824

0

6.000

Non-contact

Non-participating

Insufficient completions

Sufficient completions

12



Results

General health literacy

population have insufficient or problematic health literacy (Figure 3), which together comprise the Respondents scored an average of 67.9 points out

limited health literacy category.

of a possible 100 on the general health literacy

scale. Most scored between 60 and 70 points

(Figure 2), just under 10% scored fewer than 50

points and around the same proportion scored more

48% of the adult population of Slovenia

than 90 points. According to the number of points

have limited health literacy.

scored, and taking the criteria for determining the

categories of points scored into account, 48% of the

Figure 2: Distribution of the number of points scored for general health literacy.

The number of points scored was calculated on the basis of a self-assessment of the difficulty of carrying out each of the 47

tasks related to general health literacy. The number of possible points ranged between 0 and 100, with a higher number of points indicating a higher level of health literacy. n = 3,360

50%

40%

39%

30%

20%

18%

15%

12%

10%

8%

5%

0.2%

0.4%

0.8%

2%

0%

0−10

>10−20

>20−30

>30−40

>40−50

>50−60

>60−70

>70−80

>80−90

>90−100

Score

13

Figure 3: Categories for general health literacy scores.

The categories of scores were established on the basis of the criteria in the literature (HLS-EU Consortium, 2012; Sørensen et al., 2015). n = 3,360

48%

limited health literacy

8%

40%

37%

14%

0%

50%

100%

Inadequate

Problematic

Sufficient

Excellent

(0−50 points)

(>50−66 points)

(>66−84 points)

(>84−100 points)

14

Figure 4: Average number of points scored for general health literacy and its dimensions.

The number of points scored for general health literacy was calculated on the basis of a self-assessment of the difficulty of carrying out each of 47 tasks. For individual dimensions, the number of points was calculated on the basis of the tasks relating to the dimension in question. The number of possible points ranged between 0 and 100 for each dimension. n = 3,323–3,360

General health literacy

67.9

Health care

70.2

Disease prevention

67.8

Health domains

Health promotion

66.0

Accessing information

68.3

Understanding information

71.6

ocessing stages

Appraising information

65.7

mation pr

Applying information

66.5

Infor

0 points

25 points

50 points

75 points

100 points

Mean score

Figure 4 presents the number of points scored in information does not present a major problem. The

the different dimensions of general health literacy

results did show differences in the dimensions of

summarised in Table 1.

health information processing in the health domain.

In the domain of health care, adults in Slovenia

A comparison of all three health domains shows

have the most considerable difficulties in appraising

that the average scores are highest in the domain

health information, while in the domains of disease

of health care. In relation to the phase of health

prevention and health promotion, the everyday

information processing, the scores are, on average,

application of that information presents the biggest

higher for accessing and understanding information.

problem. One should note that the differences

This means that adults in Slovenia have more

in the scores between the dimensions depend on

considerable difficulties in appraising and applying

the difficulty of the specific tasks as measured by information, while accessing and understanding

individual dimensions in the questionnaire.

15



Health care

assessments were ‘difficult’ or ‘very difficult’), followed by appraisal of the necessity of a second medical opinion In the domain of health care, the questionnaire included (31%) and appraisal of the strengths and weaknesses

an evaluation of tasks related to the knowledge and

of different treatment options (25%). The assessed competencies required by people who are ill or are

difficulty of searching for information on the symptoms patients. In this domain, the respondents (Figure 5) rated and treatment of disease and on how to act in urgent

appraisal of the reliability of information on diseases in medical situations stands out slightly, with between

the mass media as the most difficult task (46% of the

13% and 15% of respondents rating it as ‘difficult’ or Figure 5: Assessments of the difficulty of performing tasks related to general health literacy in the domain of health care.

The tasks are divided into four phases of information processing in the domain of health care. The wording of some items is shortened in the chart. n = 3,360

24%

61%

12% 3%

Find information about symptoms of illnesses that concern you 19%

64%

14% 2%

Find information on treatments of illnesses that concern you mation

23%

63%

11% 2%

Find information about what to do in a medical emergency Accessing infor

30%

60%

8% 1%

Find out where to get professional help when you are ill 30%

61%

8% 1%

Understand what a doctor says to you

32%

59%

8% 1%

Understand the instruction leaflets that come with your medicine mation

27%

63%

9% 1%

Understand information about what to do in a medical emergency infor

Understanding

Understand your doctor’s or pharmacist’s instruction on how 42%

54%

3% 1%

to take a prescribed medicine

22%

67%

9% 1%

Judge how information from your doctor applies to you

13%

61%

23%

2%

Judge the advantages and disadvantages of different treatment options mation

12%

54%

28%

3%

Judge if you may need to get a second opinion from another doctor Appraising infor

11%

42%

38%

8%

Judge if the information about illness in the mass media is reliable 21%

69%

8% 1%

Use information your doctor gives to you to make decisions about your illness 40%

56%

4% 1%

Follow instructions on medication

mation

42%

50%

5% 2%

Call an ambulance in a medical emergency

Applying infor

34%

61%

4% 0.4%

Act on advice from your doctor or pharmacist

0%

25%

50%

75%

100%

Very easy

Easy

Difficult

Very difficult

No answer

16





‘very difficult’. No more than a tenth of respondents

health information in the domain of disease

rated the other tasks in the domain of health care as

prevention. The research shows that the respondents

‘difficult’ and ‘very difficult’.

rated tasks in the domain of disease prevention as

more difficult than tasks in the domain of health care.

Disease prevention

Again there are higher shares of ‘difficult’ and ‘very difficult’ (Figure 6) for the appraisal of information, Individuals with risk factors for the development

and particularly of the reliability of media information of disease require knowledge and skills to process

on risks to health (40%), the necessity of vaccination Figure 6: Assessments of the difficulty of performing tasks related to general health literacy in the domain of disease prevention.

The tasks are divided into four phases of information processing in the domain of disease prevention. The wording of some items is shortened in the chart . n = 3,360

39%

52%

7% 1%

Find information about how to handle unhealthy habits

23%

57%

16% 3%

Find information on how to handle mental health problems mation

22%

58%

16% 3%

Find information on recommended vaccinations for you or your family Accessing infor

Find information on how to handle health risks 28%

60%

9% 2%

42%

52%

4% 1%

Understand information about unhealthy habits

28%

55%

13% 3%

mation

Understand why you or your family may need vaccinations 35%

52%

9 % 2%

infor

Understand information about recommended health

Understanding

screenings or examinations

33%

56%

9% 1%

Judge if information on unhealthy habits are reliable

27%

59%

13% 1%

Judge when you need to go to a doctor for a check-up

21%

53%

22%

3%

mation

Judge which vaccinations you or your family may need

Appraising infor

27%

53%

16%

3%

Judge which health screenings or examinations you should have Judge if the information on health risks in the mass media is reliable 13%

46%

34% 6%

22%

43%

27% 7%

Decide if you should have a flu vaccination

Decide how you can protect yourself from illness 16%

61%

20% 3%

mation

using advice from family or friends

Applying

13%

53%

28% 6%

infor

Decide how you can protect yourself from

illness using info. from the mass media

0%

25%

50%

75%

100%

Very easy

Easy

Difficult

Very difficult

No answer

17

(25%) and the necessity of screening tests (19%). There are promotion encompasses the knowledge and

also marked difficulties in applying information to prevent competencies that individuals require to maintain

disease: decisions on whether to get vaccinated against and improve health in the community, at the

flu (34%), decisions on how to protect oneself against workplace, in the education system, in policy-disease from information in the mass media (34%) and

making and in the market (Sørensen et al., 2012).

decisions on how to protect oneself against disease from The results show that there is a significant variety in information supplied by family members or friends (23%).

the assessments within individual phases of health

information processing in this domain (Figure 7). With Health promotion

regard to accessing information, the assessments

‘difficult’ and ‘very difficult’ were highest in relation General health literacy in the domain of health

to accessing information on legislative changes that

Figure 7: : Assessments of the difficulty of performing tasks related to general health literacy in the domain of health promotion. The tasks are divided into four phases of information processing in the domain of health promotion. The wording of some items is shortened in the chart. n = 3,360

41%

52%

6% 1%

Find information on healthy life styles

33%

56 %

8% 2%

mation Find information about activities that are good for your mental health and well-being 18%

51%

24%

5%

Find out how your neighborhood could become more health-friendly Find info. about changes in laws that may affect your or your familyś health 12%

45%

32% 10%

Find information about how to promote health at work,

Accessing infor

15%

57%

21%

5%

at school or in the neighborhood

26%

65%

8% 1%

Understand advice concerning your health from family or friends 20%

56%

19% 4%

Understand information on food packaging

mation

18%

59%

18% 4%

Understand information in the mass media on how to improve your health infor

Understanding

Understand information on how to keep your mind healthy 20%

63%

14% 2%

20%

58%

18% 2%

Judge how your neighborhood may affect your health and well-being 28%

62%

8% 1 %

mation

Judge how your housing conditions may affect your health and well-being Appraising infor

32%

60%

6% 1%

Judge which everyday habits affect your health

24 %

59%

15% 2%

Make decisions to improve your health and well-being

23%

43%

24%

9%

Join a sports club or exercise group if you want to be physically active mation

18%

55%

22%

5%

Applying

Influence your living conditions that affect your health and well-being infor

14%

48%

28%

8%

Take part in activities that improve health and well-being in your community 0%

25%

50%

75%

100%

Very easy

Easy

Difficult

Very difficult

No answer

18

could affect the health of the individual or their a sports club or exercise group (33%) and influencing

family (42%), information on how a neighbourhood

living conditions for health or well-being (27%).

could become more health-friendly (29%) and

information on promoting good health in the

Communicative health literacy

individual’s social environment (26%). Just over a fifth of respondents rated understanding information

Communicative health literacy refers to those

on medical packaging (23%) and information in the

communicative and social skills of patients that

mass media on improving health (22%) as ‘difficult’.

enable them to participate actively in one-to-one

The percentages are also high in the tasks of

encounters with health professionals, provide

applying health promotion information/taking part

and find information, judge the importance of

in community health-related activities (36%), joining

information, and apply information in support of

Figure 8: Difficulty of performing tasks related to communicative health literacy.

The wording of some items is shortened in the chart. n = 3,360

43%

51%

5% 0.5%

Describe to your doctor your reasons for coming to the consultation 37%

55%

6% 1%

Make your doctor listen to you without being interrupted 37%

55%

6% 1%

Explain your health concerns to your doctor

29%

56%

12% 2%

Get enough time in the consultation with your doctor

29%

59%

10% 1%

Express your personal views and preferences to your doctor 32%

59%

7% 1%

Get the information you need from your doctor

33%

59%

6% 1%

Understand the words used by your doctor

36%

57%

6% 1%

Ask your doctor questions in the consultation

26%

61%

10% 1%

Be involved in decisions about your health in dialogue with your doctor 33%

60 %

6% 1%

Recall the information you get from your doctor

31%

62%

5% 1%

Use the information from your doctor to take care of your health 0%

25%

50%

75%

100%

Very easy

Easy

Difficult

Very difficult

No answer

19



the joint production of their own treatment and

indicated difficulty with obtaining enough time

the decision on treatment. The HLS-EU19 survey

during a consultation with their doctor (12%),

focuses on communication between doctor and

expressing their personal opinions and wishes to a

patient (Nowak et al., 2021). The measurement

doctor (11%) and being involved in making decisions

of communicative health literacy is based on the

on their own health in consultation with a doctor

conceptual framework of the Calgary-Cambridge

(11%). The difficulty of performing tasks related model of medical interview (Calgary-Cambridge

to communicative health literacy as indicated by

Guide to Medical Interview, Silverman et al., 2013).

Slovenian respondents is shown in Figure 8.

The results of the survey show that most of the

tasks related to communicating with a doctor

were rated as ‘difficult’ or ‘very difficult’ by fewer than a tenth of respondents (for no task did more

20% of adults in Slovenia have

than 2% of respondents respond with ‘difficult’ or

limited communicational health literacy.

‘very difficult’). More than a tenth of respondents Figure 9: Distribution of the number of points scored for communicative health literacy.

The number of points scored was calculated on the basis of a self-assessment of the difficulty of carrying out each of the 11

tasks related to communicative health literacy. The number of possible points ranged between 0 and 100. n = 3,347

50%

43%

40%

30%

25%

20%

12%

10%

10%

6%

0.1%

0.2%

0.4%

2%

3%

0%

0−10

>10−20

>20−30

>30−40

>40−50

>50−60

>60−70

>70−80

>80−90

>90−100

Score

20

The low-rated difficulty of most of the tasks respondents scored over 90 points and only 5%

is reflected in the relatively high scores for

scored half or less than half of the possible number

communicative health literacy (an average of

of points available (Figure 9).

74.7 points out of a possible 100). A quarter of Figure 10: Categories for scores of communicative health literacy.

The categories of scores were established on the basis of the criteria in the literature (HLS-EU Consortium, 2012; Sørensen et al., 2015). n = 3,347

20%

limited health

literacy

5%

15%

48%

31%

0%

50%

100%

Inadequate

Problematic

Sufficient

Excellent

(0−50 points)

(>50−66 points)

(>66−84 points)

(>84−100 points)

21



Almost one third of respondents had excellent

health literacy in the HLS-SI survey comprised 12

19

communicative health literacy according to the

items covering specific tasks at the system (macro)

scoring criteria (Figure 10) and a fifth had limited level, organisational (mezzo) level and interactional

(i.e. insufficient or problematic) communicative

(micro) level. They are operationalised by measuring

health literacy. Despite the relatively high score

the difficulties that patients and users encounter in

Understand information on how the health care system works in this domain, a not insignificant proportion of accessing, understanding, appraising and applying

Judge which type of health service you need in case of a health problem respondents indicated that they had certain difficulty information for the purpose of navigating through

in communicating with doctors.

the health system (Griese et al., 2020; Schaeffer et

Judge to what extent your health insurance covers a particular health service al., 2021).

Understand information on ongoing health care reforms that might affect your health care Navigational health literacy

Find out about your rights as a patient or user of the health care system According to the assessments made by the

With the growing complexity of health systems

respondents, tasks relating to navigational health

Decide for a particular health service

comes an increase in the requirements faced by

literacy were markedly more difficult than those Find information on the quality of a particular health service users of those systems when attempting to find

relating to general and communicative health

their way through them. They are required, for

literacy, as more than 15% of respondents rated all

Judge if a particular health service will meet your expectations and wishes on health care example, to locate a suitable entry point into the

of them as ‘difficult’ or ‘very difficult’ (Figure 11).

Understand how to get an appointment with a particular health service health system, orient themselves within that system

Relatively high shares of such assessments can also

Find out about support options that may help you to

and find the right place for resolving their problems.

be found in several key tasks related to orientation

orientate yourself in the health care system

through the health system, such as assessing the

Locate the right contact person for your concern within a health care institution Specific navigational health literacy is therefore scope of insurance coverage for a specific service necessary in order to confront the many challenges

(38%), familiarity with patents’ rights (38%), deciding Stand up for yourself if your health care does not meet your needs placed in front of users by a complex health system

on a specific health care service (29%) and finding

and by its structure, standards and functions. It

a person able to answer their question at a health

includes the ability to manage information in a

care institution (28%). Almost a third of respondents

way that enables a person to navigate through the

also rated as ‘difficult’ or ‘very difficult’ the tasks of health system without difficulty so that they are able obtaining information on the options available for

to find the right treatment at the right time in the

making navigation through the health system easier

right place. Navigational health literacy comprises

and standing up for oneself if the care does not

the knowledge, motivation and skills that people

meet one’s needs.

require in order to access, understand, appraise

and apply information, and to communicate in

a way that enables them to navigate the health

system adequately so that they receive the most

suitable health care for themselves or their loved

61% of Slovenian adults have limited

navigational health literacy.

ones. The instrument for measuring navigational

22

Slika 11: Difficulty of performing tasks related to navigational health literacy.

The wording of some items is shortened in the chart. n = 3,360

15%

53%

25%

6%

Understand information on how the health care system works 16%

64%

17%

2%

Judge which type of health service you need in case of a health problem 12%

48%

31%

7%

Judge to what extent your health insurance covers a particular health service 8%

42%

36% 11%

Understand information on ongoing health care reforms that might affect your health care 11%

50%

31%

7%

Find out about your rights as a patient or user of the health care system 15%

55 %

25 %

4 %

Decide for a particular health service

11%

52%

29 %

6%

Find information on the quality of a particular health service 9%

46%

37% 6%

Judge if a particular health service will meet your expectations and wishes on health care 22%

62%

13% 3%

Understand how to get an appointment with a particular health service Find out about support options that may help you to 12%

56%

27%

4%

orientate yourself in the health care system 13%

58%

24%

4%

Locate the right contact person for your concern within a health care institution 18%

50%

25%

5%

Stand up for yourself if your health care does not meet your needs 0%

25%

50%

75%

100%

Very easy

Easy

Difficult

Very difficult

No answer

23

Figure 12: Distribution of the number of points scored for navigational health literacy.

The number of points scored was calculated on the basis of a self-assessment of the difficulty of carrying out each of the 12 tasks related to navigational health literacy. The number of possible points ranged between 0 and 100 . n = 3,318

50%

40%

33%

30%

20%

18%

15%

10%

10%

7%

6%

6%

1%

2%

3%

0%

0−10

>10−20

>20−30

>30−40

>40−50

>50−60

>60−70

>70−80

>80−90

>90−100

Score

Figure 13: Categories of scores for navigational health literacy.

The categories of scores were established on the basis of the criteria in the literature (HLS-EU Consortium, 2012; Sørensen et al., 2015). n = 3,318

61%

limited health

literacy

33%

28%

30%

9%

0%

50%

100%

Inadequate

Problematic

Sufficient

Excellent

(0−50 points)

(>50−66 points)

(>66−84 points)

(>84−100 points)

24

The average score for navigational health literacy was (information on vaccination, views and knowledge

58.6 points out of a possible 100, which confirms the

of doctors, pro- and anti-vaccination lobbies, etc.)

general, relatively high perceived difficulty of tasks and vaccination itself. Although it has been shown

in this area. One third of respondents scored half that reluctance regarding vaccination depends on

the available number of points or fewer, and only

both context and the vaccine itself, several general

just over 5% scored more than 90 points (Figure 12).

factors have been identified that affect vaccination

Sixty-one per cent of Slovenian adults have limited

or non-vaccination (Biasio et al., 2020; Griebler et and just 10% have excellent navigational health

al., 2021; Lorini et al., 2018).

literacy (Figure 13).

The HLS-SI survey measured vaccination health

19

Vaccination health literacy

literacy using four items in the HLS-EU-Q47

questionnaire on general health literacy and a

Vaccination health literacy encompasses individuals’

further nine items in the additional set on health

knowledge, motivation and skills with regard to

literacy in connection with vaccination: one item

finding, understanding and appraising vaccination-

on the individual’s behaviour in connection with

related information and applying this information

vaccination in the past five years, four items relating to make a vaccination decision. In order to better

to personal trust in vaccination, three items on the

understand the concept, a distinction must be

myths regarding possible vaccination risks, and one

drawn between vaccination health literacy and

item on the risk of developing a disease for which a

other relevant determinants of vaccination-related

vaccine exists (Griebler et al., 2021).

behaviour. Research into the determinants of

vaccination or non-vaccination has shown that

Figure 14 shows assessments of the difficulty of decisions for or against vaccination are based on

carrying out vaccination-related tasks selected from

individual and collective experiences and beliefs,

the set of items for measuring general health literacy.

knowledge, situational/contextual conditions When interpreting the findings, we should point out Slika 14: Difficulty of performing tasks related to vaccination health literacy.

The distribution of the assessment shares is shown for each task, from ‘very easy’ to ‘very difficult’. The wording of some items is shortened in the chart. n = 3,360

22%

58%

16% 3%

Find information on recommended vaccinations for you or your family 28%

55%

13% 3%

Understand why you or your family may need vaccinations 21%

53%

22% 3%

Judge which vaccinations you or your family may need

22%

43%

27% 7%

Decide if you should have a flu vaccination

0%

25%

50%

75%

100%

Very easy

Easy

Difficult

Very difficult

No answer

25

that the survey was carried out immediately after Approximately one third of respondents believed

the first wave of the COVID-19 pandemic and before

that the selected myths about the supposed

a vaccine against this disease had become available.

undesirable consequences of vaccination were true

The respondents most often reported difficulties

(Figure 15). The share of respondents who were

in assessing the need for vaccination against flu unable or did not wish to take a position on a specific and in deciding whether to receive the flu vaccine

statement was also relatively high. Nevertheless,

(rated as ‘difficult’ or ‘very difficult’ by a quarter the respondents expressed predominantly positive

and just over a third of respondents, respectively).

attitudes towards vaccination (Figure 16). A total

A fifth of people rated finding information about of 90% of respondents agreed that vaccination

recommended vaccinations as ‘difficult’.

was an important tool for protecting against the

Figure 15: Opinions on the truth of selected statements on the undesirable consequences of vaccination. n = 3.360

32%

54%

14%

Vaccines overload and weaken the immune system

35%

53%

12%

Vaccines can cause the diseases against which they protect 31%

58%

12%

Vaccines often produce serious side effects

0%

25%

50%

75%

100%

True

False

No answer

Figure 16: Opinions on the safety, effectiveness and importance of vaccination. n = 3.360

2% 8%

54%

32%

Vaccinations are important to protect myself and my children 2% 14%

57%

22%

Overall I think vaccinations are safe

1% 12%

59%

23%

Overall I think vaccinations are effective

7%

10%

47%

30%

Vaccination is compatible with my religious beliefs

1% 6%

52%

38%

Vaccinations are important to prevent the spread of (severe) diseases 0%

25%

50%

75%

100%

Strongly disagree

Disagree

Agree

Strongly agree

No answer

26

spread of serious disease, and only a slightly smaller includes the capacity of the individual to navigate

share agreed that vaccination offered important

their way sensibly and effectively through the online

protection for them and for children. The lowest

environment (Levin-Zamir et al., 2021; Nutbeam,

level of agreement was with the statement on the

2021; Petrič et al., 2017; Squiers et al., 2012).

compatibility of vaccination with the respondent’s

own religious beliefs.

In the HLS-SI survey, digital health literacy was

19

measured using 32 statements within the framework

Digital health literacy

of six concepts: being smart on the net, awareness

of sources, understanding information, recognising

The rise of digital media has enabled wide access

quality, validating information and perceived

to information on health, produced an ever-

efficiency. The respondents rated their level of greater quantity of information on preventing and

agreement with the statements.

managing disease and on boosting health, and

created a growing number of information channels

Survey participants who had used at least one online

for the dissemination of this information. Along

source to seek out health information in the last 12

with the increasing availability and use of digital

months responded to the questions on digital health

(electronic) tools in health care (electronic health

literacy (two-thirds of respondents). Of the key records, telemedicine solutions, digital health apps,

findings, it is worth highlighting the fact that almost the possibility of interactive communication with

half the respondents preferred reading short, simple

health professionals, e.g. booking appointments

health explanations online over complex specialist

or reporting medical results), this presents new

explanations. At the same time, just over a third of

challenges and requires people to develop the skills

respondents frequently did not understand technical

that will enable them to seek out and apply this

terms in some of the online health resources they read knowledge. In the information age, mastering a large

and, because of the quantity of information, were

volume of information and appraising its quality and

unable to identify high-quality information important

reliability have become basic skills of digital health to their own health. A significant proportion of literacy, which is derived from the overarching

respondents regarded web browser algorithms and

concept of health literacy. Digital health literacy

number of followers as a potential aid to separating

encompasses the cognitive and social skills needed

high-quality from low-quality health information (21%

to obtain, understand, communicate and apply

and 17%, respectively). Figures 17 to 22 show the health information in order to function within today’s degree of agreement with statements related to

health system and exercise adequate self-care. It also digital health literacy.

27

Figure 17: Agreement with statements related to digital health literacy – Being smart on the net.

The wording of some items is shortened in the chart. Only respondents who had used at least one online source for obtaining health information in the last 12 months were included. n = 2,250

8%

25%

39%

25%

2%

I think we can trust most of the health information found online I am satisfied with the first health source found on the internet that 28%

40%

20% 10% 1%

provides answers to my questions

Online I prefer short and simple health explanations rather than 9%

21%

21%

42 %

6%

comprehensive professional explanations

Modern online systems automatically differentiate between low - and 15%

28%

30%

20%

1%

high-quality health information

A large number of followers on social media is a proof, that information 19%

47%

32%

16% 1%

posted online is professionally reliable

I am aware that search engines can return personalised 1% 7% 18%

50%

20%

and limited search results

0%

25%

50%

75%

100%

Strongly disagree

Disagree

Neither-nor

Agree

Strongly agree

No answer

Figure 18: Agreement with statements related to digital health literacy – Awareness of sources.

The wording of some items is shortened in the chart. Only respondents who had used at least one online source for obtaining health information in the last 12 months were included. n = 2,250

2% 11%

30%

51%

4%

I know which sources of health information are available online 8%

30%

26%

30%

4%

There are medical studies published online, but I don’t know how to access them 6%

24%

27%

37%

4%

I know how to access websites or applications and enter my symptoms to get information about my health issues

1 % 6 %

20%

62%

8%

I know how to use the internet to get answers to my health concerns 1% 7%

26%

58%

7%

I know where to find useful sources of information on health online 0%

25%

50%

75%

100%

Strongly disagree

Disagree

Neither-nor

Agree

Strongly agree

No answer

28

Figure 19: Agreement with statements related to digital health literacy – Understanding information.

The wording of some items is shortened in the chart. Only respondents who had used at least one online source for obtaining health information in the last 12 months were included. n = 2,250

13%

41%

23%

20% 2%

I sometimes don’t know where to start searching online for information about health when I have a health problem

6% 28%

30%

32%

3%

I often don’t understand the terminology used by some online health sources I’m unable to recognise high-quality information relevant for my health because of 4% 28%

32%

30%

4%

the vast amount of information online

I sometimes have difficulties understanding key information 3% 26%

32%

34%

2%

online that is relevant to my health

2% 17%

43%

34%

3%

I fully understand health-related information I find online 0%

25%

50%

75%

100%

Strongly disagree

Disagree

Neither-nor

Agree

Strongly agree

No answer

Figure 20: Agreement with statements related to digital health literacy – Recognising quality and meaning.

The wording of some items is shortened in the chart. Only respondents who had used at least one online source for obtaining health information in the last 12 months were included. n = 2,250

2% 11%

29%

50%

6%

I am able to distinguish low-quality health information from high-quality health information online 1% 9%

30%

53%

5%

I have no difficulties understanding the substance of the information online 2% 17%

29%

43%

6%

I have sufficient knowledge to assess the quality of online sources I can find a lot of health information online, but I can’t identify which can help me make 5%

31%

32%

29%

2 %

health decisions

2% 8%

29%

56%

4%

I can identify useful tips for addressing my health issues from information online 0%

25%

50%

75%

100%

Strongly disagree

Disagree

Neither-nor

Agree

Strongly agree

No answer

29

Figure 21: Agreement with statements related to digital health literacy – Validating information.

The wording of some items is shortened in the chart. Only respondents who had used at least one online source for obtaining health information in the last 12 months were included. n = 2,250

14%

42%

19%

22%

1%

If I find useful information on health online, I am not interested in who the author is 1% 7% 18%

63%

9%

When reading information about health online, I take sufficient time to really understand it

2% 19%

32%

43%

2%

I myself interpret health information that I find online When I find information related to my health online, I check its accuracy 1% 9% 18%

58%

12%

with other online sources

It is important for me to check health-related information that I find online 1% 5% 13%

62%

18%

with other sources

If I have doubts about the reliability of information about health online, I 1% 5% 13%

68%

11%

ask somebody for explanation

0%

25%

50%

75%

100%

Strongly disagree

Disagree

Neither-nor

Agree

Strongly agree

No answe

Slika 22: Agreement with statements related to digital health literacy – Perceived efficiency.

The wording of some items is shortened in the chart. Only respondents who had used at least one online source for obtaining health information in the last 12 months were included. n = 2,250

3 % 9%

25%

49%

12%

I feel confident about using the internet to improve my health 2% 12%

27%

48%

9%

The internet is very useful for helping me to take decisions about my health 2% 7%

19%

58%

13%

It is very important for me to have access to health-related sources online 2% 6%

22%

61%

8%

I know how to use the information I find on the internet to improve my health 7%

46%

33%

11% 1%

I do not usually find personally useful information about health online 0%

25%

50%

75%

100%

Strongly disagree

Disagree

Neither-nor

Agree

Strongly agree

No answe

30

Conclusion

rated as most difficult, three related to appraising and applying information from the mass media, with

Health literacy is one of the key determinants of

particularly pronounced difficulties arising in relation health. Data on health literacy in the population,

to the appraisal of the reliability of information on

something that we have not had up to now, provides

diseases in the mass media. There are many reasons

starting points for the planning and development

for this, but the intensive development of the internet of interventions and activities to improve the health

and new technologies in recent years, along with the

literacy of adults in Slovenia. This gap has been filled

‘mediatisation’ of society, are undoubtedly two of the by the first Slovenian Health Literacy Survey (HLS-most important. The COVID-19 pandemic and the

SI ), performed on a probability sample of 3,360

epidemic of competing information, both adequate

19

adults and conducted as part of the international

and inadequate, have also made a major contribution

Action Network on Measuring Population and

to the increasing complexity of information and

Organizational Health Literacy (M-POHL). The survey

the consequent difficulty in identifying proper and obtained representative data on the health literacy

credible information.

of adults in Slovenia. This survey report presents the key results of a basic descriptive data analysis, with Several other tasks that can be of essential importance an emphasis on identifying the difficulty of individual to making decisions on one’s health have also been

tasks of health information processing in different

shown to be problematic: for example, respondents

domains of the individual’s health: health care,

rated as difficult, on a relatively frequent basis, the disease prevention and health promotion.

tasks of appraising different treatment options and

screening examinations, understanding information

The survey showed that every second Slovenian adult

contained on medical packaging, and joining a sports

had limited general health literacy. From the point of club or exercise group (for those who were looking to

view of general health literacy, which covers accessing, be more physically active).

understanding, appraising and applying health

information, adults in Slovenia have fewest difficulties The survey showed that the adult population of

in making decisions on health in the domain of health

Slovenia encountered most difficulties in orienting care. They encounter the most difficulties with the themselves within the health system, with almost

dimension of appraising health information, but were

two thirds of adults having limited navigational

slightly better at accessing and understanding this

health literacy. This also indicates the importance

information. The three most difficult tasks in this of strengthening navigational health literacy skills

domain were appraising the reliability of information

within the population and of implementing user-

in the media, appraising the necessity of seeking a

and patient-friendly pathways through health care

second medical opinion, and appraising the strengths

organisations and the health system generally.

and weaknesses of different treatment options. The

processing of health information in the domains of

A fifth of the adult population of Slovenia have limited disease prevention and health promotion was rated

communicative health literacy. Respondents did not

as slightly more difficult by respondents, with tasks

generally rate the various aspects of communication

involving the use of health information in one’s

with doctors as difficult, although the highest share

everyday life being rated the most difficult. Of the

of respondents rated as most difficult the task of eight tasks relating to general health literacy and

securing enough time with their doctor.

31

The need to address these difficulties adequately is were not interested in who the author of online

also evident in relation to vaccination: despite the

information was, and a similar proportion believed

generally positive attitude towards vaccination, a

that they could trust most of the health information

relatively high proportion of respondents said they

on the internet. It is important for online sources

had difficulty deciding whether to get vaccinated of reliable health information to be adequately

against flu and appraising the need for various optimised for search engines, as a relatively high

vaccinations. This problem was further highlighted

proportion of respondents believed that search

by a fairly significant proportion of people who engines made a distinction between low- and high-believed various myths about vaccine side-effects.

quality information.

Finally, it is also worth highlighting the importance

The results of the HLS-SI19 highlight the key

of critically evaluating online health information. The problems requiring further action. The data will

quantity of accessible and frequently questionable

be analysed in detail as part of further research

information presents a challenge to internet users,

activities with the aim of identifying particularly

and to specialists and health organisations who

vulnerable groups with low levels of health

are keen to provide users with relevant specialist

literacy and of studying the determinants and

information. The position taken by many respondents

consequences of health literacy in Slovenia.

shows that they would like to receive information in

Together with the results of other activities

a suitably simplified form.

conducted as part of the ‘Improving Health

Literacy in Slovenia (ZaPiS)’ project, these findings

From the point of view of digital health literacy, the will lay the foundation for targeted public-health

survey also pointed up the issue of a lack of critical interventions to improve the health literacy of the

appraisal of information retrieved from the internet.

adult population in Slovenia.

Around a quarter of respondents claimed that they



32

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35

Appendix 1

Questionnaire of the Slovenian Health Literacy Survey (HLS-SI19) A version of the Slovenian questionnaire back-translated to English is presented in this part. For the original wordings used in the source questionnaire of the European Health Literacy Survey, consult the M-POHL report at https://m-pohl.net/Int_Re-port_methdology_results_recommendations

Prior permission of the National Institute of Public Health is required for reuse of the questionnaire or any of its parts.

Thank you for your willingness to participate in the Health Literacy Survey (HLS19). It covers health literacy, i.e. the ability to access, understand, appraise and apply relevant health information in daily decisions concerning medical care, disease prevention, and health promotion.

The HLS19 survey will be carried out in several European countries with a view to describing and comparing health literacy and providing information to those determining health policy.

You have been randomly selected for this interview. Your answers will be confidential and only anonymised data will be used for analysis; furthermore, only group data will be reported. All data protection requirements will be followed.

You can withdraw from the survey at any time and can also choose to remove your answers at any time.

By participating you agree that your anonymised answers will be used for scientific purposes.

36

Health literacy

The following questions are aimed at identifying the ease or difficulty of tasks related to the handling of medical information.The following questions are related to health literacy in health care.

How easy (on a scale from »very easy« to »very difficult«) would you say it is to: HLS-EU

Fill in the table by rows.

Very easy

Easy

Difficult

Very

difficult

1

…find information about the symptoms of illnesses that concern you?

4

3

2

1

2

…find information on the treatment of illnesses that concern you?

4

3

2

1

3

…find information about what to do in a medical emergency?

4

3

2

1

4

…find out where to get professional help when ill? [For example a doctor, nurse, pharmacist, psychologist]

4

3

2

1

5

…understand what your doctor says to you?

4

3

2

1

6

…understand the leaflets that come with your medicine? [written information or instructions concerning the medicinal product]

4

3

2

1

7

…understand information about what to do in a medical emergency?

4

3

2

1

8

…understand the instructions your doctor or pharmacist gives you on how to take a prescribed medicine?

4

3

2

1

9

…judge how information from your doctor applies to you?

4

3

2

1

10 …judge the advantages and disadvantages of various treatment options?

4

3

2

1

11 …judge when you may need to get a second opinion from another doctor?

4

3

2

1

12 …judge whether the information about illness in the media is reliable? [For example newspapers, TV, the internet]

4

3

2

1

13 …use your doctor's information to make decisions regarding your illness?

4

3

2

1

14 …follow the instructions on the leaflet that comes with your medicine?

4

3

2

1

15 …call an ambulance in an emergency?

4

3

2

1

16 …follow the advice of a doctor or pharmacist?

4

3

2

1

37

The following questions are related to health literacy in disease prevention.

How easy (on a scale from »very easy« to »very difficult«) would you say it is to: HLS-EU

Fill in the table by rows.

Very

Very easy

Easy

Difficult

difficult

…find information about how to manage unhealthy

17

behaviour such as smoking, low physical activity and

4

3

2

1

drinking too much?

18

…find information about how to cope with mental health issues? [such as stress, depression or anxiety]

4

3

2

1

19

…find information about vaccinations recommended for

you and your family?

4

3

2

1

20

…find information on how to manage health risks such as obesity, hypertension or high cholesterol

4

3

2

1

…understand information about unhealthy behaviour

21

such as smoking, low physical activity and drinking too 4

3

2

1

much?

…understand why you and your family may need a certain 22

vaccination?

4

3

2

1

…understand information about recommended health

screenings and tests? [For example screening for the

23

early detection of colorectal cancer – SVIT, cervical cancer 4

3

2

1

screening – ZORA, breast cancer screening – DORA,

blood sugar level]

…judge the reliability of information on unhealthy habits 24

such as smoking, limited physical activity and excessive 4

3

2

1

drinking?

25

…judge when you need to go to a doctor for a check-up?

4

3

2

1

26

…judge which vaccinations you and your family may

need?

4

3

2

1

27

…judge which health screenings or tests you should take?

[SVIT, ZORA, DORA, blood sugar level]

4

3

2

1

…judge whether the information on health risks in the media 28

is reliable? [For example newspapers, TV or the internet]

4

3

2

1

29

…decide whether to get a vaccination against the flu?

4

3

2

1

30

…decide how to protect yourself against illness based on advice from your family or friends?

4

3

2

1

…decide how to protect yourself against illness based on 31

information in the media? [Instruction for interviewers: for 4

3

2

1

example newspapers, TV or the internet]

38

The following questions are related to health literacy in health promotion.

How easy (on a scale from »very easy« to »very difficult«) would you say it is to: HLS-EU

Fill in the table by rows.

Very

Very easy

Easy

Difficult

difficult

32 …find information about healthy lifestyles, such as about exercise or healthy diets?

4

3

2

1

…find information about activities that are good for your 33 mental well-being? [For example relaxation, physical 4

3

2

1

activity, yoga]

…find out how your neighbourhood could be made

34 more health-friendly? [For example noise and pollution 4

3

2

1

reduction, creation of green spaces, recreational facilities]

…find information on changes in legislation that may

35 affect your or your family’s health? [For example new screening programmes, modified health services, tobacco 4

3

2

1

pricing or prohibitions on smoking, etc.]

36 …find information on how to promote health at work, at school, in the neighbourhood?

4

3

2

1

37 …understand advice on health from your family members or friends?

4

3

2

1

38 …understand information listed on food packaging?

4

3

2

1

39 …understand information in the media about how to improve your health? [For example newspapers, TV or the internet]

4

3

2

1

40 …understand information on how to maintain mental

health? [regardless of the information source]

4

3

2

1

41 …judge how your neighbourhood can affect your health and well-being?

4

3

2

1

42 …judge how your living conditions can affect your health and well-being?

4

3

2

1

43 …judge which everyday behaviours are related to your health? [Drinking and eating habits, physical activity, etc.]

4

3

2

1

44 …make decisions to improve your health and well-being?

4

3

2

1

45 …join a sports club or exercise class if you want to be physically active?

4

3

2

1

…influence your living conditions that affect your health 46 and well-being? [Workplace, change of residence, mobility, 4

3

2

1

leisure behaviour, etc.]

…engage in activities in your community that improve health 47 and well-being? [Noise and pollution reduction, creation of 4

3

2

1

green spaces, recreational facilities]

39

Health information

The following question relates to your experience in searching for health-related information.

C-HI1 Have you ever searched any source for information on health or health topics? [Sources of information include books, brochures, newspapers, magazines, the internet and social networks, information on products, etc.]

1

–

Yes.

C-DET6 What is the highest level of education you

2

–

No.

have successfully achieved?

1

–

No formal education or below ISCED 1.

Personal information

2

–

ISCED 1 Primary education.

The following questions refer to you.

3

–

ISCED 2 Lower secondary education.

4

–

ISCED 3 Upper secondary education.

C-DET1 Sex:

5

–

ISCED 4 Post-secondary but non-tertiary education.

6

–

ISCED 5 Short-cycle tertiary education.

1

–

Male.

7

–

ISCED 6 Bachelor's or equivalent level.

2

–

Female.

8

–

ISCED 7 Master's or equivalent level.

C-DET2 How old are you?

C-DET7 What is your current status of

[Enter the completed years of age.]

employment?

1

–

Employed .

2

–

Self-employed.

C-DET3 Country of birth?

3

–

Unemployed.

4

–

Retired.

5

–

Unable to work due to long-standing health problems.

6

–

Student, trainee.

7

–

Fulfilling domestic tasks.

8

–

Other : ____________

C-DET4 In which country was your father born?

C-DET8 Have you ever undergone training for a

healthcare profession (for example as a nurse,

doctor, pharmacist?)

C-DET5 In which country was your mother born?

1

–

Yes.

2

–

No.

40

C-DET9 How typically easy or difficult it is for you C-DET12 On the scale shown below, »1«

to pay for medicines when needed?

corresponds to the »lowest level of society« and

[For example the copay for prescription medicines

»10« to the »highest level of society«. Please

or the cost of OTC medicines]

indicate how you would rate your position.

1

–

Very easy.

1

–

The lowest level of society.

2

–

Easy.

2

3

–

Difficult.

3

4

–

Very difficult.

4

5

6

C-DET10 How easy or difficult it is for you to pay

7

for medical check-ups or treatment if needed?

8

[Instructions for the interviewers: medical check-ups

9

and treatments that are not fully covered by your

10

–

The highest level of society.

health insurance, for example dental prostheses,

glasses, alternative treatments, therapeutic C-SSUP1 How many people are so close to you medicines and accessories, etc.]

that you can count on them if you have serious

personal problems?

1

–

Very easy.

2

–

Easy.

1

–

None.

3

–

Difficult.

2

–

1 or 2.

4

–

Very difficult.

3

–

3 to 5.

4

–

6 or more.

C-DET11 How easy or difficult it is for you to pay

C-SSUP2 How much interest do people show in

your monthly bills?

what you are doing?

1

–

Very easy.

1

–

A lot of concern and interest.

2

–

Easy.

2

–

Some concern and interest.

3

–

Difficult.

3

–

Uncertain.

4

–

Very difficult.

4

–

Little concern and interest.

5

–

No concern and interest.

C-SSUP3 How easy is it to get help from neighbors

if you need it?

1

–

Very easy.

2

–

Easy.

3

–

Possible.

4

–

Difficult.

5

–

Very difficult.

41

Lifestyle and health

Next questions are about your height and weight as well as your health related habits..

C- HLFST1 How tall are you (without shoes)?

cm

C- HLFST2 How much do you weigh (without clothes and shoes)?

[Check for women aged 50 or younger whether they are pregnant and ask for weight before pregnancy..]

kg

C-HLFST3

Less

I

than

In an average week, how many days

don’t/

one

1

2

3

4

5

6

7

never

day

day

days

days

days

days

days

days

per

week

A

…do you smoke any tobacco

products?

99

0

1

2

3

4

5

6

7

…do you drink beverages containing

alcohol? [For example beer, wine,

spirits, cocktails, ready-made

B

carbonated alcoholic beverages,

99

0

1

2

3

4

5

6

7

liqueurs, homemade alcoholic

beverages, etc.]

…were you engaged in physical

activity for 30 minutes or more so

that your breathing or heart rate

accelerated at least a bit?

C

[For example sports or other leisure

99

0

1

2

3

4

5

6

7

activity, at work, doing chores or

gardening, or travelling from one

place to another.]

…do you eat fruit, vegetables or

lettuce? [Excluding potatoes,

D

freshly squeezed fruit and

99

0

1

2

3

4

5

6

7

vegetable juices, and juices from

concentrate.]

42

HS: general health

own needs is considered, for example ambulance,

on-duty service, etc.]

Next I would like to ask you about your health.

-krat

C-HSTAT1 How is your health in general?



C-HCUT2 How many times in the last 12 months

have you consulted a general practitioner or

1

–

Very good.

family doctor for your personal health issues?

2

–

Good.

[Only consultations for personal needs are

3

–

Fair (neither good nor bad).

4

–

Bad.

considered; consultations when accompanying

5

–

Very bad.

your child, spouse, etc. are excluded]



C- HSTAT2 Do you have any long-term illness or

-krat

health problem? By long-term I mean problems

which have lasted, or are expected to last, for 6

C-HCUT3 How many times in the last 12 months

months or more?

have you consulted a specialist doctor for your



personal health issues? [Only consultations for

1

–

Yes.

personal needs are considered; consultations when

2

–

No.

accompanying your child, spouse, etc. are excluded]

C- HSTAT3 For the last 6 months, how much have

-times

your health problems limited the activities you

would usually do?

C-HCUT4 How many times in the last 12 months



have you been admitted to a hospital for an

1

–

Severely limited.

overnight stay or longer period?

2

–

Limited but not severely.

3

–

Not limited at all.

-times

UZO: medical care utilisation

C-HCUT5 How many times in the last 12 months

have you been to a hospital for out-patient care,

i.e. for diagnostics, treatment or other medical care The following questions refer to your contacts with

that required no overnight stay?

health services. When answering, only consider

those contacts that related to your own health (not

-times

the contacts you had when accompanying your

child, spouse, etc.).

C-HCUT6 How many days in the last 12 months have

you been absent from work due to health issues?

C-HCUT1 How many times in the last 24 months

[Consider all diseases, injuries and other health issues have you used an emergency medical service?

that caused your absence from work]

[Only the use of emergency services for your

-times

43

Communication in health services

The interviewer: We would now like to know how easy or difficult it is for you to communicate with your doctor.

When answering these questions, give a general assessment of your experience regarding communication with your doctor. [Instructions to the interviewer: Your doctor means the doctor you visit most frequently and who is responsible for monitoring your health. If the respondent has no selected doctor at the moment, they are asked to refer to their previous doctor.]

OP-COM How easy (on a scale from »very easy« to »very difficult«) would you say it is to: Fill in the table by rows.

Very easy.

Easy.

Difficult.

Very

difficult.

1

…describe to your doctor the reasons why you come for

consultations?

4

3

2

1

2

…make your doctor listen without interrupting you?

4

3

2

1

3

…explain your health concerns to your doctor?

4

3

2

1

4

…get sufficient consultation time with your doctor?

4

3

2

1

5

…express personal opinions and wishes to your doctor?

4

3

2

1

6

…get the information you need from your doctor?

4

3

2

1

7

…understand the words your doctor uses?

4

3

2

1

8

…ask your doctor questions during consultations?

4

3

2

1

9

…participate in making decisions about your health

during consultations with your doctor?

4

3

2

1

10

…remember the information you received from your

doctor?

4

3

2

1

11

…use the information provided by your doctor to care

for your health?

4

3

2

1

44

Navigational health literacy

We would now like to know how easy it is to get information on how to navigate the health system. This question includes when you use this info for yourself or for someone else. »Health service« refers to a doctor, a specialist doctor, a hospital, a nursing clinic and a rehabilitation or mental health facility OP-NHL How easy (on a scale from »very easy« to »very difficult«) would you say it is to: Fill in the table by rows.

Very easy.

Easy.

Difficult.

Very

difficult.

1

…understand information on how the health system works?

[For example the types of health services available]

4

3

2

1

2

…judge what type of health service you need if you have a health issue?

4

3

2

1

…judge the share of health service covered by your compulsory 3

health insurance? [For example whether additional payments are 4

3

2

1

necessary]

4

…understand information about current health reforms that could affect your medical care?

4

3

2

1

5

…get to know your rights as a patient or health system user?

4

3

2

1

6

…decide on a specific health service?

[For example choose among different hospitals]

4

3

2

1

7

…find information on the quality of a particular health service?

4

3

2

1

8

…judge whether a given health service will meet your

expectations?

4

3

2

1

9

…understand how to make an appointment with a particular health service?

4

3

2

1

10

…find information on possible sources that can help you navigate the health system?

4

3

2

1

11

…find a person within a given medical institution to answer your question? [For example in a hospital]

4

3

2

1

12

…stand up for yourself if medical care fails to satisfy your needs?

4

3

2

1

45

Vaccinations

The following set of questions refer to the vaccination behaviour and to your opinion on vaccination.

OP-VAC1 Have you or anyone in your family been vaccinated in the last five years?

1

–

Yes

2

–

No

3

- 1 - I don't know, I would prefer not to answer.

OP-VAC2 Please indicate for each of the following statements whether they hold true or false.

True

False

1

Vaccines overload and weaken the immune system.

1

2

2

Vaccines may cause diseases against which they are supposed to protect.

1

2

3

Vaccines often produce serious side effects (in addition to normal and temporary response in the first few days).

1

2

OP-VAC3 To what extent do you agree with the following statements (on a scale from »strongly agree«

to »strongly disagree«):

Strongly

agree.

Agree.

Disagree.

Strongly

disagree.

1

Vaccination is important for my personal

protection and the protection of my children.

1

2

3

4

2

I generally believe that vaccination is safe.

1

2

3

4

3

I generally believe that vaccination is effective.

1

2

3

4

4

Vaccination is compatible with my religious

beliefs.

1

2

3

4

5

Vaccination is important to prevent the spread

of (serious) diseases.

1

2

3

4

OP-VAC4 How high do you believe the risk is of falling ill with a disease otherwise preventable by vaccination?

1

–

Very high.

2

–

High.

3

–

Low.

4

–

Very low.

46

E-health

Only ask EZ4 if the respondent DID NOT answer

with 1 – “Yes” to the EZ1 question.

EZ1 Do you use eZdravje on the zVEM web

EZ4

Why don't you use eZdravje on the zVEM

portal, for example e-appointments, access to

web portal, for example e-appointment, access

your medical file, etc.

to your medical file, etc. Multiple answers are

possible.

1

–

Yes.

2

–

No.

EZ4

1

–

I don't know the eZdravje services.

2

–

I do not have enough information about eZdravje

Only ask EZ2 if the respondent answered with 1 –

services.

“Yes” to the EZ1 question

3

–

I do not have sufficient knowledge/skills to use

eZdravje services.

EZ2 How many times have you arranged your

specialist appointment/specialist examination via

4

–

I don't use (have) a computer.

e-appointment?

5

–

I don't have a digital certificate.

6

–

I have no confidence in such operations.

7

–

I did not need eZdravje services.

1

–

Never.

8

–

Other (specify): _______________________________.

2

–

1 time.

3

–

Between 2 and 5 times.

4

–

Between 6 and 10 times.

5

–

11 times or more.

Only ask EZ3 if the respondent answered with 1 –

“Yes” to the EZ1 question.

EZ3 How often do you access your medical

documentation on the web portal zVEM?

1

–

Never.

2

–

Once a week.

3

–

Once a month.

4

–

Once a year.

5

–

Several times a year.

47

Digital literacy

V1 How often have you used any of the following online applications and/or services to obtain health-related information in the last 12 months?

Less than

Fill in the table by rows.

Every

A few times A few times

dan.

a week.

a month.

ones a

Never.

month.

A

Search engines (for example Google,

Bing, Yahoo).

1

2

3

4

5

B

Facebook pages related to health.

1

2

3

4

5

C

Online forums in Slovenia (for example

Med.over.net, Tekaskiforum.net,

1

2

3

4

5

Ringaraja.net).

D

Foreign online forums.

1

2

3

4

5

E

Slovenian specialised health-related

websites (for example nijz.si, vizita.si,

1

2

3

4

5

zdravje.si)

F

Foreign specialised websites for health-

related issues.

1

2

3

4

5

G

Other health-related websites. Which?

1

2

3

4

5

48

V2 We are also interested in your experience in searching online for health-related information. On a scale from 1 (strongly disagree) to 5 (strongly agree), please indicate the extent to which you agree with the following statements.

Neither

Fill in the table by rows.

Strongly

Not

agree

disagree.

agree.

nor

Agree.

Strongly

agree.

disagree.

A

I feel confident about using the internet to improve my health.

1

2

3

4

5

B

The internet is very useful for helping me to take decisions about my health.

1

2

3

4

5

C

I think we can trust most of the health information found online.

1

2

3

4

5

D

I am satisfied with the first health source found on the internet that provides answers to my questions.

1

2

3

4

5

When searching online, I prefer to read short and simple E

health explanations rather than comprehensive professional 1

2

3

4

5

explanations.

Modern online systems are so highly developed that they F

automatically differentiate between low- and high-quality 1

2

3

4

5

health information.

G

It is very important for me to have access to health-related sources online.

1

2

3

4

5

H

I know how to use the information I find on the internet to improve my health.

1

2

3

4

5

A large number of followers (of a person or an organisation) I

on social media is a proof, that information posted online is 1

2

3

4

5

professionally reliable.

J

I do not usually find personally useful information about health online.

1

2

3

4

5

I am aware that search engines can return personalised K

and limited search results when I search for health-related 1

2

3

4

5

information.

49

V3 Have you ever bought any medicine, dietary supplement, cosmetics, or medical device online (such as in an online pharmacy)?

1

–

Yes.

2

–

No.

V4 The following are statements related to the use of the internet to search for health-related information.

To what extent do you agree or disagree with them?

Neither

Fill in the table by rows.

Strongly

Not

agree

disagree.

agree.

nor

Agree.

Strongly

agree.

disagree.

I sometimes don't know where to start searching

A

online for information about health when I have a

1

2

3

4

5

health problem.

B

If I find useful information on health online, I am not interested in who the author is.

1

2

3

4

5

C

I often don't understand the terminology used by

some online health sources.

1

2

3

4

5

D

When reading information about health online, I take

sufficient time to really understand it.

1

2

3

4

5

I'm unable to recognise high-quality information

E

relevant for my health because of the vast amount of

1

2

3

4

5

information online.

F

I myself interpret health information that I find online.

1

2

3

4

5

G

When I find information related to my health online, I check its accuracy with other online sources.

1

2

3

4

5

H

I sometimes have difficulties understanding key

information online that is relevant to my health.

1

2

3

4

5

I

I fully understand health-related information I find

online.

1

2

3

4

5

It is important for me to check health-related

J

information that I find online with other sources (for 1

2

3

4

5

example doctors, books, friends, relatives).

50

V5 Have you ever sent an e-mail to your personal doctor or their nurse?

1

–

Yes.

2

–

No.

V6 To what extent do the statements on searching online for health information apply/not apply to you?

Neither

Fill in the table by rows.

Strongly

Not

agree

disagree.

agree.

nor

Agree.

Strongly

agree.

disagree.

A

I know which sources of health information

are available online.

1

2

3

4

5

There are medical studies published

B

online, but I don't know how to access

1

2

3

4

5

them.

I am able to distinguish low-quality health

C

information from high-quality health

1

2

3

4

5

information online.

D

I have no difficulties understanding the

substance of the information online.

1

2

3

4

5

E

I have sufficient knowledge to assess the

quality of online sources.

1

2

3

4

5

If I have doubts about the reliability of

F

information about health online, I ask

1

2

3

4

5

somebody for explanation.

I can find a lot of health information

G

online, but I can't identify the information

1

2

3

4

5

that can help me make health decisions.

I know how to access websites or

H

applications and enter my symptoms to

1

2

3

4

5

get information about my health issues.

I

I can identify useful tips for addressing my

health issues from information online.

1

2

3

4

5

J

I know how to use the internet to get

answers to my health concerns.

1

2

3

4

5

K

I know where to find useful sources of

information on health online.

1

2

3

4

5

51

Could you please provide us with your telephone number, which we will use only for the purpose of

potential monitoring and data verification?

Telephone number:

THANK YOU FOR YOUR PARTICIPATION!

© National Institute of Public Health, 2020

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