What is the Prevalence of Low Health Literacy in European Union Member States? A Systematic Review and Meta-analysis

Background Many studies have shown that low health literacy (HL) is associated with several adverse outcomes. In this study, we systematically reviewed the prevalence of low HL in Europe. Methods PubMed, Embase, and Scopus were searched. Cross-sectional studies conducted in the European Union (EU), published from 2000, investigating the prevalence of low HL in adults using a reliable tool, were included. Quality was assessed with the Newcastle-Ottawa Scale. Inverse-variance random effects methods were used to produce pooled prevalence estimates. A meta-regression analysis was performed to assess the association between low HL and the characteristics of the studies. Results The pooled prevalence of low HL ranged from of 27% (95% CI: 18-38%) to 48% (95% CI: 41-55%), depending on the literacy assessment method applied. Southern, Western, and Eastern EU countries had lower HL compared to northern Europe (beta: 0.87, 95% CI: 0.40-1.35; beta: 0.59, 95% CI: 0.25-0.93; and beta: 0.72, 95% CI: 0.06-1.37, respectively). The assessment method significantly influenced the pooled estimate: compared to word recognition items, using self-reported comprehensions items (beta: 0.61, 95% CI: 0.15-1.08), reading or numeracy comprehensions items (beta: 0.77, 95% CI: 0.24-1.31), or a mixed method (beta: 0.66, 95% CI: 0.01-1.33) found higher rates of low HL. Refugees had the lowest HL (beta: 1.59, 95% CI: 0.26-2.92). Finally, lower quality studies reported higher rates of low HL (beta: 0.56, 95% CI: 0.06-1.07). Discussion We found that low HL is a public health challenge throughout Europe, where one in every three to almost one in every two Europeans may not be able to understand essential health-related material. Additional research is needed to investigate the underlying causes and to develop remedies. PROSPERO Registration CRD42019133377