Education-based differences in alcohol health literacy in Germany
Original paper
Background
The paradox
Despite ample epidemiological evidence demonstrating alcohol as a major preventable risk factor for diseases, there is a concerning lack of health literacy on alcohol’s health risks in the European population.
According to a recent online survey in 14 European countries, the knowledge about alcohol’s causal role in the development of a range of diseases reached 90% for liver disease but dropped to 53% for cancers and only 11% for respiratory diseases (e.g., tuberculosis).
Knowledge is not enough
Knowledge about the potential health hazards of a health-related behaviour such as alcohol use is often discussed as a critical determinant to practicing this behaviour. However, just knowing about health risks appears to be insufficient to lead to behavioural change, especially for behaviours such as consuming alcohol, which is deeply rooted socially and culturally in many countries.
Health literacy as a concept
This suggests that the current narrative of ‘responsible alcohol consumption’ may penalise people with lower levels of education.”
Kilian C, Liebig M, Manthey J. Education-based differences in alcohol health literacy in Germany. Drug Alcohol Rev. 2024. https://doi.org/10.1111/dar.13985
The concept of health literacy acknowledges the complexity of making health-related decisions and involves multiple components:
- knowledge and understanding (e.g., alcohol content in beverages, health risks);
- skills (e.g., access health-related information);
- critical thinking (e.g., appraise marketing messages); and
- system competence (e.g., navigate in health systems).
If alcohol health literacy is perceived in its full complexity, including higher-level changes to the health care system and environment, for example, by reducing the affordability and availability of alcoholic beverages, it is very likely to lower population-level alcohol consumption.
In an expert panel study, education and information measures targeting the individual were rated most effective to increase alcohol health literacy, while being least effective to leading to an actual decline in population-level alcohol use, for which alcohol control policies were rated the highest.
Limits and shortcomings of the health literacy approach to alcohol harm
As most European countries follow a (alcohol industry) narrative of ‘responsible alcohol consumption’ characterised by limited regulations of alcoholic products, high levels of alcohol health literacy are vital to public health.
In fact, this approach presupposes that all consumers can make informed decision by being able to access, understand and apply the relevant information to their day-to-day life in order to achieve desirable public health outcomes (e.g., reduced alcohol-related health burden).
However, this appears not to be the case as knowledge on alcohol’s causal role in the development of different diseases were found to be higher in people with tertiary education compared to those with primary or secondary education in a sample of Europeans from 14 countries. Such a correlation between years of education and health literacy has also been reported in the reach of German alcohol prevention campaigns and on general health literacy.
This suggests that the current narrative of ‘responsible alcohol consumption’ may penalise people with lower levels of education.
With this background, the researchers aim:
- to capture the level of alcohol health literacy in the general adult population in Germany; as well as
- to investigate education-based differences therein.
The researchers conduct their research in Germany that stands out for very high levels of alcohol use (alcohol sales in 2019: 10.6 L of pure alcohol, per capita) and very flawed alcohol policy. While alcohol consumption and harms have declined slightly in the past decade in Germany, the alcohol-attributable burden remains high. Currently, there is no data available on how alcohol health literacy is distributed in Germany.
The researchers hypothesise that alcohol health literacy is significantly lower in people with low or medium levels of education compared to those with high education.
Main findings
611 individuals completed the online survey, of which 162 (26.5%) were excluded due to missing information on alcohol health literacy (i.e., response option ‘Not specified’). Another 8 (1.3%), 1 (0.1%), 2 (0.3%) and 44 (7.2%) observations were excluded due to missing information on educational attainment, gender, alcohol use and general health literacy, respectively. As only three respondents indicated ‘other’ gender, the researchers restricted their analysis to men and women.
The final sample with complete data on key variables comprised of 391 person (n = 228 men and n = 163 women, with a mean age of 44.1 and 45.7 years, respectively).
In the study sample, insufficient alcohol health literacy was recorded in 47.8% of men and 41.1% of women. The proportion of men and women with insufficient and sufficient alcohol health literacy did not statistically significantly differ regarding their age, education and general health literacy distributions.
However, there were statistically significant more men with sufficient alcohol health literacy reporting to currently abstain from alcohol (n = 23, 19.3%) compared to men with insufficient alcohol health literacy (n = 8, 7.3%). Among women, 1 in 10 indicated to not drink alcohol (for comparison, men: 13.5%).
- Most respondents (≥75%) indicated that liver diseases, injuries, fetal damage, mental health conditions, and heart diseases are causally linked to alcohol use.
- The alcohol-cancer link was known by 57.7% (low education) to 83.0% (high education).
- Alcohol’s causal contribution to dementia was reported by 50.0% (low education) to 66.0% (high education)—suggesting an educational gradient as hypothesised.
- The role of alcohol use in respiratory and infectious diseases was identified by less than a quarter of respondents across educational groups.
- Moreover, at least three out of four respondents stated that drinking wine would benefit their health and that wine would be generally better for their health than the same amount of pure alcohol in beer.
Respondents were further asked to indicate the limits of at-risk alcohol use according to the German alcohol consumption guidelines as of early 2023. Most respondents were able to report the relevant alcohol consumption limits (per day, men: 2 alcoholic drinks, women: 1 alcoholic drink, women during pregnancy: 0 alcoholic drinks). However, 23.1% to 34.6% of respondents from the low-education group indicated values above the recommended limits, while this was the case in 11.0% to 18.8% of those in the other education groups.
Lastly, the researchers asked respondents how easily they understand information on alcohol-related risks. Across education groups, the majority indicated that they consider it easy to very easy to understand health-related information on alcohol risks (low education: 61.6%, high education: 76%).
Educational differences in alcohol health literacy
According the fully adjusted model, respondents with low education were about 1.35 times more likely to have an insufficient alcohol health literacy compared to those with high education.
Moreover, current alcohol abstainers were significantly less likely to have an insufficient alcohol health literacy than low-risk alcohol users, while there was no statistically significant difference between high-risk and low-risk alcohol users.
All other covariates (gender, age group, general health literacy) were not statistically significantly associated with the outcome.
Meaning of the study results
This is the first study undertaking an in-depth exploration of alcohol health literacy and its educational distribution in Germany.
The researchers found respondents with low educational attainment to be more likely to have insufficient alcohol health literacy compared to those with high education. This educational gap is concerning given worse alcohol-related health outcomes in individuals with low socio-economic status, as it potentially increases socioeconomic differences in alcohol-attributable morbidity and mortality.
Moreover, the study findings call into question the premise of the German alcohol policy that keeps alcohol largely unregulated and is based on the notion of ‘informed consumer choice’.
However, given the observed systematic education-based differences in alcohol health literacy, this premise appears to be no longer valid. To increase alcohol health literacy across all population groups, a comprehensive strategy is needed, including effective prevention programs in schools, easily accessible information on alcohol use, information provided in simple language and languages other than German, as well as health warning labels on alcohol containers.
Abstract
Introduction
Alcohol health literacy is critical for informed consumer decision making but has yet received limited attention in public health research. The researchers therefore seek to measure alcohol health literacy and its educational distribution in Germany.
Methods
In this cross-sectional study, the researchers developed and applied a brief nine-item questionnaire on alcohol health literacy in an adult convenience sample (n = 391; February to April 2023). The association of educational attainment with ‘insufficient’ alcohol health literacy was tested in adjusted logistic regression models.
Results
Insufficient alcohol health literacy was recorded in 47.8% of men and 41.1% of women in the study sample. While most respondents correctly identified common misconceptions and wrong beliefs about alcohol and were able to specify low-risk alcohol consumption limits for women and women during pregnancy, only few correctly identified all alcohol-related health conditions, especially respiratory and infectious diseases.
Respondents with low education were 1.35 times more likely to have been classified as having insufficient alcohol health literacy than high-educated respondents. There was no statistically significant difference between respondents with medium versus high education.
Discussion and Conclusions
Educational gaps in alcohol health literacy question a policy rationale that is fundamentally based on the premise of ‘informed consumer choice’. Strategies to raise alcohol health literacy must ensure that they reach all population groups, for instance, by providing health warning labels on alcohol containers.