Understanding Health Literacy in Otolaryngology Patients - Key Factors and Impact on Medical Practice

Understanding Health Literacy in Otolaryngology Patients - Key Factors and Impact on Medical Practice | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Article Understanding Health Literacy in Otolaryngology Patients - Key Factors and Impact on Medical Practice Christian Dobel, Louisa Gund, Ralf Tostmann, Jan Löhler, André Scherag, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6328330/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract The World Health Organization (WHO) declared health literacy (HL) as a public health goal, yet global studies consistently reveal inadequate HL levels. The implications of low HL extend to delayed diagnoses, increased healthcare costs and mortality rates. This multi-center prospective cross-sectional study aims to achieve a deeper understanding for health literacy and corresponding challenges in otorhinolaryngology. 27 otolaryngology outpatient practices, 18 otolaryngology hospitals, and 14 university otolaryngology departments took part in data collection during the otolaryngology awareness week in June 2021 in Germany. Participants were v olunteer sample of adult otolaryngology patients with smell, taste, and hearing impairment, head and neck tumor, inflammation or infections. Patients completed a layman-friendly questionnaire regarding patient orientation, evidence-based medicine, need for research, and HL. HL scores were determined using the 3 items of the Brief Health Literacy Screen (BHLS), ranging from 0 to 15, with enhanced scores indicating higher HL. Important variables impacting HL were examined using Multiple Linear Regression Models and Elastic Net Regression. 2023 patient responses (46% female; 49% 46–75 years old) were analyzed. The mean HL score was 9.73 ± 1.37. Elastic net regression and multiple linear regression models identified predictors for HL, regardless of disease. Most important were hearing impairment, education, financial issues, and patient preferences and thus represent key factors for HL. These findings offer valuable insights into the patients’ view of otolaryngology, head and neck surgery and set a precedent for examining HL across medical fields. Biological sciences/Psychology/Human behaviour Health sciences/Health care/Health services Health sciences/Health care/Public health Health sciences/Health care/Quality of life Figures Figure 1 Figure 2 Introduction Otolaryngology patients have shown a growing desire to take on active roles in managing their own health 1 , reflecting the growing importance of health literacy (HL). HL encompasses individuals' abilities to access, comprehend, and apply health information for informed decision-making 2 . These skills play a fundamental role in treatment adherence, fostering patient understanding and compliance. The World Health Organization (WHO) declared HL as a public health goal 3 . Some of the first studies highlighted significant variations in HL levels among populations, with many reporting inadequate HL 4 , 5 . Results stemming from the EU, ie. the HLS-EU study 6 , indicated that about 35% of the participants struggled with problematic HL. Low HL may lead to poor mental 7 and physical 8 , 9 health outcomes, increased healthcare costs 9 , 10 , lower satisfaction 11 , and an overall increased mortality 9 , making it a global concern. Although otolaryngology patients often require complex care, there is a lack of studies in this field with not a single study addressing this issue 12 . More generally and spanning fields of medical treatment, several factors were identified as predictors for HL. Individuals with lower incomes tend to exhibit lower levels of HL 13 , 14 . Lee, Arozullah and Cho 15 found that persons with an immigrant background or low self-assessed social status portrayed significantly lower HL levels. Higher age is mainly linked to lower levels of HL 13 , 14 , 16 – 19 potentially attributed to cognitive decline. However, older age may also correlate with higher HL levels, potentially due to knowledge or experience 20 , 21 . A study investigating digital HL skills of German university students found lower digital HL in female students 22 . Other studies associated female gender with better HL 18 but differences were rather small 4 . Overall, individuals with lower levels of education tend to have lower HL scores, indicating challenges in understanding health-related information or warnings 6 , 11 , 13 , 17 , 19 , 21 , 23 , 24 . Individuals with self-assessed poor health status and frequent doctor visits exhibit lower HL levels 6 , 13 . Individuals with low HL due to hearing or vision impairment struggle with comprehending health information effectively, which can ultimately lead to difficulties in adhering medical advice and understanding health warnings 12 , 16 , 17 . Numerous frameworks depict crucial factors related to HL and their impact on health outcomes, including e.g. prior knowledge, social support, cognitive abilities, and cultural differences 14 , 17 , 20 , 25 . In this context, patient education and counseling improves self-efficacy, a factor linking HL and health outcomes 14 , 26 . One of the most impactful models in HL was introduced by Sørensen et al. 2 . This model proposes three dimensions of HL, covering healthcare, health promotion, and disease prevention. Accordingly, HL is influenced by factors such as age, education, social support, and media use. However, a universally accepted gold standard for assessing HL remains elusive 10 , 27 . Taken together, HL has gained increasing recognition in recent years due to its significant impact on patient outcomes. Despite this, there remains a gap in understanding HL within specific medical specialties, such as Otolaryngology. The current study seeks to address this gap by using a two-sided approach aimed at gaining a comprehensive understanding of the key factors influencing HL in otolaryngology, i.e. first, by employing analyses derived from existing literature (the theory driven approach) and, secondly, by identifying predictor variables through a data-driven elastic net approach (the data driven approach), to account for covariance and multicollinearity. A mere descriptive data analysis in itself is not sufficient because HL is a multidimensional construct requiring a nuanced approach to capture its complexity. Methods Study Design Multicenter prospective cross-sectional study Patient Sample/Study Population Eligible patients were adults aged 18 and above, participating voluntarily in the otolaryngology awareness week organized by the German Society of Oto-Rhino-Laryngology, Head and Neck Surgery together with the German Professional Association of Ear-Nose-Throat-surgeons spanning from June 14 to June 20, 2021. A total of 2023 patient responses could be gathered through a layman-friendly questionnaire regarding patient orientation, evidence-based medicine, need for research, and HL. Additional inclusion criteria were language proficiency in German, willingness to participate in the study, and the ability to give informed consent. Patients were excluded if these criteria were not met. Data Collection Data were collected in 27 participating otolaryngology out-patient practices, 18 otolaryngology primary and secondary care hospitals, and 14 university tertiary care otolaryngology departments. The questionnaire exclusively comprised a closed-answer format for all questions, taking 15 to 20 minutes to complete. No compensation was provided for their participation. Data collected were kept anonymous 1 . Variables The dependent variable HL was assessed using the Brief Health Literacy Screen (BHLS) from Chew, Bradley and Boyko 28 as a short and effective tool for identifying low HL levels in clinical samples 28 , 29 . Three questions addressed patient's disease and treatment status. Patient orientation was explored with ten questions. Personal needs and expectations were assessed with two questions 30 . Subsequently, participants were asked two questions about their role in the treatment decision-making process based on the concept of Degner, Sloan and Venkatesh 31 . Four questions inquired about the patient's relationship with the specialist 32 . Six questions examined the information sources used by patients regarding their condition 33 . Five questions related to personal involvement in otolaryngology and inquiries about gender, age, federal state of residence, type of health insurance, and education concluded the questionnaire. Statistical Analysis and Data Preprocessing Descriptive data are reported as absolute figures and corresponding percentages, providing an initial overview of the dataset. For the main analyses, Multiple Linear Regression Models (the theory driven approach) and an Elastic Net Regression (the data driven approach) were conducted to identify important predictors for HL. All statistical analyses were employed using the Software SPSS Statistics (IBM, Version 27, New York) and R 34 . Theory-Driven Approach: Model Testing Despite the size of the dataset, the available variables only partially matched those suggested in dominating published HL models 2 , 26 . As such, measures of general literacy, cultural factors, motivation, and social support were missing. Nevertheless, rucial variables from the existing literature were identified and categorized into overarching themes. These themes were used to guide the selection and analysis of variables within Regression Models, focusing specifically on their relevance to HL. This pathway allowed for the best alignment between existing models and the available dataset. Table 1 gives an overview of the models and the specific variables included. Technically, variables were dummy-coded and missing cases were excluded listwise. Our exploration focused on variables that achieved a nominal, two-sided p-value ≤ .05. From the five models, all variables that showed such an effect on HL were ultimately combined into a single final model for further analysis. For every model, the assumptions for Multiple Linear Regression Models were tested 35 (see Supplement 1). Table 1 Legend: Distribution of the Variables into Variable blocks Model Variable Description 1 Disease and Treatment For which diagnosis are you being treated in the ENT department? In which facility are you currently being treated in the ENT department? How long have you been receiving ENT treatment? 2 Participation in Research Have you ever participated in a research study? Would you like to actively participate in shaping future research topics in otorhinolaryngology? 3 Patient Orientation a a How much do you agree with the following statement: The disease has a very big impact on my everyday life. Which area in your everyday life has the disease affected most? b How do you currently participate in the decision-making process about your treatment option? How would you like to be involved in the decision-making process about your treatment option? How much do you agree with the following statement: I hope that my wishes and priorities will be considered by the treating ENT specialist. c Patient-centered communication is an important component in the doctor-patient relationship. Which of the statements reflects the most important factor for communication for you? Which of the following factors do you consider most important for a good or collaborative relationship with the treating practitioner? Which of the following factors do you feel is most important in reflecting modern patient involvement in otolaryngology? 4 Medical information Search a How much do you agree with the following statement: I have been informed in detail about the treatment process. Has your need for information changed from the beginning of the disease until now? b What is your primary goal when seeking out medical information sources? Choose one person to seek advice from when you have questions about your condition. Which electronic information source do you rely on when you are searching for medical information? 5 Demographics a Which gender do you identify as? To which age group do you belong? Which type of health insurance are you enrolled in? What is your highest school-leaving qualification? b In which federal state do you reside in? Insert Table 1 here Data-driven Approach: Elastic Net Regression Elastic Net Regression is a regularization technique combining Lasso 36 and Ridge Regression 37 elements and is suitable for data sets with a large number of predictors and possible multicollinearity. The two regularization parameters (i) α Alpha and (ii) λ Lambda influence the balance between the two techniques. For Elastic Net Regression, predictors were standardized using the gmlnet package in R. The dataset was split into training (70%) and testing (30%) sets. Variables with over 20% missing values were removed to ensure validity and reliability of results. A grid search with cross-validation was performed to determine the optimal lambda value. The model was evaluated using the test data set and the Root Mean Square Error (RMSE). All cases with missing values were removed for this analysis mirroring the Theory-driven Approach. Results Descriptives Table 2 describes the characteristics of the 2023 study participants (female N = 933 (46.1%), male N = 935 (46.2%); age mean = 50.5 ( SD = 17.23)). Most patients (616; 26.23%) visited the otolaryngology hospital/outpatient practice for the first time and 476 (20,28%) received treatment for over 5 years. Patients struggled with physical changes (360; 17.80%,), financial issues (7; 0.30%), anxiety and worries (136; 6,70%). 655 patients (32.40%) fully agreed that their illness has a significant impact on their daily life. Figure 1 shows the distribution of HL scores in the general sample. The median HL score was 10.00 (IQR (interquartile range) 9.00 to 12.00). Mean HL score was 9.73 ( SD = 1.37). The number of patients with HL scores between 12.00 to 15.00 was 14.50% (294). 1121 patients (55.50%) expressed a demand for detailed insights into the medical care process. 994 patients (49.20%) relied on their otolaryngology doctors as their primary source of information. Half of the participants (49.20%) exuded confidence in navigating medical forms. 3.00% expressed a lack of assurance and 3.40% admitted to always needing assistance, while 20.30% acknowledged occasionally seeking help, and 28.60% indicated never requiring assistance. In the realm of understanding medical information, 32.00% of participants occasionally found it challenging, while 9.20% reported never facing problems, and 1.70% indicated always finding it difficult to understand medical information. Insert Fig. 1 here Insert Table 2 here Table 2 Legend: Sociodemographic Characteristics of Patients in the Full Sample and Elastic Net Analysis Subsample Characteristic Full sample Elastic Net Regression n % n % Gender Female 933 935 46,1 46,2 427 474 47,2 52,4 Male Not specified 155 7,7 4, 0,4 Age 18–30 years 313 15,5 159 17,6 31–45 years 424 21 220 24,3 46–60 years 538 26,6 271 29,9 61–75 years 450 22,2 218 24,1 76 years and older 148 7,3 36 4, None/invalid information 150 7,4 1 0,1 Federal State Baden-Wuerttemberg 127 6,3 61 6,7 Bavaria 91 4,5 56 6,2 Berlin 12 0,6 5 0,6 Brandenburg 145 7,2 60 6,6 Bremen 3 0,1 3 0,3 Hamburg 104 5,1 57 6,3 Hesse 188 9,3 88 9,7 Mecklenburg-Western Pomerania 144 7,1 70 7,7 Lower Saxony 116 5,7 58 6,4 North Rhine-Westphalia 343 17 162 17,9 Rhineland-Palatinate 50 2,5 29 3,2 Saarland 26 1,3 15 1,7 Saxony 218 10,8 91 10,1 Saxony-Anhalt 24 1,2 12 1,3 Schleswig-Holstein 119 5,9 64 7,1 Thuringia 169 8,4 73 8,1 None/invalid information 144 7,1 1 0,1 Health Insurance Statutory 1556 76,9 803 88,7 Private 189 9,3 89 9,8 Other 19 0,9 11 1,2 Missing information 259 12,8 2 0,2 School Leaving Certificate Lower Secondary School Certificate 373 18,4 107 11,8 Intermediate Secondary School Certificate 632 31,2 211 23,3 University of Applied Sciences Entrance Qualification 223 11 118 13 A-levels 527 26,1 304 33,6 Other 78 3,9 31 28,3 None/invalid information 190 9,4 0 0 Note. N = 2023 for the Full sample and N = 905 for the Elastic Net Regression subsample. Theory-Driven Approach: Model Testing Table 3 summarizes the final theory driven regression model. Results for the submodels are displayed in Supplement 2. The diagnosis of tumor ( β = − .28, p = .01), facing financial issues ( β = -1.7, p = .004), needing headphones to watch TV ( β = − .81, p < .001), making all decisions independently after receiving thorough information from the treating physician ( β = .168, p = .046), being female ( β = .267, p < .001), and having completed the highest school education ( β = .381, p < .001) all were (potential) predictors of HL. The overall evaluation of the model yielded an adjusted R² of .07, indicating that approximately 7% of the variance of the dependent variable HL could be explained by the included variables. Table 3 Legend: Final Multiple Linear Regression Model Estimate SE 95% CI p LL UL Intercept 9.72 .09 9.53 9.90 < .001 tumor − .28 .11 − .49 − .06 .001 Financial issues -1.7 .58 -2.84 − .56 .004 Needing headphones to watch TV − .81 .22 -1.24 − .38 < .001 Making All Decisions Independently .17 .09 − .00 .35 .046 Female .267 .08 − .11 .42 < .001 Highest school education .381 .08 .22 .54 < .001 Note. N = 2023. Adjusted R 2 = .07; CI = confidence interval; LL = lower limit; UL = upper limit. Insert Table 3 here Data-driven Approach: Elastic Net Regression The distribution of HL scores in the subsample for this analysis is displayed in Supplement Fig. 1 . The mean BHLS score was 9.79 (SD = 1.28) with a median HL score of 10.00 and an Interquartile Range (IQR) from 9.00 to 11.00. The variables influencing HL based on this model are summarized in Supplement Tables 1 and 2 in more detail. Figure 2 below displays the 30 variables with the highest absolute coefficient values, sorted in descending order. Insert Fig. 2 here Dealing with financial issues, often failing to understand medical information, patient’s wishes never being considered, relying on friends as the primary source of information, not feeling confident when filling out medical forms, valuing honesty and empathy from the treating physician, needing help filling out medical forms, or the need to have changed the whole diet portrayed high absolute variable importance. The variables with the lowest absolute importance were being male, having a treatment duration of more than 5 years, having all decisions being made solely by the otolaryngologist, Lower Secondary School Leaving Certificate or equivalent, having a diagnosis related to smell, taste and hearing disorder and only having personal wishes and priorities considered often by the treating ENT physician as well as being aged between 61 and 75. Discussion The purpose of this study was to gain a better understanding of HL in otolaryngology, and the skills needed for accessing, understanding, appraising, and applying health-related information 2 . The concept of HL still is relatively new, and especially in the realm of otolaryngology, also an unexplored topic 24 . The general study population displayed moderate levels of HL. The most influential variables identified were financial issues, education, and hearing impairment, each significantly impacting HL. The most significant factor influencing HL were financial challenges , with a notable negative impact as shown in previous studies and, thus, further stressing the risk of low socioeconomic (SE) status 13 , 14 , 16 , 38 ,39 40 41 . Adding to the impact of SE, having the highest German school education level (Abitur) was associated with a substantial increase in HL corroborating earlier research 41 , 42 . Higher education levels are essential for various aspects of HL, including understanding, evaluating information as well as sharing and applying it appropriately. Only about half of the patients felt confident filling out medical forms, despite the high educational background of patients. Importantly, the current analyses highlighted the profound impact of hearing impairment on HL. This impact was negative and substantial, underscoring the significant challenges faced by individuals with hearing impairments in comprehending information. Furthermore, these findings align with broader research, illustrating a positive association between limited HL and both unaided and aided severe hearing loss in adults aged 65 years and older 43 . The current analyses stress the significant impact of hearing impairment on HL. This aspect is of particular importance for otolaryngology patients, as a substantial proportion of these patients already struggle with hearing impairments, further complicating the communication process. A patient's difficulty in acoustically understanding the clinician's explanations or embarrassment about hearing impairments might pose challenges to their treatment progress and health outcomes. Considering hearing problems in different patient groups is essential. The strong desire for patient-centered care among ENT patients emphasizes the urgency of integrating patient preferences and needs into healthcare strategies 1 . In addition to these variables, several other ones had an effect on HL, but to a lesser degree. The presence of severe or chronic illnesses (presence of a tumor, diagnoses such as sleep disorders, smell, taste, and hearing disorders, or voice and speech disorders) went along with lower HL corroborating earlier studies 38 ,44 21 .This is particularly concerning for patients with chronic diseases, who rely on these skills to navigate the complexities of their conditions 45 . Patients who autonomously made informed decisions in their healthcare journey exhibited higher levels of HL, indicating the significance of an active patient role and informed decision-making process which was also observed in other practice settings 46 , 47 . Patients’ active role was also supported by Elastic Net Regression with additional factors. First, if patients had to change their entire diet, and second, if they no longer were able to drive a car by themselves. These aspects can be subsumed under self-efficacy , which has been associated with HL 48 , 49 . A complete dietary change requires a lot of time and adherence to the recommendations 50 . Thus, patients who successfully implement these changes may also be able to successfully implement other health-related aspects in their lives, competencies known as HL 51 , 52 . Similarly in the current sample, patients who relied on family members as information source about their illness exhibited lower HL levels, possibly due to the varied reliability of this kind of information source and the potential presence of bias within family-based advice. This finding emphasizes the critical importance of reliable and expert sources for health information and HL skills. In the Multiple Linear regression model, female gender showed a substantial, in the Elastic Net Regression only a minor impact. This aligns with a previous study 18 , but in a systematic review including 85 studies no significant association between HL and gender could be found 23 . Higher age displayed a minor positive magnitude in the Elastic Net Regression consistent with one other study 21 , but was reversed in other studies 14 , 16 – 19 . Strengths and Limitations This research provides a foundation for subsequent studies, wherein factors like participation in self-help groups, auditory abilities, self-efficacy should be considered as these are mostly included in current models. Due to the two-sided approach of this study, financial disparities, education, and patient preferences can be seen as robust variables influencing patients HL. These findings should be integrated into future models to further elucidate the relationship between HL and its global effects on patient outcomes. The study exhibits some limitations, predominantly because of the nature of the variables and the German origin. The dataset may not be optimal for the current study. HL was only one aspect of the study, potentially affecting the results. Secondly, cultural variations in HL of otolaryngology patients in other countries cannot be excluded as at least hearing and understanding of health care information varies between different cultures 53 . Thirdly, missing variables and the handling of missing values within this study are a limitation. Our literature search related to the theory-driven analyses revealed HL relevant variables that should be include in future assessments, such as measures of general literacy, cultural factors, motivation, and social support. Additionally, the BHLS tool used in this study does not provide specific levels for categorizing HL as adequate, problematic, or insufficient. The use of BHLS-specific cut-off scores varies across studies 54 and therefore the different levels could not be identified. Regarding missing values in the study, we decided against a multiple imputation step due to the data level not supporting this approach. Elastic Net Regression identified a multitude of variables for predicting HL, indicating the complexity of the factors involved. This complexity is further underscored by the low R-squared values from the Linear Regression Models, suggesting that numerous variables collectively influence HL levels. Since this approach is novel and indicates room for improvement, the low R-squared values are unsatisfactory; however, they provide insights into areas for enhancement in future studies. In the multiple linear regression models, HL was influenced by a multitude of factors. Crucially, these relationships do not adhere to a simple linear pattern, primarily because not all assumptions could be confirmed. This understanding aligns with previous research suggesting a non-linear relationship between HL and health outcomes 14 . This complexity also underscores the challenge of establishing direct causal relationships as well as the interpretation of the highlighted variables. Conclusions Limited HL contributes to delays in the diagnosis of health conditions, resulting in missed opportunities for early intervention. It may also lead to riskier behavior, weaker self-management skills, and an overall inadequate management of their health conditions. In line with previous research education, socioeconomic inequalities, and patient preferences are crucial for high levels of HL in the field of otolaryngology. For all medical fields considerations regarding hearing impairment should be included in future surveys and assessment of individual HL. Understanding and addressing factors for HL are essential for healthcare professionals worldwide to provide effective clinician-patient communication and improve adherence to treatment. Declarations Ethics Statement The study was approved by the Ethics Committee of Jena University Hospital (No. 2021–2167). Before participation, patients were informed about data privacy and their written consent was obtained. The survey was performed following the principles and guidelines of the Declaration of Helsinki. Author Contribution Dobel and Gund analysed the data and wrote the paperScherag proposed data analysis strategy and supervised execution.Tostmann, Löhler and Guntinas-Lichius organised data collection and collected data Acknowledgement We acknowledge gratefully the contribution of all patients and colleagues in distributing and completing the survey. Data Availability Data can be received from the authors ( [email protected] ; [email protected] ) upon reasonable request by researchers and clinicians. References Horn J, Tostmann R, Dobel C, Löhler J, Guntinas-Lichius O. [The ENT patients' perspective on otorhinolaryngology, head and neck surgery - a Germany-wide survey]. Laryngorhinootologie . Dec 21 2022;Die Perspektive der Patienten auf die HNO-Heilkunde – eine deutschlandweite Befragung. doi:10.1055/a-1970-6558 Sørensen K, Van den Broucke S, Fullam J, et al. 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Using multiple linear regression in pharmacy education scholarship. Currents in Pharmacy Teaching and Learning . 2020/10/01/ 2020;12(10):1258-1268. doi:https://doi.org/10.1016/j.cptl.2020.05.017 Tibshirani R. Regression Shrinkage and Selection via the Lasso. Journal of the Royal Statistical Society Series B (Methodological) . 1996;58(1):267-288. Hoerl AE, Kennard RW. Ridge Regression: Biased Estimation for Nonorthogonal Problems. Technometrics . 1970/02/01 1970;12(1):55-67. doi:10.1080/00401706.1970.10488634 Miller TA. Health literacy and adherence to medical treatment in chronic and acute illness: A meta-analysis. Patient Educ Couns . Jul 2016;99(7):1079-1086. doi:10.1016/j.pec.2016.01.020 Sørensen K, Pelikan JM, Röthlin F, et al. Health literacy in Europe: comparative results of the European health literacy survey (HLS-EU). European Journal of Public Health . 2015;25(6):1053-1058. doi:10.1093/eurpub/ckv043 Barnett M, Hixon B, Okwiri N, et al. Factors involved in access and utilization of adult hearing healthcare: A systematic review. Laryngoscope . May 2017;127(5):1187-1194. doi:10.1002/lary.26234 Estrela M, Semedo G, Roque F, Ferreira PL, Herdeiro MT. Sociodemographic determinants of digital health literacy: A systematic review and meta-analysis. International Journal of Medical Informatics . 2023/09/01/ 2023;177:105124. doi:https://doi.org/10.1016/j.ijmedinf.2023.105124 Haun J, Luther S, Dodd V, Donaldson P. Measurement variation across health literacy assessments: implications for assessment selection in research and practice. J Health Commun . 2012;17 Suppl 3:141-59. doi:10.1080/10810730.2012.712615 Wells TS, Rush SR, Nickels LD, Wu L, Bhattarai GR, Yeh CS. Limited Health Literacy and Hearing Loss Among Older Adults. Health Lit Res Pract . Jun 4 2020;4(2):e129-e137. doi:10.3928/24748307-20200511-01 Schönfeld MS, Pfisterer-Heise S, Bergelt C. Self-reported health literacy and medication adherence in older adults: a systematic review. BMJ Open . Dec 16 2021;11(12):e056307. doi:10.1136/bmjopen-2021-056307 Schaeffer D, Gille S, Vogt D, Hurrelmann K. National Action Plan Health Literacy in Germany origin, development and structure. Journal of Public Health . 2023/06/01 2021;31(6):905-915. doi:10.1007/s10389-021-01616-9 Hester N, Pang C-L, Cho A, Kasivisvanathan R, Gooneratne M. Shared perioperative decision making: a shift in the doctor–patient paradigm. British Journal of Hospital Medicine . 2019/04/02 2019;80(4):216-219. doi:10.12968/hmed.2019.80.4.216 van Leijen-Zeelenberg JE, Huismans GW, Bisschop JA, et al. Experiences and preferences of patients visiting an otorhinolaryngology outpatient clinic: a qualitative study. Health Expect . Apr 2016;19(2):275-87. doi:10.1111/hex.12347 Como JM. Health Literacy and Health Status in People With Chronic Heart Failure. Clin Nurse Spec . Jan/Feb 2018;32(1):29-42. doi:10.1097/nur.0000000000000346 McAnally K, Hagger MS. Health literacy, social cognition constructs, and health behaviors and outcomes: A meta-analysis. Health Psychol . Apr 2023;42(4):213-234. doi:10.1037/hea0001266 Pereira RA, Alvarenga MS, Avesani CM, Cuppari L. Strategies designed to increase the motivation for and adherence to dietary recommendations in patients with chronic kidney disease. Nephrology Dialysis Transplantation . 2020;36(12):2173-2181. doi:10.1093/ndt/gfaa177 Cuevas H, Heitkemper E, Huang Y-C, Jang DE, García AA, Zuñiga JA. A systematic review and meta-analysis of patient activation in people living with chronic conditions. Patient Education and Counseling . 2021/09/01/ 2021;104(9):2200-2212. doi:https://doi.org/10.1016/j.pec.2021.02.016 Hibbard JH, Greene J. What The Evidence Shows About Patient Activation: Better Health Outcomes And Care Experiences; Fewer Data On Costs. Health Affairs . 2013/02/01 2013;32(2):207-214. doi:10.1377/hlthaff.2012.1061 Scrimshaw SC. Science, health, and cultural literacy in a rapidly changing communications landscape. Proc Natl Acad Sci U S A . Apr 16 2019;116(16):7650-7655. doi:10.1073/pnas.1807218116 Cavanaugh KL, Osborn CY, Tentori F, Rothman RL, Ikizler TA, Wallston KA. Performance of a brief survey to assess health literacy in patients receiving hemodialysis. Clin Kidney J . Aug 2015;8(4):462-8. doi:10.1093/ckj/sfv037 Additional Declarations No competing interests reported. Supplementary Files HealthLiteracyfinalSciRepR1Supplement.docx Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Each variable is color-coded based on its importance, with green indicating highest importance. The focus lies on the absolute magnitudes of the variables, considering the bias towards zero in Elastic Net regularization. This enhances interpretability within this context.\u003c/p\u003e","description":"","filename":"2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6328330/v1/5c4d65ecd1a88da0a382a3e8.jpg"},{"id":84379684,"identity":"e65d2920-c196-4e9d-a80a-d1360a8b5646","added_by":"auto","created_at":"2025-06-11 09:02:20","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":969220,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6328330/v1/9b01b7d2-2700-4e97-9ed7-e1458049ae8d.pdf"},{"id":82561880,"identity":"c1d3ab55-1401-47fa-99f5-44637c5b715f","added_by":"auto","created_at":"2025-05-13 01:40:58","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":52543,"visible":true,"origin":"","legend":"","description":"","filename":"HealthLiteracyfinalSciRepR1Supplement.docx","url":"https://assets-eu.researchsquare.com/files/rs-6328330/v1/36149d51982fc742e08acb76.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Understanding Health Literacy in Otolaryngology Patients -\r\nKey Factors and Impact on Medical Practice","fulltext":[{"header":"Introduction","content":"\u003cp\u003eOtolaryngology patients have shown a growing desire to take on active roles in managing their own health \u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e, reflecting the growing importance of health literacy (HL). HL encompasses individuals' abilities to access, comprehend, and apply health information for informed decision-making \u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e. These skills play a fundamental role in treatment adherence, fostering patient understanding and compliance. The World Health Organization (WHO) declared HL as a public health goal \u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e. Some of the first studies highlighted significant variations in HL levels among populations, with many reporting inadequate HL \u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e,\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e. Results stemming from the EU, ie. the HLS-EU study \u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e, indicated that about 35% of the participants struggled with problematic HL. Low HL may lead to poor mental \u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e and physical \u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e,\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e health outcomes, increased healthcare costs \u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e,\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e, lower satisfaction \u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e, and an overall increased mortality \u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e, making it a global concern. Although otolaryngology patients often require complex care, there is a lack of studies in this field with not a single study addressing this issue \u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eMore generally and spanning fields of medical treatment, several factors were identified as predictors for HL. Individuals with lower incomes tend to exhibit lower levels of HL \u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e,\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e. Lee, Arozullah and Cho \u003csup\u003e\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e found that persons with an immigrant background or low self-assessed social status portrayed significantly lower HL levels. Higher age is mainly linked to lower levels of HL \u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e,\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e,\u003cspan additionalcitationids=\"CR17 CR18\" citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u003c/sup\u003e potentially attributed to cognitive decline. However, older age may also correlate with higher HL levels, potentially due to knowledge or experience \u003csup\u003e\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e,\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u003c/sup\u003e. A study investigating digital HL skills of German university students found lower digital HL in female students \u003csup\u003e\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u003c/sup\u003e. Other studies associated female gender with better HL \u003csup\u003e\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u003c/sup\u003e but differences were rather small \u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e. Overall, individuals with lower levels of education tend to have lower HL scores, indicating challenges in understanding health-related information or warnings \u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e,\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e,\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e,\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e,\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e,\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e,\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e,\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u003c/sup\u003e. Individuals with self-assessed poor health status and frequent doctor visits exhibit lower HL levels \u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e,\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e. Individuals with low HL due to hearing or vision impairment struggle with comprehending health information effectively, which can ultimately lead to difficulties in adhering medical advice and understanding health warnings \u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e,\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e,\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e. Numerous frameworks depict crucial factors related to HL and their impact on health outcomes, including e.g. prior knowledge, social support, cognitive abilities, and cultural differences \u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e,\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e,\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e,\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e\u003c/sup\u003e. In this context, patient education and counseling improves self-efficacy, a factor linking HL and health outcomes \u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e,\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u003c/sup\u003e .\u003c/p\u003e \u003cp\u003eOne of the most impactful models in HL was introduced by S\u0026oslash;rensen et al. \u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e. This model proposes three dimensions of HL, covering healthcare, health promotion, and disease prevention. Accordingly, HL is influenced by factors such as age, education, social support, and media use. However, a universally accepted gold standard for assessing HL remains elusive \u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e,\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eTaken together, HL has gained increasing recognition in recent years due to its significant impact on patient outcomes. Despite this, there remains a gap in understanding HL within specific medical specialties, such as Otolaryngology.\u003c/p\u003e \u003cp\u003eThe current study seeks to address this gap by using a two-sided approach aimed at gaining a comprehensive understanding of the key factors influencing HL in otolaryngology, i.e. first, by employing analyses derived from existing literature (the theory driven approach) and, secondly, by identifying predictor variables through a data-driven elastic net approach (the data driven approach), to account for covariance and multicollinearity. A mere descriptive data analysis in itself is not sufficient because HL is a multidimensional construct requiring a nuanced approach to capture its complexity.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy Design\u003c/h2\u003e \u003cp\u003eMulticenter prospective cross-sectional study\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003ePatient Sample/Study Population\u003c/h3\u003e\n\u003cp\u003e Eligible patients were adults aged 18 and above, participating voluntarily in the otolaryngology awareness week organized by the German Society of Oto-Rhino-Laryngology, Head and Neck Surgery together with the German Professional Association of Ear-Nose-Throat-surgeons spanning from June 14 to June 20, 2021. A total of 2023 patient responses could be gathered through a layman-friendly questionnaire regarding patient orientation, evidence-based medicine, need for research, and HL. Additional inclusion criteria were language proficiency in German, willingness to participate in the study, and the ability to give informed consent. Patients were excluded if these criteria were not met.\u003c/p\u003e\n\u003ch3\u003eData Collection\u003c/h3\u003e\n\u003cp\u003eData were collected in 27 participating otolaryngology out-patient practices, 18 otolaryngology primary and secondary care hospitals, and 14 university tertiary care otolaryngology departments. The questionnaire exclusively comprised a closed-answer format for all questions, taking 15 to 20 minutes to complete. No compensation was provided for their participation. Data collected were kept anonymous\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e\n\u003ch3\u003eVariables\u003c/h3\u003e\n\u003cp\u003eThe dependent variable HL was assessed using the Brief Health Literacy Screen (BHLS) from Chew, Bradley and Boyko \u003csup\u003e\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e\u003c/sup\u003e as a short and effective tool for identifying low HL levels in clinical samples \u003csup\u003e\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e,\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e\u003c/sup\u003e. Three questions addressed patient's disease and treatment status. Patient orientation was explored with ten questions. Personal needs and expectations were assessed with two questions \u003csup\u003e\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e\u003c/sup\u003e. Subsequently, participants were asked two questions about their role in the treatment decision-making process based on the concept of Degner, Sloan and Venkatesh \u003csup\u003e\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e\u003c/sup\u003e. Four questions inquired about the patient's relationship with the specialist \u003csup\u003e\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e\u003c/sup\u003e. Six questions examined the information sources used by patients regarding their condition \u003csup\u003e\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e\u003c/sup\u003e. Five questions related to personal involvement in otolaryngology and inquiries about gender, age, federal state of residence, type of health insurance, and education concluded the questionnaire.\u003c/p\u003e\n\u003ch3\u003eStatistical Analysis and Data Preprocessing\u003c/h3\u003e\n\u003cp\u003eDescriptive data are reported as absolute figures and corresponding percentages, providing an initial overview of the dataset. For the main analyses, Multiple Linear Regression Models (the theory driven approach) and an Elastic Net Regression (the data driven approach) were conducted to identify important predictors for HL. All statistical analyses were employed using the Software SPSS Statistics (IBM, Version 27, New York) and R \u003csup\u003e\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eTheory-Driven Approach: Model Testing\u003c/h2\u003e \u003cp\u003eDespite the size of the dataset, the available variables only partially matched those suggested in dominating published HL models \u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e,\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u003c/sup\u003e. As such, measures of general literacy, cultural factors, motivation, and social support were missing. Nevertheless, rucial variables from the existing literature were identified and categorized into overarching themes. These themes were used to guide the selection and analysis of variables within Regression Models, focusing specifically on their relevance to HL. This pathway allowed for the best alignment between existing models and the available dataset. Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e gives an overview of the models and the specific variables included. Technically, variables were dummy-coded and missing cases were excluded listwise. Our exploration focused on variables that achieved a nominal, two-sided p-value\u0026thinsp;\u0026le;\u0026thinsp;.05. From the five models, all variables that showed such an effect on HL were ultimately combined into a single final model for further analysis. For every model, the assumptions for Multiple Linear Regression Models were tested \u003csup\u003e\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e\u003c/sup\u003e (see Supplement 1).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003e\u003cem\u003eLegend: Distribution of the Variables into Variable blocks\u003c/em\u003e\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eModel\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eVariable Description\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1 Disease and Treatment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFor which diagnosis are you being treated in the ENT department?\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIn which facility are you currently being treated in the ENT department?\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHow long have you been receiving ENT treatment?\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2 Participation in Research\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHave you ever participated in a research study?\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWould you like to actively participate in shaping future research topics in otorhinolaryngology?\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3 Patient Orientation \u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ea\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHow much do you agree with the following statement: The disease has a very big impact on my everyday life.\u003c/p\u003e \u003cp\u003eWhich area in your everyday life has the disease affected most?\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eb\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHow do you currently participate in the decision-making process about your treatment option?\u003c/p\u003e \u003cp\u003eHow would you like to be involved in the decision-making process about your treatment option?\u003c/p\u003e \u003cp\u003eHow much do you agree with the following statement: I hope that my wishes and priorities will be considered by the treating ENT specialist.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ec\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePatient-centered communication is an important component in the doctor-patient relationship. Which of the statements reflects the most important factor for communication for you?\u003c/p\u003e \u003cp\u003eWhich of the following factors do you consider most important for a good or collaborative relationship with the treating practitioner?\u003c/p\u003e \u003cp\u003eWhich of the following factors do you feel is most important in reflecting modern patient involvement in otolaryngology?\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4 Medical information Search\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ea\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHow much do you agree with the following statement: I have been informed in detail about the treatment process.\u003c/p\u003e \u003cp\u003eHas your need for information changed from the beginning of the disease until now?\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eb\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWhat is your primary goal when seeking out medical information sources?\u003c/p\u003e \u003cp\u003eChoose one person to seek advice from when you have questions about your condition.\u003c/p\u003e \u003cp\u003eWhich electronic information source do you rely on when you are searching for medical information?\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e5 Demographics\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ea\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWhich gender do you identify as?\u003c/p\u003e \u003cp\u003eTo which age group do you belong?\u003c/p\u003e \u003cp\u003eWhich type of health insurance are you enrolled in?\u003c/p\u003e \u003cp\u003eWhat is your highest school-leaving qualification?\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eb\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIn which federal state do you reside in?\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003eInsert\u003c/b\u003e Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e \u003cb\u003ehere\u003c/b\u003e\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eData-driven Approach: Elastic Net Regression\u003c/h3\u003e\n\u003cp\u003eElastic Net Regression is a regularization technique combining Lasso \u003csup\u003e\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e\u003c/sup\u003e and Ridge Regression \u003csup\u003e\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e\u003c/sup\u003e elements and is suitable for data sets with a large number of predictors and possible multicollinearity. The two regularization parameters (i) α Alpha and (ii) λ Lambda influence the balance between the two techniques. For Elastic Net Regression, predictors were standardized using the \u003cem\u003egmlnet\u003c/em\u003e package in R. The dataset was split into training (70%) and testing (30%) sets. Variables with over 20% missing values were removed to ensure validity and reliability of results. A grid search with cross-validation was performed to determine the optimal lambda value. The model was evaluated using the test data set and the Root Mean Square Error (RMSE). All cases with missing values were removed for this analysis mirroring the Theory-driven Approach.\u003c/p\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eDescriptives\u003c/h2\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e describes the characteristics of the 2023 study participants (female N\u0026thinsp;=\u0026thinsp;933 (46.1%), male N\u0026thinsp;=\u0026thinsp;935 (46.2%); age mean\u0026thinsp;=\u0026thinsp;50.5 (\u003cem\u003eSD\u003c/em\u003e\u0026thinsp;=\u0026thinsp;17.23)). Most patients (616; 26.23%) visited the otolaryngology hospital/outpatient practice for the first time and 476 (20,28%) received treatment for over 5 years. Patients struggled with physical changes (360; 17.80%,), financial issues (7; 0.30%), anxiety and worries (136; 6,70%). 655 patients (32.40%) fully agreed that their illness has a significant impact on their daily life. Figure\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e shows the distribution of HL scores in the general sample. The median HL score was 10.00 (IQR (interquartile range) 9.00 to 12.00). Mean HL score was 9.73 (\u003cem\u003eSD\u003c/em\u003e\u0026thinsp;=\u0026thinsp;1.37). The number of patients with HL scores between 12.00 to 15.00 was 14.50% (294). 1121 patients (55.50%) expressed a demand for detailed insights into the medical care process. 994 patients (49.20%) relied on their otolaryngology doctors as their primary source of information.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eHalf of the participants (49.20%) exuded confidence in navigating medical forms. 3.00% expressed a lack of assurance and 3.40% admitted to \u003cem\u003ealways\u003c/em\u003e needing assistance, while 20.30% acknowledged \u003cem\u003eoccasionally\u003c/em\u003e seeking help, and 28.60% indicated \u003cem\u003enever\u003c/em\u003e requiring assistance. In the realm of understanding medical information, 32.00% of participants \u003cem\u003eoccasionally\u003c/em\u003e found it challenging, while 9.20% reported \u003cem\u003enever\u003c/em\u003e facing problems, and 1.70% indicated \u003cem\u003ealways\u003c/em\u003e finding it difficult to understand medical information.\u003c/p\u003e \u003cp\u003e \u003cb\u003eInsert\u003c/b\u003e Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e \u003cb\u003ehere\u003c/b\u003e\u003c/p\u003e \u003cp\u003e \u003cb\u003eInsert\u003c/b\u003e Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e \u003cb\u003ehere\u003c/b\u003e\u003c/p\u003e\u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003e\u003cem\u003eLegend: Sociodemographic Characteristics of Patients in the Full Sample and Elastic Net Analysis Subsample\u003c/em\u003e\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eCharacteristic\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eFull sample\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003eElastic Net Regression\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003en\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003en\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGender\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e933\u003c/p\u003e \u003cp\u003e935\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e46,1\u003c/p\u003e \u003cp\u003e46,2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e427\u003c/p\u003e \u003cp\u003e474\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e47,2\u003c/p\u003e \u003cp\u003e52,4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003cp\u003eNot specified\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e155\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e7,7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4,\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0,4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e18\u0026ndash;30 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e313\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e15,5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e159\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e17,6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e31\u0026ndash;45 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e424\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e220\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e24,3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e46\u0026ndash;60 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e538\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e26,6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e271\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e29,9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e61\u0026ndash;75 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e450\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e22,2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e218\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e24,1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e76 years and older\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e148\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e7,3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4,\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNone/invalid information\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e150\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e7,4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0,1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFederal State\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBaden-Wuerttemberg\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e127\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e6,3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e61\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e6,7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBavaria\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e91\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e4,5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e56\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e6,2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBerlin\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0,6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0,6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBrandenburg\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e145\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e7,2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e6,6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBremen\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0,1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0,3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHamburg\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e104\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e5,1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e57\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e6,3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHesse\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e188\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e9,3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e88\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e9,7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMecklenburg-Western Pomerania\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e144\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e7,1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e70\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e7,7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLower Saxony\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e116\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e5,7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e58\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e6,4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNorth Rhine-Westphalia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e343\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e162\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e17,9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRhineland-Palatinate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2,5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3,2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSaarland\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1,3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1,7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSaxony\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e218\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e10,8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e91\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e10,1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSaxony-Anhalt\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1,2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1,3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSchleswig-Holstein\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e119\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e5,9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e64\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e7,1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eThuringia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e169\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e8,4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e73\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e8,1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNone/invalid information\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e144\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e7,1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0,1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHealth Insurance\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStatutory\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1556\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e76,9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e803\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e88,7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrivate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e189\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e9,3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e89\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e9,8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOther\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0,9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1,2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMissing information\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e259\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e12,8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0,2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSchool Leaving Certificate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLower Secondary School Certificate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e373\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e18,4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e107\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e11,8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIntermediate Secondary School\u003c/p\u003e \u003cp\u003eCertificate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e632\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e31,2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e211\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e23,3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUniversity of Applied Sciences\u003c/p\u003e \u003cp\u003eEntrance Qualification\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e223\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e118\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eA-levels\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e527\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e26,1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e304\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e33,6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOther\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e78\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3,9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e28,3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNone/invalid information\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e190\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e9,4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003e\u003cem\u003eNote. N\u003c/em\u003e\u0026thinsp;=\u0026thinsp;2023 for the Full sample and \u003cem\u003eN\u003c/em\u003e\u0026thinsp;=\u0026thinsp;905 for the Elastic Net Regression subsample.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eTheory-Driven Approach: Model Testing\u003c/h2\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e summarizes the final theory driven regression model. Results for the submodels are displayed in Supplement 2. The diagnosis of tumor (\u003cem\u003eβ\u003c/em\u003e = \u0026minus;\u0026thinsp;.28, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.01), facing financial issues (\u003cem\u003eβ\u003c/em\u003e = -1.7, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.004), needing headphones to watch TV (\u003cem\u003eβ\u003c/em\u003e = \u0026minus;\u0026thinsp;.81, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.001), making all decisions independently after receiving thorough information from the treating physician (\u003cem\u003eβ\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.168, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.046), being female (\u003cem\u003eβ\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.267, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.001), and having completed the highest school education (\u003cem\u003eβ\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.381, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.001) all were (potential) predictors of HL. The overall evaluation of the model yielded an adjusted \u003cem\u003eR\u0026sup2;\u003c/em\u003e of .07, indicating that approximately 7% of the variance of the dependent variable HL could be explained by the included variables.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003e\u003cem\u003eLegend: Final Multiple Linear Regression Model\u003c/em\u003e\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eEstimate\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cem\u003eSE\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e95% CI\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cem\u003ep\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003eLL\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cem\u003eUL\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIntercept\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e9.72\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.09\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e9.53\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e9.90\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003etumor\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.49\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.06\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFinancial issues\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e-1.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.58\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e-2.84\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.56\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.004\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNeeding headphones to watch TV\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.81\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e-1.24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.38\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMaking All Decisions Independently\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e.17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.09\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.046\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e.267\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.08\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHighest school education\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e.381\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.08\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.54\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003e\u003cem\u003eNote. N\u003c/em\u003e\u0026thinsp;=\u0026thinsp;2023. Adjusted \u003cem\u003eR\u003c/em\u003e\u003csup\u003e\u003cem\u003e2\u003c/em\u003e\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;.07; CI\u0026thinsp;=\u0026thinsp;confidence interval; \u003cem\u003eLL\u003c/em\u003e\u0026thinsp;=\u0026thinsp;lower limit; \u003cem\u003eUL\u003c/em\u003e\u0026thinsp;=\u0026thinsp;upper limit.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003eInsert\u003c/b\u003e Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e \u003cb\u003ehere\u003c/b\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eData-driven Approach: Elastic Net Regression\u003c/h2\u003e \u003cp\u003eThe distribution of HL scores in the subsample for this analysis is displayed in Supplement Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. The mean BHLS score was 9.79 (SD\u0026thinsp;=\u0026thinsp;1.28) with a median HL score of 10.00 and an Interquartile Range (IQR) from 9.00 to 11.00. The variables influencing HL based on this model are summarized in Supplement Tables\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e and \u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e in more detail. Figure\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e below displays the 30 variables with the highest absolute coefficient values, sorted in descending order.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003eInsert\u003c/b\u003e Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e \u003cb\u003ehere\u003c/b\u003e\u003c/p\u003e \u003cp\u003eDealing with financial issues, often failing to understand medical information, patient\u0026rsquo;s wishes never being considered, relying on friends as the primary source of information, not feeling confident when filling out medical forms, valuing honesty and empathy from the treating physician, needing help filling out medical forms, or the need to have changed the whole diet portrayed high absolute variable importance.\u003c/p\u003e \u003cp\u003eThe variables with the lowest absolute importance were being male, having a treatment duration of more than 5 years, having all decisions being made solely by the otolaryngologist, Lower Secondary School Leaving Certificate or equivalent, having a diagnosis related to smell, taste and hearing disorder and only having personal wishes and priorities considered \u003cem\u003eoften\u003c/em\u003e by the treating ENT physician as well as being aged between 61 and 75.\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe purpose of this study was to gain a better understanding of HL in otolaryngology, and the skills needed for accessing, understanding, appraising, and applying health-related information \u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e. The concept of HL still is relatively new, and especially in the realm of otolaryngology, also an unexplored topic \u003csup\u003e\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u003c/sup\u003e. The general study population displayed moderate levels of HL. The most influential variables identified were financial issues, education, and hearing impairment, each significantly impacting HL.\u003c/p\u003e \u003cp\u003eThe most significant factor influencing HL were \u003cem\u003efinancial challenges\u003c/em\u003e, with a notable negative impact as shown in previous studies and, thus, further stressing the risk of low socioeconomic (SE) status \u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e,\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e,\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e,\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e,39 40 41\u003c/sup\u003e. Adding to the impact of SE, having the highest German school education level (Abitur) was associated with a substantial increase in HL corroborating earlier research \u003csup\u003e\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e,\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e\u003c/sup\u003e. Higher education levels are essential for various aspects of HL, including understanding, evaluating information as well as sharing and applying it appropriately. Only about half of the patients felt confident filling out medical forms, despite the high educational background of patients.\u003c/p\u003e \u003cp\u003eImportantly, the current analyses highlighted the profound impact of \u003cem\u003ehearing impairment\u003c/em\u003e on HL. This impact was negative and substantial, underscoring the significant challenges faced by individuals with hearing impairments in comprehending information. Furthermore, these findings align with broader research, illustrating a positive association between limited HL and both unaided and aided severe hearing loss in adults aged 65 years and older \u003csup\u003e\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e\u003c/sup\u003e. The current analyses stress the significant impact of hearing impairment on HL. This aspect is of particular importance for otolaryngology patients, as a substantial proportion of these patients already struggle with hearing impairments, further complicating the communication process. A patient's difficulty in acoustically understanding the clinician's explanations or embarrassment about hearing impairments might pose challenges to their treatment progress and health outcomes. Considering hearing problems in different patient groups is essential. The strong desire for patient-centered care among ENT patients emphasizes the urgency of integrating patient preferences and needs into healthcare strategies \u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eIn addition to these variables, several other ones had an effect on HL, but to a lesser degree. The presence of \u003cem\u003esevere or chronic illnesses\u003c/em\u003e (presence of a tumor, diagnoses such as sleep disorders, smell, taste, and hearing disorders, or voice and speech disorders) went along with lower HL corroborating earlier studies \u003csup\u003e\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e,44 21\u003c/sup\u003e.This is particularly concerning for patients with chronic diseases, who rely on these skills to navigate the complexities of their conditions \u003csup\u003e\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003ePatients who autonomously made informed decisions in their healthcare journey exhibited higher levels of HL, indicating the significance of an active patient role and informed decision-making process which was also observed in other practice settings \u003csup\u003e\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e,\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e\u003c/sup\u003e. Patients\u0026rsquo; active role was also supported by Elastic Net Regression with additional factors. First, if patients had to change their entire diet, and second, if they no longer were able to drive a car by themselves. These aspects can be subsumed under \u003cem\u003eself-efficacy\u003c/em\u003e, which has been associated with HL \u003csup\u003e\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e,\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e\u003c/sup\u003e. A complete dietary change requires a lot of time and adherence to the recommendations \u003csup\u003e\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e\u003c/sup\u003e. Thus, patients who successfully implement these changes may also be able to successfully implement other health-related aspects in their lives, competencies known as HL \u003csup\u003e\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e,\u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e\u003c/sup\u003e. Similarly in the current sample, patients who relied on family members as \u003cem\u003einformation source\u003c/em\u003e about their illness exhibited lower HL levels, possibly due to the varied reliability of this kind of information source and the potential presence of bias within family-based advice. This finding emphasizes the critical importance of reliable and expert sources for health information and HL skills. In the Multiple Linear regression model, female \u003cem\u003egender\u003c/em\u003e showed a substantial, in the Elastic Net Regression only a minor impact. This aligns with a previous study \u003csup\u003e\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u003c/sup\u003e, but in a systematic review including 85 studies no significant association between HL and gender could be found \u003csup\u003e\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eHigher age displayed a minor positive magnitude in the Elastic Net Regression consistent with one other study \u003csup\u003e\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u003c/sup\u003e, but was reversed in other studies \u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e,\u003cspan additionalcitationids=\"CR17 CR18\" citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eStrengths and Limitations\u003c/h2\u003e \u003cp\u003eThis research provides a foundation for subsequent studies, wherein factors like participation in self-help groups, auditory abilities, self-efficacy should be considered as these are mostly included in current models. Due to the two-sided approach of this study, financial disparities, education, and patient preferences can be seen as robust variables influencing patients HL. These findings should be integrated into future models to further elucidate the relationship between HL and its global effects on patient outcomes.\u003c/p\u003e \u003cp\u003eThe study exhibits some limitations, predominantly because of the nature of the variables and the German origin. The dataset may not be optimal for the current study. HL was only one aspect of the study, potentially affecting the results. Secondly, cultural variations in HL of otolaryngology patients in other countries cannot be excluded as at least hearing and understanding of health care information varies between different cultures \u003csup\u003e\u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e\u003c/sup\u003e. Thirdly, missing variables and the handling of missing values within this study are a limitation. Our literature search related to the theory-driven analyses revealed HL relevant variables that should be include in future assessments, such as measures of general literacy, cultural factors, motivation, and social support. Additionally, the BHLS tool used in this study does not provide specific levels for categorizing HL as adequate, problematic, or insufficient. The use of BHLS-specific cut-off scores varies across studies \u003csup\u003e\u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e\u003c/sup\u003e and therefore the different levels could not be identified.\u003c/p\u003e \u003cp\u003eRegarding missing values in the study, we decided against a multiple imputation step due to the data level not supporting this approach.\u003c/p\u003e \u003cp\u003eElastic Net Regression identified a multitude of variables for predicting HL, indicating the complexity of the factors involved. This complexity is further underscored by the low R-squared values from the Linear Regression Models, suggesting that numerous variables collectively influence HL levels. Since this approach is novel and indicates room for improvement, the low R-squared values are unsatisfactory; however, they provide insights into areas for enhancement in future studies.\u003c/p\u003e \u003cp\u003eIn the multiple linear regression models, HL was influenced by a multitude of factors. Crucially, these relationships do not adhere to a simple linear pattern, primarily because not all assumptions could be confirmed. This understanding aligns with previous research suggesting a non-linear relationship between HL and health outcomes \u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e. This complexity also underscores the challenge of establishing direct causal relationships as well as the interpretation of the highlighted variables.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusions","content":"\u003cp\u003eLimited HL contributes to delays in the diagnosis of health conditions, resulting in missed opportunities for early intervention. It may also lead to riskier behavior, weaker self-management skills, and an overall inadequate management of their health conditions. In line with previous research education, socioeconomic inequalities, and patient preferences are crucial for high levels of HL in the field of otolaryngology. For all medical fields considerations regarding hearing impairment should be included in future surveys and assessment of individual HL. Understanding and addressing factors for HL are essential for healthcare professionals worldwide to provide effective clinician-patient communication and improve adherence to treatment.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eEthics Statement\u003c/h2\u003e \u003cp\u003e The study was approved by the Ethics Committee of Jena University Hospital (No. 2021\u0026ndash;2167). Before participation, patients were informed about data privacy and their written consent was obtained. The survey was performed following the principles and guidelines of the Declaration of Helsinki.\u003c/p\u003e \u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eDobel and Gund analysed the data and wrote the paperScherag proposed data analysis strategy and supervised execution.Tostmann, L\u0026ouml;hler and Guntinas-Lichius organised data collection and collected data\u003c/p\u003e\u003ch2\u003eAcknowledgement\u003c/h2\u003e\u003cp\u003eWe acknowledge gratefully the contribution of all patients and colleagues in distributing and completing the survey.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eData can be received from the authors ([email protected]; [email protected]) upon reasonable request by researchers and clinicians.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eHorn J, Tostmann R, Dobel C, L\u0026ouml;hler J, Guntinas-Lichius O. 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Aug 2015;8(4):462-8. doi:10.1093/ckj/sfv037\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-6328330/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6328330/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eThe World Health Organization (WHO) declared health literacy (HL) as a public health goal, yet global studies consistently reveal inadequate HL levels. The implications of low HL extend to delayed diagnoses, increased healthcare costs and mortality rates. This multi-center prospective cross-sectional study aims to achieve a deeper understanding for health literacy and corresponding challenges in otorhinolaryngology. 27 otolaryngology outpatient practices, 18 otolaryngology hospitals, and 14 university otolaryngology departments took part in data collection during the otolaryngology awareness week in June 2021 in Germany. Participants were \u003cb\u003ev\u003c/b\u003eolunteer sample of adult otolaryngology patients with smell, taste, and hearing impairment, head and neck tumor, inflammation or infections. Patients completed a layman-friendly questionnaire regarding patient orientation, evidence-based medicine, need for research, and HL. HL scores were determined using the 3 items of the Brief Health Literacy Screen (BHLS), ranging from 0 to 15, with enhanced scores indicating higher HL. Important variables impacting HL were examined using Multiple Linear Regression Models and Elastic Net Regression. 2023 patient responses (46% female; 49% 46\u0026ndash;75 years old) were analyzed. The mean HL score was 9.73\u0026thinsp;\u0026plusmn;\u0026thinsp;1.37. Elastic net regression and multiple linear regression models identified predictors for HL, regardless of disease. Most important were hearing impairment, education, financial issues, and patient preferences and thus represent key factors for HL. These findings offer valuable insights into the patients\u0026rsquo; view of otolaryngology, head and neck surgery and set a precedent for examining HL across medical fields.\u003c/p\u003e","manuscriptTitle":"Understanding Health Literacy in Otolaryngology Patients -\nKey Factors and Impact on Medical Practice","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-05-13 01:40:53","doi":"10.21203/rs.3.rs-6328330/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"009b1c9f-63e9-4084-b297-173d6de807b9","owner":[],"postedDate":"May 13th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":48230865,"name":"Biological sciences/Psychology/Human behaviour"},{"id":48230866,"name":"Health sciences/Health care/Health services"},{"id":48230867,"name":"Health sciences/Health care/Public health"},{"id":48230868,"name":"Health sciences/Health care/Quality of life"}],"tags":[],"updatedAt":"2025-06-11T08:54:08+00:00","versionOfRecord":[],"versionCreatedAt":"2025-05-13 01:40:53","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6328330","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6328330","identity":"rs-6328330","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}