Introduction

In todays world, in the era of digitization, the use of digital media affects all areas of everyday life. This applies not only to politics, education, transportation and the overall economy, but increasingly also to health care systems. For patients, the primary source of health information is still their doctor (Krüger-Brand 2019). However, the second most important source for patients today is the Internet (Krüger-Brand 2019). The requirements for patients to understand and process digital health information are steadily increasing. Although a variety of different websites on health topics can be found, assessing and understanding the data poses a complex task for many (Karnoe et al. 2018). A lot of information is incomprehensible, inherently contradictory or it is hard to assess for consumers if the information is applicable to their individual case (Kolpatzik and Zeeb 2020). Distinguishing between relevant and unhelpful health information requires a diverse skillset (Bittlingmayer 2020) and applying that information to their own life situation, especially concerning prevention and care requires even more skills (Norman and Skinner 2006). According to different studies, consumers consider finding information online and evaluating it appropriately to be particularly difficult (IQWiG 2018).

The term health literacy is the sum of the skills needed to access health-related information in everyday life (Sørensen et al. 2012). Basically, it is about finding, understanding, evaluating and exploiting health-related data. The term digital health literacy is inspired by this description. Everyday life without digital helpers such as smartphones, apps, computer and wearables is hardly imaginable today. However, dealing with these digital helpers requires digital skills as well (Jordan et al. 2013). It not only requires operational skills, such as competent use of health-related apps or using links on the Internet, but many more such as social as well as technical competencies that are necessary for finding relevant and reliable health information. The term digital health literacy best encompasses all the skills required for the correct handling of digital health information. Digital health literacy is a term established through the process of digitizing healthcare systems. This term is far from being an isolated concept, as the understanding quickly emerged that the matter of digital health literacy is considerably broader than this. Digital health literacy includes not only confidently navigating the Internet in the context of answering health-related questions but also, for example, dealing with interactive digital healthcare services or communicating with health service providers (Kolpatzik and Zeeb 2020).

Validated instruments in the form of questionnaires became a common tool to assess the digital health literacy of an individual (Nutbeam 1996). Most instruments ask the participants to rate their own (digital) health literacy (e.g. The European Health Literacy Survey Questionnaire) and only a few use performance tests (e.g. The health literacy management scale) (Liu et al. 2018).

For example, a recent study by the largest German statutory health insurance company found that 28.1% of the representative participant group had low digital health literacy (Kolpatzik and Zeeb 2020). It is therefore essential to improve the digital health literacy score of Germans so that new achievements of digital healthcare such as video consultation or the e-prescription can also be used successfully. The ‘smart health study’ found that 75% of Germans were in favour of a digital patient record and considered it helpful and practical (Harms 2018). The interest of citizens to digitalize is high; therefore, it is important to equip them with the necessary skills to achieve their full potential.

Numerous studies have shown the impact of digital health literacy in healthy people on health and prevention. Moreover, patients with higher (digital) health literacy have better prognosis in case of disease. Furthermore, high digital health literacy is associated with higher mental well-being (Schaeffer et al. 2020, 2023). It has also been associated with a higher use of screening examinations and a reduction in the risk of suffering from a chronic disease (Jacobs et al. 2016). These factors reduce costs for the health system and are beneficial for greater acceptance of digital health offers (Kolpatzik and Zeeb 2020).

E-Health can make a decisive contribution in making prevention of diseases more efficient. In other words, eHealth can have a beneficial impact on the health of the entire population, as prevention is a crucial element in ensuring long-term health and quality of life in every age and population group. Therefore, eHealth is a factor that should not be neglected in the organization of our healthcare system.

From a societal perspective, higher education is linked to higher digital health literacy (Kontos 2014), while lower income is often associated with lower digital health literacy (Kolpatzik and Zeeb 2020).

Digitalization may be essential to improve medical care for people and patients living in rural and structurally weak parts of modern countries with long ways to medical specialists and sometimes even to general practitioners. Moreover, with an aging society, physicians and nurses will have to take care of more patients, which may be easier to realize with digital support.

We aimed to learn more about how prepared communities are to accept digitalization and participate in its organization.

While so far, several surveys have pointed to the limited health literacy and digital health literacy in the German and European population (Hurrelmann et al. 2023), these surveys were conducted on the national perspective using representative populations, a closer look at a defined community is missing. A meta-analysis found that there are four types of community readiness for healthcare digitalization (Jennett et al. 2003). The level of readiness varied across six main themes: core readiness, structural readiness, projection of benefits, risk assessment, awareness and education, and intra- and inter-group dynamics. The study found that understanding of telemedicine was strongly related to readiness. It also found that education and awareness campaigns, as well as demonstrations of how to use telemedicine, were highly beneficial to readiness, as they increased feelings of curiosity and understanding. This highlights the importance of ensuring that communities are highly motivated and ready to implement healthcare digitization. The NASS study also recognized that communities play a central role in the implementation of digital health applications (Greenhalgh et al. 2017). The community, with its socio-cultural aspects, strongly influences the decision to adopt digital health applications. For example, the TCRM (Telemedicine Community Readiness Model) is a valuable tool for assessing the readiness of communities to embrace digital health (Otto et al. 2023). Moreover, this tool can also support the identification of aspects to improve this readiness.

Therefore, we chose to conduct a survey in a small town in the east of Germany, where the inhabitants themselves decided to actively organize the digital transformation of their healthcare system starting with becoming a Healthcare City (Dingelstädt 2021). The results of this study may help the citizens and representatives to better evaluate the status of digital health literacy in their town and to decide on strategies to improve it on their way to being a Healthcare City. The findings are also useful for deriving general conclusions for small towns and rural regions, allowing to expand the local offers on digitization in the health care system.

Methods

Design

Dingelstädt is located in the middle of Germany, in the federal state of Thuringia. It is characterized by its affiliation with the former DDR. Dingelstädt represents a typical rural village municipality in Germany. With just under 9000 inhabitants, it has a town hall, a primary school and a high school. The economic focus today is on the metal processing industry. More than half of Germany’s population lives in rural areas, such as the community of Dingelstädt. Thus, the people of Dingelstädt represent very well the current state of knowledge on digital health literacy in rural communities (Thünen-Institut 2022).

Participants inclusion/exclusion

The questionnaire was developed and tested in a pilot phase before the questionnaire was distributed to the residents in paper format from 18.06.-16.07.2021, in cooperation with the city of Dingelstädt; 3300 copies were printed and attached to the official local newspaper of Dingelstädt. Furthermore, the questionnaire was displayed in the town library, the citizens’ office and the town hall. Private businesses in Dingelstädt also helped with the distribution of the questionnaire. The participants were asked to fill in the questionnaire within 4 weeks and to return it to one of the various collection points (pharmacies, bakeries, schools, bookstores, libraries). Finally, the questionnaire was made available on the online portal ‘sosciesurvey’ for digital completion.

Questionnaire

This study adopts the concepts and methods of a study by the University of Jena on ‘eHealth literacy among cancer patients and their relatives’ (Halwas et al. 2017). We used the questionnaire from this study as a template. We added additional questions with a focus on physical activity, state of health, and if there is currently care provided by a general practitioner.

Closed questions were used for the questionnaire, meaning that the respondent could choose between different answer options. In the section about eHealth literacy, participants were asked to rate the importance of each statement on a 4-point scale in Likert scale format (for example, Internet services on health topics I generally understood well: ‘I fully agree’; ‘I tend to agree’; ‘I tend to disagree’; ‘I disagree at all’). The questionnaire was divided into eight sections.

  1. 1.

    Demographic data (4 questions: gender, age, education level, status (student/employee/retiree).

  2. 2.

    Data on general Internet usage (4 questions: regarding frequency and setting of Internet usage and quality of Internet connection).

  3. 3.

    Data on eHealth usage (3 questions: concerning frequency and various eHealth offers).

  4. 4.

    Data on data privacy (2 questions: concerning abilities and frequencies to handle personal data on the Internet).

  5. 5.

    Data on eHealth literacy (ten questions: concerning comprehension, searching, usefulness, secureness, reliability, knowledge growth of health information, handling apps/smartphones/tablets).

  6. 6.

    Data on Single Item Literacy Screener (1 question: concerning the frequency with which they need help from others to understand certain health information).

  7. 7.

    Data on physical activities (1 question concerning the frequency).

  8. 8.

    Data on general practitioner and frequency of doctor’s visits (2 questions).

Statistics

For all data analytics the program IBM SPSS 28 was used. Associations were carried out using t-tests and Chi-squares test; p < 0.05 was considered significant.

Ethical vote

The study had a positive vote of the ethics committee at the University Hospital of the Friedrich Schiller University at Jena (Reg. No. 2021-2256-Bef).

Results

Demographic data

There were 488 responses from 8835 inhabitants (5.52% response rate) to the questionnaire (see Table 1). In total, 201 (41.18%) of those were male, 254 (52.37%) were female and 11 (2.26%) were diverse. Regarding the age distribution, the majority belongs to the age group ‘under 18 years old’ (210); 40 (8.24%) to the 18–30 age group; 131 (27.01%) are between 31–64 years old; and 51 (10.51%) are older than 65 (Table 1). For 131 of 458 (28.6%), the highest degree was elementary school; 93 out of 458 (20.30%) achieved an intermediate school certificate; 27 out of 458 (5.89%) have a high school diploma; and 69 out of 458 (15.06%) reported to have a university degree (Table 1).

Table 1 Demographic data (N = 488)
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For the next sections, the questionnaire was designed in a way that the participants did not have to answer every question. Therefore, there are now also different values for N.

Internet usage

Of all respondents, 96.9% (438 of 452) said they had Internet access (see Fig. 1a). Most (408 of 458; 89.08%) participants used the Internet daily in the past 3 months (see Fig. 1c). Furthermore, participants were asked to choose between different sets of statements concerning the quality of their Internet connection, most of them (325 of 443; 71.27%) find their Internet connection at home fast enough for what they need (see Fig. 1b). Another question regarding Internet usage asked how and where the citizens used the Internet and most of the respondents (187 of 480; 38.95%) use their computer at work to access the Internet (see Fig. 1d).

Fig. 1
figure 1

a Do you have Internet access? (N = 452). b Quality of Internet connection (N = 443) c Frequency of Internet usage in the past 3 months (N = 458) d Internet usage (N = 480)

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eHealth

In the third part of the questionnaire, participants were asked about the frequency of using eHealth services. Out of 449, 66 (14.69%) use eHealth offers on a regular base, such as websites about health services, health forums on the Internet, or health applications on smartphones (see Fig. 2a). One hundred fourty-one of 449 (31.40%) use eHealth offers rather irregularly. Eighty-six out of 449 (19,15%) would be willing to use eHealth offers but have not tried yet. In contrast, 97 out of 449 (21,6%) are not willing to use eHealth for themselves. The participants were also asked to indicate which of the following health services they had ever used (see Fig. 2b). Two hundred eighty-five out of 473 (60.25%) have searched for information about their health on the Internet. Videos on health topics, for example, on the video portal Youtube, have been used by 161 of 473 (34.03%). To make a doctor’s appointment, 132 out of 473 (2.,9%) have used the Internet. One hundred thirty-four out of 473 (28.32%) used health apps on their smartphones. Fitness bracelets and smartwatches for health purposes are owned by 144 out of 473 (30.44%) of the respondents. Most of the respondents would be willing to use health apps in the future (see Fig. 2c). Of those with a higher level of education, 91.75% (89 of 97) were already using electric health services or would be willing to do so in future (p < 0.001). Among those with lower educational qualifications, the figure was only 69.94% (242 of 346) (p < 0.001). Of those who have a high school diploma, 81.48% (22 of 27) have searched for information on health topics on the Internet (p < 0.001). There was no significant association between age and eHealth related services.

Fig. 2
figure 2

a Frequency of using eHealth services (N = 449) b Which of the following health services have you ever used? (N = 473). c Are you willing to use health apps in the future? (N = 339)

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Data security

Most of the respondents have an antivirus program (see Fig. 3a). In general, most respondents do not provide any private information on the Internet (see Fig. 3b). Of those with a low level of education, 39.01% (135 of 346) do not have an antivirus program installed on their computer (p < 0.001). In contrast to 88.65% (86 of 97) from a high education class have an antivirus program installed on their computer (p < 0.001). In addition, 83.81% (290 of 346) of those with low education do not regularly change the password of their computer (p < 0.001). There were no other significant associations found.

Fig. 3
figure 3

a Data security (N = 488) b How often do you specifiy private information such as name or place of residence on the Internet? (N = 451)

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eHealth literacy

eHealth literacy addresses the skills and knowledge that are essential in the usage of technology-based health applications (Geukes et al. 2022). The majority of respondents understand health information well (see Table 2). Most respondents know where to find information on the Internet concerning questions about their health (see Table 2). Many respondents feel uncomfortable basing decisions regarding their health on web-based health information (see Table 2). For 191 of 411 (46.47%) respondents, Internet offers on health topics already helped with health-related decisions (see Table 2). We have seen that eHealth literacy is quite high in general. The respondents’ interest in eHealth services provide a valid foundation for the digital transformation of the health care system.

Table 2 eHealth literacy
Full size table

When asked to assess whether Internet offers on health topics had already helped with health-related decisions, the majority of 191 (46.46%) agreed. Thirty of 423 (7.09%) stated that they fully agreed to knowing for sure whether the information comes from reliable sources when using health information from the Internet, and 69 out of 423 (16.31%) did not agree with the statement at all. ‘The own knowledge increased after Internet research on health topics’, 56 out of 417 (13.42%) fully agreed. The vast majority, 247 out of 417 (59.23%), ‘tended to agree’ with this statement. When asked whether participants know how to find suitable apps that can help with their own health, more than half of respondents said they felt able to do so (85 of 426; 19.95%) ‘I fully agree’; 181 of 426 (42.48%) ‘I tend to agree’). Each participant was asked to estimate his or her skills concerning apps in general. Three hundred seventy-three (84.77%; N = 440) feel mostly confident in using apps. Most of the respondents know how to use apps on a smartphone or tablet to help them with health-related problems (79.93%; 327 out of 425). This question was answered by 444 respondents, 126 (28.37%) of them, never asked any other person (e.g. medical professionals, acquaintances) anything regarding their health or used another source of information (for example, books or the Internet) to answer questions about their health in the past month. Two hundred sixty-three of 444 people (59.23%) indicated a frequency of 1–4 times per month. The remaining respondents (55 out of 444; 12.38%) tend to do so more often. Respondents who scored lower in eHealth literacy indicated they need help reading medical applications or other health related material more often (p < 0.001). Among those who have less than a high school diploma, only 17.81% (49 of 275) can easily find suitable Internet information on health issues. In contrast to those with a high school diploma or higher, 91.25% (167 of 183) of whom know where they can access suitable content on their health issues (p = 0.006). There were no other significant associations found.

Single item literacy screener

Thus, 9.33% (41 of 439) of the respondents found it difficult to read and understand medical instructions, brochures, or other written materials from their doctor or pharmacist and accordingly needed help from others. The majority (311 of 439; 70.84%) of the respondents reported never or rarely asking other people for help with reading.

Of those with a higher educational qualification, 95.87% (93 of 97) generally understand Internet content on health topics quite well (p < 0.001). In contrast, only 53.81% (148 of 275) of those with less than a high school diploma, have a good understanding of health-related information on the Internet (p < 0.001). There were no other significant associations.

Physical activity

Results show that 15.11% (68 of 450) are not doing sports at all. The majority, 196 out of 450 (43.55%) are active 2–4 h per week and 87 out of 450 (19.33%) are active more than 4 h per week.

A statistically significant association was found between physical activity and regular preventive checkups at the general practitioner (p < 0.001). This might be explained by a higher consciousness of the importance of health issues in those who exercise on a regular basis. In addition, an association could also be found between an overall physically active lifestyle and higher eHealth literacy (p < 0.001). Thus, those who exercise regularly are also more willing to use digital health applications in the future (p = 0.007).

Physician

This survey of 447 persons found that the majority (421 of 447; 94.18%) have a general practitioner they see. Most (241 of 442; 54.52%) said they see their doctor every 6 months. Sixty-four of 442 (14.47%) said they did not see their doctor at all. There were no significant associations found.

Discussion

We received 488 questionnaires. The vast majority of almost 90% use the Internet daily. Three-quarters of the population were willing to use digital media for health purposes in the future. Furthermore, there was no significant association between age and usage of eHealth related services. On contrast, low education levels was the most important factor for a low understanding of digital health information, as well as for finding digital health information less trustworthy. To our knowledge, this is the first survey on eHealth Literacy on a community level in a small town with such a high rate of participation (5.52%).

Technical equipment for Internet usage

The presence of adequate basic digital equipment is an important requirement for a population with a high level of digital health literacy (Lee et al. 2022). However, in many rural areas in Germany, a stable Internet connection is often still not ensured. Further, our survey found that a quarter of respondents have an Internet connection that is too slow for their needs. The fact that this study also found that 1 out of 5 residents has to rely on public places (like cafes or stores) to use the Internet proves the importance of a need for action. As 3 out of 4 residents would be willing to use digital health apps in the future, it is crucial to equip those citizens with the necessary digital skills. Other studies also came to a similar conclusion that most patients would be willing to use more digital apps to improve their health status if access to these services was more adequate (Vanagas 2011; Thapa et al. 2021).

Also, Internet speed has a strong impact on the usage of the Internet regarding health services (Graves et al. 2021). Eighty percent of respondents who have a high-speed Internet connection have a better understanding of Internet services on health topics. The easier and more convenient it is for the respondents to access the Internet, the more likely they are to use Internet services on health topics. This was also the case in another study (Halwas et al. 2017). The fact that 20% are dependent on going to a cafe to be able to use the Internet indicates the high demand on the one hand but on the other hand also the lack of infrastructure. By increased usage, people also develop better skills in dealing with digital devices and digital health services. For this reason, the availability of a functioning and fast Internet should be an absolute priority.

Ability to actively engage with digital services

The findings tend to confirm the results of previous surveys, as around 40% of respondents have difficulties finding suitable apps and general information on the Internet that may help with their health situation (Ernsting et al. 2019).

It is surprising that we did not find any correlation between technical skills and age. Usually a correlation was found between higher age and poor digital skills (Breil et al. 2021). In our study, this can possibly be explained by the fact that the older population that participated in the survey also had a fairly high level of education. As many studies confirm, a high level of education correlates with high eHealth literacy (Howard et al. 2006). The high level of education of the older population in Dingelstädt is not astounding, as the municipality of Dingelstädt is very committed to becoming a ‘digital health city’. This shows that there is a great interest in educational health subjects.

Being female was a consistent predictor of eHealth in many previous studies (Dewalt et al. 2004; Protière et al. 2012). However, our findings demonstrate that being female was only linked to a higher frequency in scheduling doctor’s appointment online. Except for that, the Internet usage of female compared to male respondents showed no significant variation.

Comprehensibility of Health Information

Of central importance is that nearly 80% of respondents stated that they need to ask other people for advice or help to understand health information or medical instructions or had to search for health information on the Internet to be able to answer personal health-related questions. Another study also showed a similar result: Fifty-five percent of the sample searched for health information on the Internet to be able to answer personal health questions or make decisions regarding their own health (Breil et al. 2021). This supports the need to provide easy access or general to digital health information and support for using those digital devices for patients and citizens, to ensure inclusive and understandable access to resources. Those who do not have sufficient skills in the use of media will not be able to be part of the digitalization of the healthcare system. Bevilacqua et al. have clearly demonstrated that interventions such as a digital skills course significantly improve the eHealth literacy of participants (Bevilacqua et al. 2021).

However, the fact that almost 60% of respondents do not feel confident basing their decision on health-related information found online is not just an issue caused by a lack of comprehension. Comparing these results with other research outcomes, there are approximately 20% more in Dingelstädt who feel insecure about deciding health matters based on digital information (De Santis et al. 2021). One possible explanation for our results could be the high percentage of pupils who participated in our survey. Pupils do not yet have sufficient knowledge about general health issues and necessary skills in examining the accuracy of information on the Internet. This survey could confirm what many other studies also showed: residents with a lower level of education are less likely to understand websites on health topics and generally find digital health information less reliable (Howard et al. 2006). However, there is not only uncertainty due to lack of knowledge. Knowledge about the uncontrolled flood of data on health topics, insecure data storage and possible misuse of personal data on the Internet and its possible consequences also creates uncertainty when dealing with digital health information, as we could prove in our survey. This can also be confirmed by numerous studies (Barrows Jr and Clayton 1996; Reyes and Vance-Chalcraft 2022; Geukes et al. 2022).

Uncertainty about health information is not only due to the vast amount of unfiltered Google results, but also the fact that 60% of respondents stated a difficulty in determining whether the available health information online comes from a trustworthy source. This was also reported by Chan and colleagues (Chan 2021).

Digitalization of the healthcare system

Not only patients but also many doctors are still very reluctant to digitalize healthcare (World-Health-Organization, 2018, Towards a roadmap for the digitalization of national health systems in Europe). However, digitalization is an important element in the process of making the healthcare system simpler and making it easier for healthcare professionals to work more efficiently because there is less bureaucracy involved. All health data is recorded digitally, allowing a quick overview of a patient’s medical history. This not only saves office work that is necessary to store and file analogue data, but also makes it possible to diagnose more quickly as a better overview of all examination results is given. As we determined that the vast majority has a general practitioner, this would allow doctors to have a much better overview of their patients’ records. This allows for better assessment of treatment success, as digital values can be more easily compared and statistically evaluated as diverse studies found (Choudhary et al. 2021).

Numerous health tracking apps exist that offer educational content, but in our survery, only 1 in 4 participants had used these apps. By using these services, patients would have access to data that could help them and their attending doctor with further diagnostics. For example, apps are already being used for the diagnosis of melanoma, as the success of therapy for this disease depends decisively on the time of diagnosis (Tyagi et al. 2012). However, digital devices are not solely useful for diagnostic purposes; the use of digital tools can also be beneficial for therapy, as has been shown in the treatment of cancer patients, for example (Basch et al. 2022). According to the results of the survey, many patients are open to the use of health tracking apps. However, there seems to be a problem with the doctor’s knowledge of how to integrate data from health tracking apps into their health practice as studies found (Dahlhausen et al. 2021). However, especially chronic and elderly patients can benefit from health tracking apps (Madrigal and Escoffery 2019).

In general, digital therapy concepts should not be seen as a replacement for conservative therapy, but rather as an addition. It is important that the doctor remains a key element in the treatment of the patient.

Physical health and eHealth literacy

That people are more likely to attend preventive check-ups with their general practitioner if they exercise on a regular basis, could be explained by the fact that health-conscious people also consider it sensible to have regular check-ups with their general practitioner to ensure that an active lifestyle is still possible for them in the future.

Limitations

The central question is whether these results are representative for Germany or Europe. In comparison to nation-wide German data, the level of eHealth literacy is rather high, as 60% of the population in Germany have a low health literacy according to the HLS-GER 2 (Schaeffer et al. 2023).

The prevalence of limited health literacy was particularly high among interviewers belonging to the age group of under 18 years. Looking at the demographic details, the question arises whether the sample was representative enough to be able to generalize the results to the inhabitants of Dingelstädt. It seems that a high percentage (around 40%) of respondents are younger than 18 years old. One explanation for this is that the distribution of the questionnaire was supported by the high school of Dingelstädt. This may have led to an increase in participation among this age group. The high school health week around the time of the survey may also have contributed to a greater participation of high school students. For a whole week there were various lectures, activities and discussion rounds on health topics to encourage interest in health issues among pupils (Dingelstädt 2021).

The results show that for approximately 30% of the respondents, the highest educational degree is elementary school. Half of the respondents counted themselves in the group of ‘students/trainees’. Young participants have very likely not completed their education, resulting in assignment to a lower educational level. This explains why many of them have completed their highest level of education at elementary school, because they are not yet in the appropriate stage of life to have already finished high school or completed their studies at university, for example. The new view of young and middle-aged people also has the potential to inform the digital transformation, as they become the next generation using digital health tools.

Conclusion

The willingness of the participants to take part in the digitization of healthcare is probably the most important prerequisite for a successful transition. It can be deduced that digital health literacy is a key qualification for today’s population for a high quality of life and health. However, the quantity of health information is rapidly expanding in many directions, with digitalization further accelerating this development. Even if the demands on users of digital health offers are already very high, they will continue to increase. The variety of information has also increased the complexity, as the quality of the information is very heterogenous (Harms 2018; Keinki et al. 2018). It is therefore essential to have strategies in place to guide people and give them the skills needed to cope with the demands of dealing with digital health information.

Overall, the results of our questionnaire demonstrate a clear need for measures that systematically link media skills and health literacy. Future studies should examine the needs of doctors and healthcare institutions but also of lay-persons and patients with respect to tele-medicine in addition to analogue therapy to provide patients with the best possible medical care. It is important to know where the difficulties lie, whether the doctors are simply unaware of digital services that they can recommend to their patients, or whether they do not have the digital skills to understand and learn the proper use of digital health applications. Some may have considered the usage of digital devices and are concerned about the potential risks with regard to data security or the readiness of people with low eHealth literacy to use these tools. It would also be useful to know which digital equipment is currently being used in each polyclinic and hospital. A better understanding of these issues will make it possible to take more targeted measures to promote the digitization of healthcare.

For stakeholders in the health care system, physicians, politicians and those engaged in medical education of whole populations, the model of this small towns shows that high education in general offers a strong base to build up health literacy. Moreover, engagement of and in a community helps to lower barriers and to improve access to a larger group of the community.