Article

Health Information Use and Trust: The Role of Health Literacy

and Patient Activation in a Multilingual European Region
Christian J. Wiedermann 1, * , Verena Barbieri 1 , Stefano Lombardo 2 , Timon Gärtner 2 , Patrick Rina 1 ,
Klaus Eisendle 3 , Giuliano Piccoliori 1 , Adolf Engl 1 and Dietmar Ausserhofer 1,4

1 Institute of General Practice and Public Health, Claudiana College of Health Professions, 39100 Bolzano, Italy
2 Provincial Institute for Statistics of the Autonomous Province of Bolzano, South Tyrol (ASTAT),
39100 Bolzano, Italy
3 Directorate, Claudiana College of Health Professions, 39100 Bolzano, Italy
4 Claudiana Research, Claudiana College of Health Professions, 39100 Bolzano, Italy
* Correspondence: [email protected]

Abstract: The acquisition of reliable health information plays a pivotal role in shaping
informed decision-making and health-related behaviours. This investigation examined
the factors influencing health information use and trust in health sources among the adult
population in South Tyrol, Italy, employing a population-based cross-sectional survey
(n = 2090). Descriptive analyses revealed sociodemographic disparities, with younger indi-
viduals and those with higher educational attainment demonstrating increased engagement
with digital sources, while older adults and those with lower educational levels exhibited a
greater reliance on traditional media and healthcare professionals. Correlation analyses
showed that elevated health literacy (HLS-EU-Q16) was linked to enhanced engagement
with structured and professional health sources, whereas higher patient activation (PAM-10)
exhibited a negative correlation with a dependence on healthcare professionals, indicat-
ing that more activated individuals are less reliant on medical consultations for health
information. Individuals reporting a better health status were less inclined to use health
information sources, such as media, healthcare professionals, or the internet, as opposed to
Academic Editor: Hae-Ra Han relying on personal knowledge or experience. Ordinal regression models further identified
Received: 18 February 2025
age, education, and linguistic background as crucial predictors of health information use
Revised: 28 March 2025 and trust in sources. These findings highlight the influence of health literacy and patient
Accepted: 3 April 2025 activation on information engagement and trust and emphasise the need for tailored public
Published: 5 April 2025 health initiatives to ensure equitable access to reliable health information across diverse
Citation: Wiedermann, C.J.; Barbieri, demographic groups.
V.; Lombardo, S.; Gärtner, T.; Rina, P.;
Eisendle, K.; Piccoliori, G.; Engl, A.; Keywords: health information-seeking behaviour; trust in health sources; health literacy;
Ausserhofer, D. Health Information
patient activation; digital health literacy
Use and Trust: The Role of Health
Literacy and Patient Activation in a
Multilingual European Region. Int. J.
Environ. Res. Public Health 2025, 22,
570. https://doi.org/10.3390/ 1. Introduction
ijerph22040570 Access to reliable health information is a fundamental determinant of informed
Copyright: © 2025 by the authors. decision-making and health-related behaviours [1,2]. In the contemporary digital era,
Licensee MDPI, Basel, Switzerland. individuals obtain health information from a wide variety of sources, including personal
This article is an open access article healthcare providers such as general practitioners, nurses, and health coaches, profes-
distributed under the terms and
sional experts like nutritionists, scientists, and academics, official government websites
conditions of the Creative Commons
(e.g., WHO, CDC, and NHS), and digital channels including search engines, health-related
Attribution (CC BY) license
(https://creativecommons.org/
websites, scientific news outlets, blogs, podcasts, and social media platforms such as Face-
licenses/by/4.0/). book and WhatsApp. Interpersonal networks (e.g., family, friends, and colleagues) and

Int. J. Environ. Res. Public Health 2025, 22, 570 https://doi.org/10.3390/ijerph22040570

Int. J. Environ. Res. Public Health 2025, 22, 570 2 of 22

traditional media sources like books, newspapers, and television also continue to play a
role in shaping how health information is accessed and shared [3–5].
However, the selection of health information sources and the trust placed in them vary
across different demographic and sociocultural groups, influencing both health literacy
and patient activation [6,7]. Throughout this study, the term “reliance” refers specifically to
the self-reported frequency of using a particular health information source, as assessed by
Likert-scale responses. It does not imply trust or habitual dependence on the source for
decision-making unless otherwise stated. This usage aligns with prior research distinguish-
ing reliance from trust and active seeking [8,9]. Trust is defined as a willingness to accept
vulnerability based on positive expectations of the intentions or behaviour of a source, even
in the absence of direct control or the ability to verify the information provided [10,11].
Use is a general term encompassing both active and passive engagement with sources.
Understanding the determinants of health information use and trust is crucial for tailoring
effective public health communication strategies [12].
Health information use is influenced by multiple sociodemographic factors, including
age, sex, education level, and cultural group membership [13,14]. Research has demon-
strated that younger individuals and those with higher education are more inclined to
engage with digital health sources, whereas older adults tend to rely on traditional me-
dia and healthcare professionals [15]. Gender disparities have also been observed, with
women generally exhibiting higher engagement in health information-related activities
than men [7]. In bilingual and multilingual regions, linguistic group membership may
further influence access to and preference for different health information sources [15].
However, empirical evidence regarding these determinants in South Tyrol, a linguistically
diverse region in Italy, remains limited.
Health literacy, defined as the ability to access, comprehend, and utilise health infor-
mation effectively, plays a crucial role in self-care and decision-making [6]. The Patient
Activation Measure (PAM-10) assesses an individual’s knowledge, skills, and confidence
in managing their health, with higher activation levels associated with improved health
outcomes and self-care behaviours [16]. A substantial body of research suggests that dig-
ital health information seekers—individuals who actively search for health information
online—may demonstrate higher levels of health literacy and patient activation as they
are more engaged in proactive health management [7]. However, the applicability of these
trends in South Tyrol, where both linguistic and regional differences may influence access
to digital health information, remains unclear.
Trust is a key determinant of whether individuals accept and act on health information
or not. Studies indicate that healthcare professionals (general practitioners, specialists,
pharmacists, and nurses) are among the most trusted sources, whereas trust in internet-
based sources and social media is comparatively low [15]. Nevertheless, some individuals,
particularly those with lower health literacy, may overly rely on online information and
exhibit lower trust in traditional medical sources [7,17]. It is also unclear whether trust in
traditional media (newspapers, TV, and books) correlates positively with health literacy
and patient activation levels.
This study aimed to explore the determinants of health information use and trust in
health information sources among adults in South Tyrol. To systematically investigate
the relationship between demographic and health-related factors with health information
behaviours and trust in information sources, we applied the conceptual framework outlined
in Figure 1. This framework illustrates the independent variables considered in this analysis,
the dependent variables representing information-seeking behaviour and trust, and the
categorization of different types of health information sources. Specifically, we addressed
the following research questions:
 1. What sociodemographic factors influence health information use and trust in health
sources?
2. How do health literacy and patient activation relate to health information use?
Int. J. Environ. Res. Public Health 2025, 22, 570 3 of 22
3. What factors predict trust in health information sources, and how does trust influ
ence engagement with information sources?
1. What sociodemographic
By addressing factors influence
these questions, this studyhealth
soughtinformation
to provideuse and trust
insights into in
how indi
health sources?
viduals in South Tyrol navigate health information, with implications for public health
2. How do health literacy and patient activation relate to health information use?
communication, digital health strategies, and healthcare professional engagement.
3. What factors predict trust in health information sources, and how does trust influence
engagement with information sources?

Figure 1. Conceptual framework of predictors and outcomes in the use of health information and
Figure 1. Conceptual framework of predictors and outcomes in the use of health information and
trust in information sources.
trust in information sources.
By addressing these questions, this study sought to provide insights into how indi-
2. Materials
viduals in Southand
TyrolMethods
navigate health information, with implications for public health
communication, digital health strategies, and healthcare professional engagement.
2.1. Study Design, Setting, and Sample
From 1 March
2. Materials to 30 May 2024, a comprehensive, multi-sectoral population survey
and Methods
wasStudy
2.1. conducted
Design, in the Autonomous
Setting, and Sample Province of Bolzano, South Tyrol. This research initi
ativeFrom
was 1aMarch
collaborative
to 30 Mayendeavour between themulti-sectoral
2024, a comprehensive, Provincial Institute
populationof survey
Statistics
was(ASTAT
Istituto Provinciale
conducted di Statistica-Landesinstitut
in the Autonomous Province of Bolzano, für
SouthStatistik) andresearch
Tyrol. This the Institute of Genera
initiative
Practice
was and Public
a collaborative Health. between the Provincial Institute of Statistics (ASTAT; Istituto
endeavour
Provinciale di Statistica-Landesinstitut
The Autonomous Province of Bolzano, für Statistik)
alsoand the Institute
known as South of General
Tyrol, isPractice
situated in the
and Public Health.
Trentino–Alto Adige region of Italy, bordering Austria. With a total population of 535,000
The Autonomous
the linguistic Province
composition of Bolzano,
comprises also known as
approximately South
70% Tyrol, is situated
of German speakers,in 25%
the of Ital
Trentino–Alto Adige region of Italy, bordering Austria. With a total population of 535,000,
ian speakers, and 5% of speakers of Ladin and other languages. The survey’s target de
the linguistic composition comprises approximately 70% of German speakers, 25% of
mographics encompassed approximately 400,000 residents of South Tyrol aged 18 years
Italian speakers, and 5% of speakers of Ladin and other languages. The survey’s target
and above. This study employed stratified probabilistic sampling methodology. ASTAT
demographics encompassed approximately 400,000 residents of South Tyrol aged 18 years
conducted
and a random
above. This selection stratified
study employed of adultsprobabilistic
aged 18 years and older
sampling from the ASTAT
methodology. province-wide
register ofacurrent
conducted randomresidents.
selection ofThis selection
adults aged 18was
yearsstratified
and older according to age groups (18–34
from the province-wide
35–54, and 55 and above), gender (male and female), citizenship status
register of current residents. This selection was stratified according to age groups (Italian
(18–34,or other)
and place
35–54, and 55ofand
residence (municipalities).
above), gender A sample
(male and female), of 4000
citizenship individuals
status (Italian orwas drawn to
other),
and place of residence (municipalities). A sample of 4000 individuals was drawn to achieve
an appropriate level of precision considering the distribution and variation across the strata.
Int. J. Environ. Res. Public Health 2025, 22, 570 4 of 22

2.2. Participant Survey

ASTAT and the Institute of General Practice and Public Health jointly created the
participant questionnaire. The German and Italian versions provided by ASTAT underwent
a linguistic equivalence review by researchers at the Institute for General Practice and
Public Health. The final questionnaire comprised 91 items, covering sociodemographic
data, health information use, trust in health sources, health literacy (HLS-EU-Q16), patient
activation (PAM-10), and self-reported health status. Not all items are analysed in the
present study; selected sections will be used in future publications. A machine-translated
English version of the full questionnaire using DeepL is provided in Supplementary File
S1. The translation was subsequently reviewed and manually corrected by a bilingual
researcher to ensure linguistic accuracy and contextual consistency.

2.2.1. Health Information Use and Trust

The evaluation included ten common sources of health-related information: (1) layper-
son medical discussions (being asked for advice), (2) magazines and newspapers, (3) tele-
vision and radio broadcasts, (4) friends and acquaintances, (5) healthcare professionals,
(6) educational courses, (7) the medical literature, (8) general online searches, (9) targeted
searches in electronic databases, and (10) online forums. To enable a direct comparison
of the results with those from a decade ago, the same survey questions as those used by
Ausserhofer et al. [15] were selected. These self-developed items, adapted from existing
instruments but without formal validation, were assessed using a 4-point Likert scale
ranging from 1 (“regularly”) to 4 (“never”). The survey item was phrased to capture both
active engagement with information (e.g., targeted searches) and passive exposure (e.g.,
encountering information by chance).
Trust in various sources of health information was assessed utilising the following
inquiry: “How much do you trust the following sources for health information?” The
evaluated sources comprised (1) specialists in outpatient clinics or hospitals, (2) family
doctors, (3) personal feelings or experiences, (4) pharmacists, (5) nurses, (6) information
from books, (7) advice from friends or relatives, and (8) information from the internet.
Responses were recorded on a 4-point Likert scale ranging from 1 (“very”) to 4 (“not
at all”).

2.2.2. HLS-EU-Q16
Health literacy was assessed using the European 16-item Health Literacy Survey
(HLS-EU-Q16), which measures an individual’s ability to access, understand, appraise, and
apply health-related information in healthcare, disease prevention, and health promotion
contexts [18]. The HLS-EU-Q16 is a validated short version of the original 47-item HLS-
EU questionnaire (HLS-EU-Q47) [19], retaining 16 key items while maintaining reliability
and validity.
The questionnaire was administered in German and Italian using validated transla-
tions that demonstrated strong psychometric properties, including high internal consistency
and construct validity [18,20,21]. Each item was rated on a 4-point Likert scale: (1) very
difficult, (2) fairly difficult, (3) fairly easy, and (4) very easy. Following the HLS-EU-Q16
manual, the response option ‘don’t know’ was treated as a missing value and excluded
from scoring. Participants were only included in the analysis if they provided at least
13 valid responses. Responses were summed to a raw score (0–16), which was then trans-
formed into a standardised health literacy index ranging from 0 (lowest) to 50 (highest),
following the established HLS-EU-Q16 scoring procedure. Categories were defined as
follows: inadequate (0–25), problematic (26–33), and adequate (34–50). This transformation
Int. J. Environ. Res. Public Health 2025, 22, 570 5 of 22

allows for comparability with other European HLS-EU studies. Alternative classifications
based on raw sum scores exist but were not applied in this study.

2.2.3. Patient Activation Measure 10 (PAM-10)

Patient activation was assessed using the 10-item Patient Activation Measure
(PAM-10), which evaluates individuals’ knowledge, skills, and confidence in managing
their health [22]. A licence for the use of PAM-10 was obtained by the South Tyrol Provin-
cial Statistics Institute (ASTAT) via co-author Stefano Lombardo from Insignia® , who also
received the required data for analysis.
The PAM-10 is a shortened version of the original 13-item PAM (PAM-13), which
retains 10 of the original items while maintaining reliability and validity. As no specifically
validated PAM-10 versions were available in Italian or German, the corresponding 10 items
from the validated PAM-13 versions in these languages were used. These validated transla-
tions have demonstrated good psychometric properties, including high internal consistency
and construct validity [16,23].
Each item was rated on a 5-point Likert scale: (1) strongly disagree, (2) disagree,
(3) neutral, (4) agree, and (5) strongly agree. Raw scores were transformed into a standard-
ised activation score ranging from 0 (lowest activation) to 100 (highest activation) following
the established PAM scoring methodology. The PAM score was categorised into four levels
to provide a structured interpretation of patient activation [24]:
• Level 1 (≤47.0): Disengaged and overwhelmed.
• Level 2 (47.1–55.1): Becoming aware but still struggling.
• Level 3 (55.2–72.4): Taking action.
• Level 4 (≥72.5): Maintaining behaviours and pushing further.

2.2.4. Demographic and Health Characteristics

The survey collected data on the respondents’ demographic characteristics, including
birth year, gender (male/female), native language (German/Italian/Ladin or Others), citi-
zenship (Italian/other), educational level (below school/high school or higher), community
and region of origin (rural/urban), and living situation (alone/with spouse, family member,
or with parents or children). Health-related variables included self-reported health status
on a scale of 1–100.
ASTAT dispatched letters to a random selection of potential participants, inviting them
to voluntarily participate in this study. Respondents were given the option to complete
the survey independently or with the assistance of a family member. The survey was
completed online or via telephone interviews conducted by the ASTAT collaborators. A
follow-up letter was sent one month after the initial communication to remind individuals
about the study and encourage their participation. The survey platform, LimeSurvey [25],
was used to create an online questionnaire.

2.3. Statistical Analysis

Health literacy (HLS-EU-Q16) scores were categorised into inadequate, problem-
atic, and adequate levels following the standard classification criteria. Patient activation
(PAM-10) was categorised into four levels, with the highest proportion of respondents in
Level 2 indicating that they were becoming aware but still struggling with health-related
self-management. Self-reported health status was categorised based on the WHO clinical
thresholds, ranging from poor to excellent health. These weighted distributions provided a
representative overview of the study population.
Only fully completed questionnaires were included in the statistical analyses. Descrip-
tive statistics were used to describe the measured variables. To adjust for non-participation
Int. J. Environ. Res. Public Health 2025, 22, 570 6 of 22

bias (i.e., differences between respondents and non-respondents) and ensure that the sample
was representative of the target population, weighted descriptive statistics were calculated
using post-stratification weights using iterative proportional fitting (raking) to align the
sample distributions with population-level margins for age group, gender, citizenship,
and municipality of residence, as provided by ASTAT. The weights were scaled to the
sample size. Weighted medians and interquartile ranges were computed for continuous
variables. Weighted proportions and 95% confidence intervals (CIs) were reported for
categorical variables. No imputation was performed; only fully completed questionnaires
were analysed. Notably, 95% confidence intervals for categorical variables were calculated
using the Wald method.
To assess differences in health information source use across age groups, one-way
analysis of variance (ANOVA) was conducted. The dependent variable was age (contin-
uous), and the independent variable was the frequency of using each health information
source (four levels: regular, sometimes, seldom, and never). The homogeneity of variances
was tested using Levene’s test, and when violated, the robustness of the ANOVA with
large sample sizes was considered. Post hoc pairwise comparisons were performed using
Tukey’s honest significant difference test with adjusted p-values for multiple comparisons.
Effect sizes were estimated using omega squared (ω2 ) to quantify the difference magni-
tude, interpreted as very small (≤0.01), small (0.01–0.06), moderate (0.06–0.14), and large
(≥0.14) [26].
Sample size estimation was based on general guidelines for population-based survey
research and recommendations for detecting small effect sizes (ω2 = 0.02) in subgroup
analyses. Prior survey research has suggested that a sample size of approximately 1000
respondents is sufficient to ensure representativeness and detect small differences in health
behaviour studies [27,28]. Given the planned subgroup analyses, the final target sample size
was increased to 2000 participants to account for stratification and potential non-response
adjustments.
Weighted Spearman’s rank correlation coefficients (ρ) were computed to examine
the relationships between patient activation (PAM-10), health literacy (HLS-EU-Q16),
and self-reported health status (0–100 scale) with the use of ten health information
sources: newspapers/magazines, TV/radio, friends/acquaintances, healthcare profes-
sionals, events/courses, the specialist literature, incidental exposure to health information
online, targeted internet searches, internet forums, and social media.
Ordinal regression models were employed to investigate the predictors of health
information use and trust in health information sources, adhering to established recommen-
dations for ordinal regression in public health research [29]. The analyses examined the
influence of age, sex, education level, geographic region, native language, health literacy
(HLS-EU-Q16), patient activation (PAM-10), and subjective health status on both outcomes.
Each source was analysed separately to account for potential differences in predictor effects.
Given the ordered nature of the dependent variables, ordinal regression with a cumula-
tive logit link function was used. All predefined predictors were retained in the models,
including geographic region and native language, owing to their relevance to South Tyrol.
Model performance was evaluated using Akaike Information Criterion (AIC), Bayesian
Information Criterion (BIC), deviance, and Pearson goodness-of-fit tests. Odds ratios (ORs)
and 95% confidence intervals (CIs) were derived from the regression coefficients. No
formal collinearity diagnostics were conducted; however, given the exploratory nature
of this study, collinearity was not anticipated to substantially impact the interpretation.
Predictors were selected based on prior research and theoretical frameworks, rather than
data-driven selection.
Int. J. Environ. Res. Public Health 2025, 22, 570 7 of 22

Findings were categorised into traditional media, personal sources, literature-based

sources, online sources for health information use and healthcare professionals, per-
sonal/social trust, and educational/media sources for trust analyses.
Analyses were conducted using Jeffreys’ Amazing Statistics Program (JASP; University
of Amsterdam, Amsterdam, The Netherlands). Statistical significance was set at p < 0.05.

3. Results
3.1. Characteristics of the Study Sample
The study sample was designed to be representative of the population, with demo-
graphic distributions reflecting the regional characteristics. Of the 4000 individuals invited,
approximately 2120 returned the questionnaire, yielding a response rate of 53%. Among
these, 2090 adults provided fully completed responses and were included in the analysis,
corresponding to a completion rate of approximately 98.6% (Table 1).

Table 1. Demographic and other characteristics of the sample were the weighted distribution of
categorical variables, including sociodemographic characteristics, health literacy (HLS-EU-Q16),
patient activation (PAM-10), and self-reported health status (n = 2090).

Weighted
Weighted 95% CI Low 95% CI High
Variable Category Proportion
n % %
%
Female 1158 55.5 54.2 56.8
Gender Male 932 44.5 43.2 45.8
18–34 378 18.1 16.9 19.3
Age Group (Years) 1 35–54 643 30.7 29.3 32.1
55+ 1070 51.2 49.7 52.7
German 1395 66.8 65.5 68.1
Native Language Italian 499 23.9 22.7 25.1
Other 194 9.3 8.5 10.1
Italian 2009 96.1 95.4 96.8
Citizenship
Other 81 3.9 3.2 4.6
Urban 387 18.5 17.3 19.7
Community Type
Rural 1703 81.5 80.3 82.7
Alone 378 18.1 17.0 19.3
Living Situation With partner/family 1327 63.5 62.1 64.9
With children 787 37.7 36.3 39.1
Middle school or lower 487 23.3 22.0 24.6
Vocational school 670 32.1 30.7 33.5
Educational Level High school 533 25.6 24.3 26.9
University 396 19.0 17.9 20.1
Inadequate 262 12.5 11.6 13.4
Health Literacy 2 Problematic 570 27.2 26.0 28.4
Adequate 823 39.3 38.0 40.6
Disengaged 340 16.3 15.3 17.3
Becoming aware 888 42.6 41.2 44.0
PAM-10 3 Taking action 648 31.1 29.8 32.4
Maintaining 204 9.8 9.0 10.6
Int. J. Environ. Res. Public Health 2025, 22, 570 8 of 22

Table 1. Cont.

Weighted
Weighted 95% CI Low 95% CI High
Variable Category Proportion
n % %
%
Poor (0–50) 255 12.2 11.3 13.1
Fair (51–75) 625 29.8 28.5 31.1
Health Status(0–100) 4
Good (76–90) 820 39.1 37.8 40.4
Excellent (91–100) 390 18.9 17.9 19.9
1 weighted mean age of 53.8 years (standard deviation of 17.6); median of 54 years (interquartile range of 39–69).
2 HLS-EU-Q16: health literacy was grouped into inadequate (0–25), problematic (26–33), and adequate (34–50).
3 PAM-10: patient activation was categorised into four levels: low (≤47.0, disengaged) to high (≥72.5, maintaining

behaviours). 4 Health status: categorised into poor (0–50), fair (51–75), good (76–90), and excellent (91–100).
CI, confidence interval.

The weighted gender distribution closely mirrors the population estimates. The
weighted mean age was 53.8 years (SD: 17.6), with a median age of 54 years (IQR:
39–69 years). More than half of the respondents were in the oldest age group, while
the youngest age group comprised the smallest proportion.
Most respondents were German speakers, followed by Italian speakers and other
linguistic groups. The linguistic distribution in the weighted sample aligns with provincial
census data, supporting representativeness. Most respondents held Italian citizenship.
Most respondents resided in rural areas, whereas a smaller proportion lived in urban
settings. Regarding living situations, most respondents lived with a partner or family,
whereas a smaller proportion reported living alone. The educational levels varied, with a
notable proportion having vocational training or a high school education, while a smaller
segment had a university-level education.
Of the 2090 cases, 442 (21.1%) did not provide sufficient data to calculate a health
literacy score. Among the remaining 1648 evaluable cases, health literacy was categorised
as inadequate (266 cases, 16.1%), problematic (559 cases, 33.9%), or adequate (823 cases,
50.0%), based on the classification criteria described in the Methods Section.

3.2. Health Information Sources and Trust

Table 2 presents the descriptive statistics for the use of health information sources and
trust in various health-related entities among the surveyed respondents. Regarding health
information use, traditional media sources such as newspapers, magazines, television,
and radio were used occasionally, but not as primary sources. Conversations with friends
and acquaintances as well as direct discussions with healthcare professionals remained
common sources of information, albeit with some variability. Formal educational events
and the specialist literature were consulted less frequently, with the latter exhibiting broader
variability in use.
Digital sources demonstrated mixed patterns. Targeted internet searches were em-
ployed more frequently than incidental exposure to health information online, which was
slightly less prevalent. Social media and internet forums were the least frequently used
sources of health information, as the majority of respondents reported using them rarely
or never.
When considering trust in health information sources, medical professionals—
including general practitioners, specialists, and nurses—were reported as the most trusted
sources. However, trust scores were analysed separately from self-reported use, as defined
in the Methods Section. Pharmacists were also considered reliable, although slightly less
so than physicians. Books and personal experiences ranked higher than online sources
and advice from friends and relatives. Conversely, trust in internet-based sources and
Int. J. Environ. Res. Public Health 2025, 22, 570 9 of 22

social media was lower, reflecting limited perceived credibility of digital platforms for
health information.

Table 2. Sources of and trust in health information (n = 2090).

Item 1 Median IQR Mean SD

How do you generally engage with health information?
Conversations with friends or acquaintances 2 1 2.35 0.81
Discussions with specialists, e.g., doctors or nursing staff 2 1 2.40 0.89
Targeted internet searches for health information 2 1 2.50 1.01
Television or radio programmes on health topics 3 1 2.65 0.91
Articles in newspapers or magazines 3 1 2.69 0.90
Incidental exposure to health information online
3 2 2.80 0.93
(e.g., while browsing)
Specialist literature, e.g., health encyclopaedias or how-to books 3 2 3.10 0.94
Social networks (Facebook, Instagram, etc.) 4 1 3.28 0.93
Events or courses 4 1 3.32 0.86
In internet forums in which personal questions are asked
4 1 3.33 0.89
or answered
How much do you trust the following sources for
health information?
The specialists in the outpatient clinics or hospitals 2 1 1.70 0.68
Your family doctor 2 1 1.72 0.72
Your own feeling or experience 2 1 1.85 0.64
The pharmacists 2 0 1.95 0.65
The nurses 2 0 1.97 0.69
Information from books 2 1 2.38 0.83
The advice of friends or relatives 3 1 2.56 0.69
Health information from the Internet 3 1 2.97 0.74
1 weighted descriptive statistics of health information use and trust ratings: 1 = regularly or very, 2 = occasionally
or quite, 3 = rarely or little, and 4 = never or not at all. Abbreviations: SD, standard deviation; IQR, interquar-
tile range.

Overall, the findings confirmed a strong preference for obtaining health information
directly from healthcare professionals, as compared to online or non-professional sources,
emphasising the continued importance of trusted medical guidance in health-related
decision-making.
Additional analyses provided in the Supplementary Materials (Tables S1–S4) further
detail the sociodemographic differences in health information use and trust. These analyses
were conducted using non-weighted data. Women were more likely than men to use formal
and interpersonal sources, whereas individuals with higher education used more digital
and specialised sources. Linguistic differences were observed, with German speakers
favouring traditional media and healthcare professionals, whereas Italian speakers exhib-
ited a greater use of social media. In terms of trust, education level played a significant role,
with individuals with a lower education level demonstrating greater reliance on family
and the internet, while those with a higher education level placed more trust in books and
professional sources. Age-related differences were also identified, with older individuals
more likely to use traditional sources such as newspapers and TV, while younger indi-
Int. J. Environ. Res. Public Health 2025, 22, 570 10 of 22

viduals engaged more with digital platforms, particularly targeted internet searches and
social media.
Figures S1 and S2 illustrate the overall frequency distributions of health information
use and trust, respectively, confirming the variation in reliance on professional, social, and
digital sources.

3.3. Correlations of Health Activation, Health Literacy, and Health Status with Use of
Information Sources
Weighted Spearman’s rank correlation coefficients were computed to explore associa-
tions between PAM-10 scores, HLS-EU-Q16 scores, and self-rated health status (0–100 scale),
with the reported frequency of using health information sources (Table 3).

Table 3. Correlation between patient activation, health literacy, and the use of health informa-
tion sources.

Patient Activation Health Literacy Health Status

Information Source n (PAM-10) (HLS-EU-Q16) (0–100 Scale)
ρ p-Value ρ p-Value ρ p-Value
Newspapers/Magazines 2079 −0.145 <0.001 −0.191 <0.001 −0.127 <0.001
TV/Radio 2079 −0.083 <0.001 −0.111 <0.001 −0.094 <0.001
Friends/Acquaintances 2079 −0.157 <0.001 −0.121 <0.001 −0.134 <0.001
Healthcare Professionals 2079 −0.255 <0.001 −0.167 <0.001 −0.201 <0.001
Events/Courses 2079 −0.176 <0.001 −0.133 <0.001 −0.116 <0.001
Specialist Literature 2079 −0.143 <0.001 −0.143 <0.001 −0.099 <0.001
Incidental Exposure to
2079 −0.097 <0.001 −0.097 <0.001 −0.076 <0.001
Health Information Online
Targeted Internet Search 2079 −0.130 <0.001 −0.130 <0.001 −0.090 <0.001
Internet Forums 2079 −0.071 <0.001 −0.071 <0.001 −0.053 <0.001
Social Media 2079 −0.058 <0.001 −0.058 <0.001 −0.044 <0.001
ρ, Spearman’s rank correlation coefficient.

Results showed weak but consistent negative correlations between these scores and
most health information sources. For example, PAM-10 scores correlated negatively with
the use of healthcare professionals as information sources (ρ = −0.255, p < 0.001), indicating
that respondents with higher activation levels reported a less frequent use of professional
consultations for health information. HLS-EU-Q16 scores showed a similar negative
correlation with the use of newspapers or magazines (ρ = −0.191, p < 0.001) and with
social media (ρ = –0.172, p < 0.001).
Self-reported health status also showed negative correlations with the use of health
information sources, though these were generally weaker. For instance, the correlation
between health status and internet forums was ρ = −0.118 (p < 0.001), and with professional
healthcare providers, ρ = −0.093 (p < 0.001).
Among all the sources, the strongest negative correlation for health status was ob-
served with healthcare professionals, indicating that healthier individuals are less likely to
report obtaining health information from doctors or nurses. Similar trends were found for
friends and acquaintances and newspapers/magazines, suggesting a lower engagement
with interpersonal and traditional media sources among those with better self-reported
health. The weakest correlations were found for social media and internet forums.

3.4. Predictors of the Use of Health Information Sources

Ordinal regression models examined the association between demographic and health-
related factors and the frequency of use of different health information sources. Across all
models, AIC and BIC values indicated a reasonable model fit, with AIC values generally
Int. J. Environ. Res. Public Health 2025, 22, 570 11 of 22

ranging between approximately 3600 and 4000 and BIC values ranging between 3700 and
4200. The deviance goodness-of-fit tests consistently returned p-values of 1.000, indicating
no significant lack of fit, while Pearson goodness-of-fit tests demonstrated a better fit in
some models compared to others, particularly online-related sources, where overdispersion
was more apparent. Given the comparability of model performance and the importance of
assessing the roles of all predefined predictors, the full models are presented in Table 4 to
allow for a comprehensive evaluation of the demographic and health-related influences on
health information use.
The results indicated that age, education, and health literacy were consistent predictors
across multiple sources. Older individuals were more likely to rely on traditional media,
such as newspapers and healthcare professionals, while younger individuals demonstrated
a strong preference for online sources, including targeted internet searches, social media,
and online forums. Education was positively associated with health information use across
all sources, with higher education levels predicting greater engagement with the specialist
literature, books, and online health searches. Gender differences were observed, with
men being less likely to use newspapers and more likely to engage in social media and
online forums. Language effects showed higher social media use among Italian speakers
than German speakers, while the geographic region played a role in TV and radio use,
which was more common in urban populations but had no significant effect on most other
information sources.
Higher HLS-EU-Q16 scores were positively associated with the frequency of using
various health information sources. The strongest correlations were observed with targeted
internet searches (ρ = 0.225, p < 0.001), specialist literature (ρ = 0.203, p < 0.001), and
healthcare professionals (ρ = 0.196, p < 0.001). Health status was negatively associated with
the use of health information sources. For example, individuals reporting better health were
less likely to use online forums (ρ = −0.118, p < 0.001), healthcare professionals (ρ = −0.093,
p < 0.001), and newspapers or magazines (ρ = −0.084, p < 0.001).
Int. J. Environ. Res. Public Health 2025, 22, 570 12 of 22

Table 4. Generalised linear regression model output for predictors of the use of health information sources.

Regression Coefficient β, Odds Ratio [95% Confidence Interval], p-Value 1

Information Source
Intercept HLS-EU-Q16 PAM-10 Health Status Age Gender 2 Education 3 Language 4 Rural/Urban 5
Mass Media
−8.012 0.205 0.016 0.003 0.057 −1.037 1.000 6 −0.140 0.431
Newspapers/Magazines [−9.920; −6.104] [0.125; 0.284] [0.000; 0.033] [−0.010; 0.016] [0.042; 0.072] [−1.513; −0.561] [0.612; 1.387] [−0.515; 0.235] [−0.217; 1.043]
<0.001 <0.001 n.s. n.s. <0.001 <0.001 <0.001 n.s. n.s.
−5.924 0.105 0.013 0.003 0.050 −0.970 −0.316 6 −0.089 0.818
TV/Radio [−7.706; −4.142] [0.036; 0.174] [−0.004; 0.029] [−0.010; 0.015] [0.036; 0.064] [−1.407; −0.533] [−0.676; 0.045] [−0.476; 0.279] [0.181; 1.455]
<0.001 0.003 n.s. n.s. <0.001 <0.001 n.s. n.s. 0.012
Personal Contacts
1.115 0.109 0.008 0.016 7 −0.037 −1.215 0.274 8 0.199 −0.029
Friends/Acquaintances [−0.707; 2.937] [0.036; 0.182] [−0.011; 0.027] [0.004; 0.028] [−0.052; −0.022] [−1.700; −0.730] [−0.260; 0.808] [−0.343; 0.741] [−0.694; 0.636]
n.s. 0.004 n.s. 0.007 <0.001 <0.001 n.s. n.s. n.s.
−3.132 0.134 0.036 −0.023 0.011 −0.034 1.449 6 0.126 0.422
Healthcare Professionals [−4.714; −1.550] [0.070; 0.197] [0.019; 0.053] [−0.034; −0.011] [−0.001; 0.024] [−0.437; 0.368] [0.870;2.028] [−0.347; 0.598] [−0.139; 0.984]
<0.001 <0.001 <0.001 <0.001 n.s. n.s. <0.001 n.s. n.s.
Educational and Academic
Sources
−4.567 0.073 0.044 −0.007 −0.026 −0.805 1.449 6 0.046 0.063
Events/Courses [−6.694; −2.439] [−0.025; 0.171] [0.025; 0.063] [−0.023; 0.009] [−0.044; −0.008] [−1.376; −0.234] [0.870; 2.028] [−0.327; 0.418] [−0.669; 0.796]
<0.001 n.s. <0.001 n.s. 0.005 0.006 <0.001 n.s. n.s.
−5.971 0.061 0.044 −0.007 0.017 −0.774 1.051 6 −0.579 0.237
Specialist Literature [−7.712; −4.229] [−0.012; 0.134] [0.029; 0.060] [−0.020; 0.006] [0.003; 0.031] [−1.220; −0.328] [0.693; 1.410] [0.936; 0.221] [−0.374; 0.848]
<0.001 n.s. <0.001 n.s. 0.015 <0.001 <0.001 <0.001 n.s.
Online Sources
Incidental Exposure to 0.049 0.111 0.005 0.000 −0.060 −0.239 0.442 6 0.380 0.002
[−1.645; 1.744] [0.038; 0.184] [−0.012; 0.022] [−0.013; 0.012] [−0.074; -0.046] [−0.678; 0.199] [0.071; 0.813] [0.022; 0.738] [−0.603; 0.607]
Health Information Online n.s. 0.003 n.s. n.s. <0.001 n.s. 0.037 n.s.
0.020
1.550 0.083 0.009 0.002 −0.070 −0.265 1.479 6 0.386 0.211
Targeted internet Search [0.033; 3.066] [0.026; 0.141] [−0.006; 0.024] [−0.008; 0.013] [−0.082; −0.057] [−0.628; 0.098] [0.902; 2.055] [−0.031; 0.802] [−0.335; 0.757]
0.045 0.005 n.s. n.s. <0.001 n.s. <0.001 n.s. n.s.
−2.071 0.084 0.000 −0.003 −0.032 −0.535 0.579 6 0.300 0.124
Internet Forums [−4.182; 0.040] [−0.006; 0.173] [−0.020; 0.021] [−0.020; 0.014] [−0.049; −0.015] [−1.079; 0.008] [−0.088;1.246] [−0.056; 0.656] [−0.610; 0.857]
n.s. n.s. n.s. n.s. <0.001 n.s. n.s. n.s. n.s.
−0.095 0.105 0.002 0.000 −0.067 −0.796 −0.355 6 0.640 9 −0.008
Social Media [−1.907; 1.718] [0.024; 0.186] [−0.016; 0.020] [−0.015; 0.013] [−0.083; −0.052] [−1.279; −0.312] [−0.950; 0.241] [0.288; 0.992] [−0.667; 0.651]
n.s. 0.011 n.s. n.s. <0.001 0.001 n.s. <0.001 n.s.
1 unless otherwise indicated, regression coefficients represent the effect of the predictor on the cumulative log-odds of reporting a more frequent use of information sources (e.g.,

‘Seldom’, ‘Sometimes’, or ‘Regularly’) compared to all lower categories (e.g., ‘Never’). The proportional odds model assumes that this relationship holds across all thresholds of the
ordinal outcome. 2 reference category: female. 3 education level: primary (middle school), secondary (high school), or tertiary (university). 4 reference category: German. Coefficients for
‘Italian’ and ‘Other’ represent comparisons to German speakers. Language was treated as a nominal variable with three categories (German, Italian, and Other). 5 reference category:
rural. 6 effect of a tertiary education level on the log-odds of reporting “Sometimes” or “Often” rather than “Rarely” or “Never”, compared to the primary education level. 7 effect of
better self-rated health on the log-odds of reporting “Sometimes” or “Often” rather than “Rarely” or “Never”, compared to individuals with lower self-rated health. 8 effect of secondary
education level on the log-odds of reporting “Sometimes” or “Often” rather than “Rarely” or “Never”, compared to the primary education level. 9 effect of speaking Italian on the
log-odds of reporting ‘Sometimes’ or ‘Often’ rather than ‘Rarely’ or ‘Never’, compared to the reference category of German.
Int. J. Environ. Res. Public Health 2025, 22, 570 13 of 22

3.5. Predictors of Trust in Sources of Health Information

Ordinal regression models examined the association between demographic and health-
related factors and the level of trust in different health information sources. Across all
models, AIC values ranged between approximately 2900 and 3700, whereas BIC values var-
ied between 3000 and 3800, indicating a reasonable model fit. The deviance goodness-of-fit
tests consistently returned p-values of 1.000, suggesting no significant lack of fit, whereas
Pearson goodness-of-fit tests demonstrated superior fit in some models compared to others,
particularly for trust in online sources, where overdispersion was more pronounced. Given
the comparability of model performance and the theoretical significance of geographic
and linguistic factors in South Tyrol, full models are presented to provide a comprehen-
sive evaluation of demographic and health-related influences on trust in different health
information sources.
Ordinal regression models identified key demographic and health-related variables
influencing trust in various health information sources (Table 5). Health literacy (HLS-EU-
Q16) was consistently associated with higher trust in traditional medical sources, such as
family doctors, hospital specialists, and pharmacists, as well as in books and the literature.
Patient activation (PAM-10) showed heterogeneous associations with trust in information
sources. Higher PAM-10 scores were associated with a greater trust in nurses (OR = 1.23,
95% CI: 1.09–1.38, p = 0.001) and in personal experience (OR = 1.31, 95% CI: 1.17–1.46,
p < 0.001), while no significant associations were observed for other sources such as the
Internet, pharmacists, or books. Self-rated health was positively associated with trust in
family doctors and books, suggesting that individuals with a higher self-reported health
status tend to place greater confidence in these sources.
Age was positively associated with trust in traditional medical professionals, such as
family doctors (OR = 1.34, 95% CI: 1.19–1.51, p < 0.001), and negatively associated with
trust in Internet-based sources (OR = 0.82, 95% CI: 0.73–0.92, p = 0.001). Gender differences
were limited, except for books and the literature, where males reported lower trust than
females (OR = 0.87, 95% CI: 0.76–0.99, p = 0.035).
Educational attainment showed source-specific associations. Individuals with sec-
ondary education (compared to lower education) reported a higher trust in advice from
family and friends (OR = 1.21, 95% CI: 1.02–1.44, p = 0.029), while tertiary education was
associated with a greater trust in books and the literature (OR = 1.41, 95% CI: 1.20–1.66,
p < 0.001).
Language group differences were particularly evident regarding trust in interpersonal
sources: Italian speakers reported lower trust in friends and relatives compared to German
speakers (OR = 0.75, 95% CI: 0.63–0.89, p = 0.001). No significant associations were found
for geographic region (rural vs. urban).
Int. J. Environ. Res. Public Health 2025, 22, 570 14 of 22

Table 5. Generalised linear regression model outputs for predictors of trust in sources of health information.

Regression Coefficient β, Odds Ratio [95% Confidence Interval], p-Value 1

Information Source
Intercept HLS-EU-Q16 PAM-10 Health Status Age Gender 2 Education 3 Language 4 Rural/Urban 5
Healthcare Professionals
−3.628 0.284 −0.005 0.033 0.034 −0.272 0.745 6 −0.233 0.228
Family Doctor [−6.458; −0.798] [0.174; 0.393] [−0.039; 0.029] [0.016; 0.050] [0.009; 0.059] [−1.095; 0.551] [−0.465;1.954] [−1.326; 0.860] [−0.913; 1.369]
0.012 <0.001 n.s. <0.001 0.007 n.s. n.s. n.s. n.s.
−2.651 0.144 0.033 0.013 0.031 −0.144 1.181 6 0.352 −0.279
Hospital Specialists [−5.888; 0.585] [0.023; 0.265] [−0.008; 0.074] [−0.008; 0.034] [0.004; 0.058] [−1.016; 0.728] [−0.130;2.492] [−1.039; 1.744] [−1.648; 1.089]
n.s. 0.019 n.s. n.s. 0.023 n.s. n.s. n.s. n.s.
0.584 0.193 0.007 0.005 −0.016 −0.886 1.181 6 0.773 0.581
Pharmacists [−2.914; 4.083] [0.065; 0.322] [−0.033; 0.047] [−0.018; 0.028] [−0.045; 0.014] [−1.537; 0.032] [−0.130; 2.492] [−0.618; 2.164] [−0.691; 1.852]
n.s. 0.003 n.s. n.s. n.s. n.s. n.s. n.s. n.s.
0.922 0.055 0.040 0.000 −0.020 −0.298 0.911 6 0.969 −0.527
Nurses [−1.942; 3.785] [−0.052; 0.161] [0.007; 0.073] [−0.020; 0.019] [−0.042; 0.003] [−0.993; 0.398] [−0.185; 2.008] [−0.197; 2.136] [−1.699; 0.645]
n.s. n.s. 0.017 n.s. n.s. n.s. n.s. n.s. n.s.
Personal and Social Trust
−2.698 0.116 0.052 0.026 0.009 −1.214 0.721 6 −0.188 0.293
Personal Experience [−5.924; 0.528] [0.013; 0.244] [0.009; 0.095] [0.007; 0.046] [−0.019; 0.038] [−2.217; −0.210] [−0.618; 2.059] [−1.519; 1.143] [−0.965; 1.552]
n.s. n.s. 0.017 0.008 n.s. 0.018 n.s. n.s. n.s.
−0.394 0.116 7 0.018 0.000 −0.019 0.031 1.032 6 −1.125 −0.323
Family and Friends [−3.018; 2.231] [0.051; 0.181] [−0.008; 0.044] [−0.019; 0.018] [−0.040; 0.002] [−0.622; 0.684] [0.367;1.698] [−1.663; −0.586] [−1.349; 0.704]
n.s. <0.001 n.s. n.s. n.s. n.s. 0.002 <0.001 n.s.
Educational and Media Sources
−2.318 0.108 0.022 0.017 −0.032 −0.504 1.522 0.095 0.228
Books and Literature [−4.120; −0.517] [0.038; 0.177] [0.003; 0.041] [0.004; 0.030] [−0.046; −0.018] [−0.951; −0.057] [0.833; 2.211] [−0.395; 0.505] [−0.418; 0.874]
0.012 0.002 0.021 0.010 <0.001 0.027 <0.001 8 n.s. n.s.
−2.514 0.136 0.000 0.008 −0.038 −0.010 0.593 5 −0.313 −0.038
Internet Information [−5.817; 0.790] [0.000; 0.271] [−0.020; 0.006] [−0.007; 0.011] [−0.063; −0.013] [−0.787; 0.766] [0.241; 0.945] [−1.428; 0.803] [−1.204: 1.127]
n.s. 0.049 n.s. n.s. 0.003 n.s. <0.001 n.s. n.s.
1 unless otherwise indicated, regression coefficients represent the effect of the predictor on the cumulative log-odds of reporting a more frequent use of information sources (e.g.,

‘Seldom’, ‘Sometimes’, or ‘Regularly’) compared to all lower categories (e.g., ‘Never’). The proportional odds model assumes that this relationship holds across all thresholds of the
ordinal outcome. 2 reference category: female. 3 education level: primary (middle school), secondary (high school), or tertiary (university). 4 reference category: German. Coefficients for
‘Italian’ and ‘Other’ represent comparisons to German speakers. Language was treated as a nominal variable with three categories (German, Italian, and Other). 5 reference category:
rural. 6 effect of a secondary education level on the log-odds of reporting ‘Sometimes’ or ‘Often’ rather than ‘Rarely’ or ‘Never’, compared to the primary education level. 7 effect of
higher health literacy on the log-odds of reporting ‘Sometimes’ or ‘Often’ rather than ’Rarely’ or ‘Never’, compared to individuals with lower health literacy. 8 effect of a university
degree (tertiary level) on the log-odds of reporting ‘Sometimes’ or ‘Often’ rather than ‘Rarely’ or ‘Never’, compared to the primary education level.
Int. J. Environ. Res. Public Health 2025, 22, 570 15 of 22

4. Discussion
This study elucidates the essential roles of health literacy, education, and health-related
factors in influencing both health information use and trust in health information sources.
While healthcare professionals remained the most trusted sources, engagement with digital
health information varied across population groups, with younger individuals and those
with higher education demonstrating a greater reliance on digital sources. Health literacy
emerged as an important factor associated with trust and the use of structured health
information sources, such as the specialist literature and healthcare professionals. Lower
educational levels were linked to a greater reliance on interpersonal sources, such as family
and friends. Self-rated health status was positively associated with trust in structured and
expert-based sources, including books and healthcare professionals. Patient activation
showed positive associations with trust in healthcare professionals and educational sources;
however, its relationship with digital information use was limited, suggesting that higher
activation may support engagement with formal healthcare contexts, but not necessarily
with online information. Linguistic and geographic effects were present but modest: Italian
speakers were more likely to use social media than German speakers, and individuals
living in urban areas reported a higher use of television and radio for health information.
These findings reinforce the importance of improving health literacy, addressing disparities
in information trust, and ensuring equitable access to reliable health information across
different population groups.

4.1. The Role of Health Literacy and Patient Activation

This study reinforces the distinction between health literacy (HLS-EU-Q16) and patient
activation (PAM-10) in shaping health information use and trust in health information
sources. Health literacy primarily influences an individual’s ability to access, evaluate,
and engage with structured health information, whereas patient activation is linked to
motivation, confidence, and self-management behaviours in health contexts.
These findings align with Hibbard’s [30] framework, which conceptualises health
literacy as a cognitive skill set for processing health information, whereas patient activation
extends to confidence in managing one’s health and interacting with healthcare providers.
Higher health literacy (HLS-EU-Q16) was consistently associated with greater use and
trust in structured and professional sources, including books, the specialist literature, and
healthcare professionals. These observations are in line with prior research highlighting the
role of health literacy in navigating and evaluating evidence-based health information [31].
Patient activation (PAM-10), by contrast, showed a more selective pattern of associa-
tions. Higher activation scores were significantly associated with greater trust in nurses
(OR = 1.23, p = 0.001) and personal experience (OR = 1.31, p < 0.001), but not with most
other sources, including digital media. This suggests that while patient activation reflects
confidence and engagement in managing one’s own health, it does not necessarily corre-
spond to broader use or trust in publicly available health information sources outside of
the formal healthcare context.
These distinctions reinforce the need to consider health literacy and patient activation
as related but distinct dimensions when analysing health information behaviours.
The findings also highlight the importance of cultural and linguistic factors. Native
language influenced health information use, particularly in online settings, with Italian
speakers being more likely to trust social media than German speakers. The integration of
linguistic and regional differences emphasises the need to consider sociocultural contexts
when assessing the relationship between health literacy, activation, and trust in health
information sources.
Int. J. Environ. Res. Public Health 2025, 22, 570 16 of 22

4.2. Age and Education

Age was a significant determinant of health information use. Older individuals demon-
strated a greater propensity to rely on traditional media and healthcare professionals,
consistent with previous studies indicating that older adults prefer familiar, authoritative
sources over digital ones for health information [32–34]. This is partly due to heightened
concerns about health risks [35]. Conversely, younger individuals reported higher engage-
ment with social media and targeted internet searches, highlighting a generational shift
towards digital health information use [36]. A 2014 investigation conducted in South Tyrol
identified an ‘interpersonal’ health information-seeking group, characterised by a prefer-
ence for information obtained through direct communication with friends and healthcare
professionals [15]. This finding aligns with our study, where older adults reported the more
frequent use of traditional media and professional sources, while younger individuals more
often engaged with targeted internet searches and social media.
Education significantly influences both health information use and trust patterns [12,37].
Higher education was associated with greater engagement with the specialist literature
and structured health resources, whereas lower education was linked to a greater reliance
on family and informal sources. This supports the findings of Sørensen et al. [21], who
indicate that education enhances health information use and fosters trust in evidence-based
sources. Ausserhofer et al. [15] found that individuals with lower education were more
likely to rely on interpersonal sources, whereas those with higher education engaged more
frequently with digital and structured health sources. This is consistent with the present
findings, showing that higher education levels were associated with a greater reliance on
books, the professional literature, and healthcare professionals, whereas lower education
was linked to an increased dependence on family and informal networks.

4.3. Trust in Health Information Sources

Consistent with previous research [12,38], healthcare professionals—particularly gen-
eral practitioners and hospital specialists—were among the most trusted health information
sources in this study. Trust in books and printed literature was moderate, while trust in
internet sources was lower on average [39,40]. It has been suggested that this pattern
reflects persistent scepticism towards the trustworthiness and accuracy of online health
information. However, not all studies have confirmed this trend, particularly in contexts
involving controversial or polarising health topics, where trust in professionals may be
challenged, and alternative sources gain salience. Although healthcare professionals re-
main among the most trusted sources in many studies, the recent literature also highlights
the increasing role of online sources in shaping health decisions, particularly in younger
populations or among those who question professional authority. Trust in online health
information is influenced by various design and content factors and does not always align
with traditional credibility hierarchies [41]. Adolescents primarily rely on the internet for
health information, often through social media and peer networks, rather than consulting
online health professionals [42]. This contrasts with adult populations, where professional
sources remain more trusted.
Notably, trust in family and personal experiences varied by education level, with
individuals possessing lower educational attainment demonstrating greater reliance on
interpersonal sources. This pattern is consistent with prior research, indicating that individ-
uals with limited health literacy are more likely to use and trust non-professional sources
such as family, friends, or social media, which may feel more accessible or relatable [12,43].
Int. J. Environ. Res. Public Health 2025, 22, 570 17 of 22

4.4. Linguistic and Regional Differences in Health Information-Seeking and Trust

Language plays a crucial role in shaping health information use beyond traditional
sociodemographic factors, such as age and education. Ausserhofer et al. [15] identified
distinct patterns of health information engagement among linguistic groups in South Tyrol,
with German speakers more likely to rely on interpersonal and professional sources, while
Italian speakers showed greater engagement with digital health sources. These findings
agree with the results of the present study, where in the sample analysed, Italian speakers
reported a higher reliance on social media for health information [44], whereas German
speakers preferred traditional media and healthcare professionals. The observed differences
may be due to cultural media consumption patterns [45,46], healthcare communication
strategies, or varying levels of trust in public institutions across linguistic groups [47,48].
The findings, when juxtaposed with those of Ausserhofer et al. [15], elucidate the
evolution of health information use in South Tyrol over time, particularly in the decade
encompassing the pre- and post-pandemic periods. While both studies identified linguistic
group differences in media preferences, the increased utilisation of digital sources, particu-
larly among Italian speakers and younger individuals, became more pronounced in the
years following the COVID-19 pandemic. This shift reflects broader trends in digital health
information use, increased accessibility to online health information, and the growing
influence of social media on shaping health perceptions. However, the sustained high level
of trust in healthcare professionals across both studies suggests that traditional medical
authorities remain the foundation of health information-seeking behaviours, even as digital
sources gain prominence.

4.5. Strengths and Limitations

This study has several strengths. This is based on a representative cross-sectional
survey conducted in South Tyrol, a region with a unique cultural and linguistic composi-
tion within an economically strong area of Central Europe. The stratified sampling design
enabled representativeness, allowing for comparisons across age groups, linguistic back-
grounds, and urban and rural populations. The inclusion of health literacy (HLS-EU-Q16),
patient activation (PAM-10) and subjective health status along with sociodemographic
variables provides a thorough analysis of the factors influencing health information use
and trust in information sources. This study builds upon previous research from more
than a decade ago, enabling the evaluation of changes over time, particularly in the post-
pandemic period.
However, this study has several limitations that must be considered. As a cross-
sectional study, causal relationships cannot be established between predictors and health
information use or trust. Self-reported data introduce potential recall bias and social
desirability effects, particularly in responses related to trust in sources and digital health
information use. While stratified sampling ensured representativeness, non-response bias
could not be fully excluded. This study relied on subjective self-assessments of health
literacy and patient activation, which, while validated, may differ from objective measures.
The survey did not differentiate between interpersonal and media-based engagement
with healthcare professionals as information sources. Thus, interpretations regarding the
role of health literacy in shaping direct versus indirect information-seeking behaviours
should be made with caution.
From a statistical perspective, collinearity between predictors has not been formally
assessed, although theoretical considerations suggest that multicollinearity is unlikely to
have a substantial impact on interpretability because of the low correlation coefficients
observed (Table 3). Although the sample size was sufficient to support ordinal regression
modelling, the number of variables and categorical predictors could contribute to model
Int. J. Environ. Res. Public Health 2025, 22, 570 18 of 22

complexity. While AIC, BIC, and goodness-of-fit tests indicated robust model performance,
potential interactions or collinearity among predictors may influence individual parameter
estimates. Future research could further explore these relationships with alternative mod-
elling approaches. Future research may benefit from variance inflation factor (VIF) analysis
or structural equation modelling approaches to further explore complex interrelationships.
While ordinal regression is an appropriate methodological choice, given the ordered nature
of dependent variables, alternative modelling approaches could be explored in future
studies to refine predictions and enhance interpretability. Although multiple tests were
performed, this study follows an exploratory approach, and findings should be interpreted
in context rather than based solely on p-values. While adjusting for multiple comparisons
(e.g., Bonferroni correction) can reduce the risk of Type I errors, it may also increase Type II
errors, potentially masking relevant associations. Therefore, significance levels should be
considered alongside effect sizes and theoretical justification rather than strictly corrected.
Notwithstanding these constraints, this study offers insightful observations on how
individuals seek health information and their confidence in various health sources across a
heterogeneous European region.

4.6. Implications for Public Health Strategies

The independent but complementary roles of health literacy and patient activation
suggest that interventions should be tailored accordingly. (1) Health literacy initiatives
should focus on enhancing individuals’ abilities to access, evaluate, and utilise evidence-
based health information, particularly in online environments where misinformation is
prevalent. (2) Patient activation strategies should emphasise confidence-building measures
to enhance patient–provider communication and engagement in formal healthcare settings.
Moreover, the findings highlight the need for future research on digital health lit-
eracy, particularly on how it intersects with activation and trust in online sources. The
further exploration of linguistic and regional disparities in health information use could
provide a better understanding of how health literacy and patient activation function across
diverse populations.
Findings from this study and Ausserhofer et al. [15] reinforce the need for demograph-
ically targeted health communication strategies, particularly in linguistically and culturally
diverse regions, such as South Tyrol.
• Linguistic differences: Health information campaigns should ensure equitable
access to accurate and reliable health information across German and Italian-
speaking populations.
• Education-based disparities: Efforts should focus on simplifying complex health
information for lower-educated populations, while providing advanced resources for
highly educated individuals.
• Age-related digital engagement: Strategies should emphasise bridging the digital
divide for older adults while ensuring that younger individuals critically evaluate
online health sources.
By integrating these insights, sociodemographic influences on health information use
and trust can be better understood, strengthening the case for tailored, linguistic, and
culturally adaptive health communication strategies in South Tyrol.

5. Conclusions
This study analyses health information use and trust in health information sources
in South Tyrol, a diverse region of Central Europe. The findings highlight the role of
health literacy, education, and demographics in shaping engagement with and trust in
health information sources. Healthcare professionals remain the most trusted, but younger
Int. J. Environ. Res. Public Health 2025, 22, 570 19 of 22

individuals and Italian speakers rely more on digital sources, whereas older individuals
and German speakers trust traditional media and interpersonal sources more.
This study emphasises the independent roles of health literacy and patient activation.
Higher health literacy is associated with engagement in structured and professional health
sources, while higher patient activation predicts greater trust in healthcare professionals.
Despite its cross-sectional design and dependence on self-reported data, this study
offers insights into evolving health information use patterns, particularly after the pan-
demic. A comparison with previous research suggests a shift towards digital sources,
but with persistent disparities in information trust across demographic groups. Public
health strategies should focus on ensuring equitable access to accurate health information,
addressing digital literacy disparities, and integrating trusted health professionals into
digital health communication.
Future research should explore the role of social media in health communication, the
long-term effects of digital health literacy interventions, and the interplay between trust,
misinformation, and engagement with health services. South Tyrol serves as a valuable
case study for understanding how sociodemographic factors shape health information
seeking and trust in broader European and global contexts.

Supplementary Materials: The following supporting information can be downloaded at: https:
//www.mdpi.com/article/10.3390/ijerph22040570/s1, File S1: Questionnaire English (translation).
Table S1: Health information source utilisation by linguistic group. Table S2: Association between
sociodemographic factors and health information sources. Table S3: Trust in health information
sources by education level Table S4: Age differences in the use and trust of health information sources.
Table S5: Association between sociodemographic factors and trust in health information sources.
Figure S1: Distribution of trust ratings for various sources of health information (n = 2090). Figure S2:
Distribution of trust ratings for various sources of health information (n = 2090).

Author Contributions: Conceptualization, C.J.W., D.A., P.R., G.P., K.E. and A.E.; methodology, D.A.,
S.L., T.G. and V.B.; formal analysis, V.B., D.A. and C.J.W.; investigation, S.L. and T.G.; data curation,
D.A. and V.B.; writing—original draft preparation, C.J.W.; writing—review and editing, D.A., P.R.,
S.L., T.G., G.P., K.E. and A.E.; supervision, A.E., K.E. and T.G. All authors have read and agreed to
the published version of the manuscript.

Funding: This study received no external funding.

Institutional Review Board Statement: Ethical approval was obtained from the institutional board
of the Institute of General Practice and Public Health, Bolzano, Italy (Prot. 20/11/2023). The survey
is included in the statistics program 2024, which was approved by a resolution of the government of
the Autonomous Province of Bolzano. The information collected as part of this study is protected by
the Italian Statistics Act (Art. 9, Legislative Decree no. 322/1989) and is subject to the provisions on
the protection of personal data (EU Regulation 679/2016 and Legislative Decree no. 196/2003 as last
amended by Legislative Decree no. 101 of 10 August 2018). This study was conducted in accordance
with the principles of the Declaration of Helsinki.

Informed Consent Statement: Participation in the study was voluntary. Before completing the
online questionnaire, the participants were asked to provide informed consent. Filling out the
paper questionnaire and sending it back by post were considered as participants’ informed consent.
Although the survey was conducted in accordance with official statistical procedures defined under
Italian law (Legislative Decree 322/1989), participants were not explicitly offered the option to
withdraw consent after completing the survey. However, participation was voluntary, and individuals
could decline participation or request removal from the sample prior to submission.

Data Availability Statement: Data are available from the corresponding author upon reason-
able request.
Int. J. Environ. Res. Public Health 2025, 22, 570 20 of 22

Acknowledgments: During the preparation of this manuscript, the authors used ChatGPT (Ope-
nAI) for drafting support and language refinement, as well as Paperpal for grammar checks and
improvements in academic writing style.

Conflicts of Interest: The authors declare no conflicts of interest.

Abbreviations
The following abbreviations are used in this manuscript:
AIC Akaike Information Criterion
ANOVA Analysis of Variance
ASTAT Istituto Provinciale di Statistica-Landesinstitut für Statistik
BIC Bayesian Information Criterion
COVID-19 Coronavirus Disease-2019
HISB Health Information-Seeking Behaviour
HLS-EU-Q16 Health Literacy Survey-European Union-16 Items
HSD Honestly Significant Difference
IQR Interquartile Range
JASP Jeffreys’ Amazing Statistics Program
OR Odds Ratio
PAM-10 Patient Activation Measure-10 Items
VIF Variance Inflation Factor
SD Standard Deviation

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