Health Literacy, Mental Health and Medication Adherence among Adult Primary Care Patients: A Comparative Study between Bulgaria and Germany
Peneva Y. B. 1, Gencheva D. 2, Genchev G. 2, Georgieva L. M. 1
 
1 Medical University – Sofia, Bulgaria
2 Medical University – Plovdiv, Bulgaria
 

Abstract

Background and Aim of Study: Cardiovascular diseases remain the leading cause of mortality worldwide. Effective management of cardiovascular risk depends not only on medical treatment but also on patients’ health literacy, psychological status and adherence to prescribed therapy. Increasing evidence suggests that psychosocial determinants play an important role in long-term cardiovascular outcomes.
The aim of the study: to compare health literacy, mental health status and medication adherence among patients from Bulgaria and Germany and to evaluate their associations.
Material and Methods: A cross-sectional survey was conducted among 862 adult patients from Bulgaria (n=186) and Germany (n=676). Data were collected using a structured questionnaire including measures of cardiovascular risk factors, health literacy, mental health (PHQ-based assessment) and medication adherence (Modified Medication Adherence Report Scale). Statistical analyses were performed using IBM SPSS Statistics 27.0 and MedCalc 23.5.5.
Results: German patients demonstrated significantly higher medication adherence scores compared to Bulgarian patients (p<0.01). Bulgarian participants showed a higher prevalence of moderate and severe psychological symptoms. A significant association was found between mental health status and medication adherence (p=0.009), with patients reporting normal psychological status demonstrating higher adherence levels. Health literacy was also significantly associated with medication adherence (p=0.034), particularly among German participants. No significant relationship was observed between health literacy and lifestyle score.
Conclusions: Health literacy and mental health are important determinants of medication adherence among adult primary care patients from Bulgaria and Germany. Integrating psychological assessment and health literacy interventions into primary care may improve cardiovascular prevention and long-term treatment outcomes. The findings also support the development of the Bulgarian-HEART Model as an integrated framework for cardiovascular risk management in primary care.

 

 
 

Keywords

ardiovascular risk, primary care, health literacy, mental health, medication adherence, Bulgaria; Germany

 
 
  

References

Berkman, N. D., Sheridan, S. L., Donahue, K. E., Halpern, D. J., & Crotty, K. (2011). Low health literacy and health outcomes: An updated systematic review. Annals of Internal Medicine, 155(2), 97–107. https://doi.org/10.7326/0003-4819-155-2-201107190-00005

Brown, M. T., & Bussell, J. K. (2011). Medication adherence: WHO cares? Mayo Clinic Proceedings, 86(4), 304–314. https://doi.org/10.4065/mcp.2010.0575

Bueno, H., Deaton, C., Farrero, M., Forsyth, F., Braunschweig, F., Buccheri, S., Dragan, S., Gevaert, S., Held, C., Kurpas, D., Ladwig, K. H., Lionis, C. D., Maas, A. H. E. M., Merșa, C. O., Mindham, R., Pedersen, S. S., Rojnic Kuzman, M., Szmit, S., Taylor, R. S., … Makhkamova, N. (2025). 2025 ESC Clinical Consensus Statement on mental health and cardiovascular disease: Developed under the auspices of the ESC Clinical Practice Guidelines Committee. European Heart Journal, 46(41), 4156–4225. https://doi.org/10.1093/eurheartj/ehaf191

Chan, A. H. Y., Horne, R., Hankins, M., & Chisari, C. (2020). The Medication Adherence Report Scale: A measurement tool for eliciting patients’ reports of nonadherence. British Journal of Clinical Pharmacology, 86(7), 1281–1288. https://doi.org/10.1111/bcp.14193

Horne, R., Weinman, J., & Hankins, M. (1999). The beliefs about medicines questionnaire: The development and evaluation of a new method for assessing the cognitive representation of medication. Psychology & Health, 14(1), 1–24. https://doi.org/10.1080/08870449908407311

Kardas, P., Bennett, B., Borah, B., Burnier, M., Daly, C., Hiligsmann, M., Menditto, E., Peterson, A. M., Slejko, J. F., Tóth, K., Unni, E., & Ágh, T. (2024). Medication non-adherence: Reflecting on two decades since WHO adherence report and setting goals for the next twenty years. Frontiers in Pharmacology, 15, Article 1444012. https://doi.org/10.3389/fphar.2024.1444012

Kroenke, K., Spitzer, R. L., & Williams, J. B. W. (2001). The PHQ-9: Validity of a brief depression severity measure. Journal of General Internal Medicine, 16(9), 606–613. https://doi.org/10.1046/j.1525-1497.2001.016009606.x

Kroenke, K., Spitzer, R. L., Williams, J. B. W., & Lowe, B. (2009). An ultra-brief screening scale for anxiety and depression: The PHQ-4. Psychosomatics, 50(6), 613–621. https://doi.org/10.1176/appi.psy.50.6.613

Levine, G. N., Cohen, B. E., Commodore-Mensah, Y., Fleury, J., Huffman, J. C., Khalid, U., Labarthe, D. R., Lavretsky, H., Michos, E. D., Spatz, E. S., Kubzansky, L. D., & On behalf of the American Heart Association Council on Clinical Cardiology; Council on Arteriosclerosis, Thrombosis and Vascular Biology; Council on Cardiovascular and Stroke Nursing; and Council on Lifestyle and Cardiometabolic Health. (2021). Psychological health, well-being, and the mind-heart-body connection: A scientific statement from the American heart association. Circulation, 143(10). https://doi.org/10.1161/CIR.0000000000000947

Lichtman, J. H., Froelicher, E. S., Blumenthal, J. A., Carney, R. M., Doering, L. V., Frasure-Smith, N., Freedland, K. E., Jaffe, A. S., Leifheit-Limson, E. C., Sheps, D. S., Vaccarino, V., & Wulsin, L. (2014). Depression as a risk factor for poor prognosis among patients with acute coronary syndrome: systematic review and recommendations: A scientific statement from the American heart association. Circulation, 129(12), 1350–1369. https://doi.org/10.1161/CIR.0000000000000019

Magnani, J. W., Mujahid, M. S., Aronow, H. D., Cené, C. W., Dickson, V. V., Havranek, E., Morgenstern, L. B., Paasche-Orlow, M. K., Pollak, A., Willey, J. Z., & On behalf of the American Heart Association Council on Epidemiology and Prevention; Council on Cardiovascular Disease in the Young; Council on Cardiovascular and Stroke Nursing; Council on Peripheral Vascular Disease; Council on Quality of Care and Outcomes Research; and Stroke Council. (2018). Health Literacy and cardiovascular disease: Fundamental relevance to primary and secondary prevention: A scientific statement from the american heart association. Circulation, 138(2). https://doi.org/10.1161/CIR.0000000000000579

OECD/European Observatory on Health Systems and Policies. (2025a). Country Health Profile 2025: Bulgaria. State of Health in the EU. OECD Publishing, Paris/ European Observatory on Health Systems and Policies, Brussels. https://www.oecd.org/content/dam/oecd/en/publications/reports/2025/12/country-health-profile-2025-country-notes_7e72146d/bulgaria_242bb908/cd5706eb-en.pdf

OECD/European Observatory on Health Systems and Policies. (2025b). Country Health Profile 2025: Germany. State of Health in the EU. OECD Publishing, Paris/ European Observatory on Health Systems and Policies, Brussels. https://www.oecd.org/content/dam/oecd/en/publications/reports/2025/12/country-health-profile-2025-country-notes_7e72146d/germany_51f2550b/a5911973-en.pdf

Roth, G. A., Mensah, G. A., Johnson, C. O., Addolorato, G., Ammirati, E., Baddour, L. M., Barengo, N. C., Beaton, A. Z., Benjamin, E. J., Benziger, C. P., Bonny, A., Brauer, M., Brodmann, M., Cahill, T. J., Carapetis, J., Catapano, A. L., Chugh, S. S., Cooper, L. T., Coresh, J., … Fuster, V. (2020). Global burden of cardiovascular diseases and risk factors, 1990–2019. Journal of the American College of Cardiology, 76(25), 2982–3021. https://doi.org/10.1016/j.jacc.2020.11.010

SCORE2 working group and ESC Cardiovascular risk collaboration, Hageman, S., Pennells, L., Ojeda, F., Kaptoge, S., Kuulasmaa, K., De Vries, T., Xu, Z., Kee, F., Chung, R., Wood, A., McEvoy, J. W., Veronesi, G., Bolton, T., Achenbach, S., Aleksandrova, K., Amiano, P., Sebastian, D.-S., Amouyel, P., … Di Angelantonio, E. (2021). SCORE2 risk prediction algorithms: New models to estimate 10-year risk of cardiovascular disease in Europe. European Heart Journal, 42(25), 2439–2454. https://doi.org/10.1093/eurheartj/ehab309

Sorensen, K., Van Den Broucke, S., Fullam, J., Doyle, G., Pelikan, J., Slonska, Z., Brand, H., & (HLS-EU) Consortium Health Literacy Project European. (2012). Health literacy and public health: A systematic review and integration of definitions and models. BMC Public Health, 12(1), Article 80. https://doi.org/10.1186/1471-2458-12-80

Visseren, F. L. J., Mach, F., Smulders, Y. M., Carballo, D., Koskinas, K. C., Bäck, M., Benetos, A., Biffi, A., Boavida, J.-M., Capodanno, D., Cosyns, B., Crawford, C., Davos, C. H., Desormais, I., Di Angelantonio, E., Franco, O. H., Halvorsen, S., Hobbs, F. D. R., Hollander, M., … Williams, B. (2021). 2021 ESC Guidelines on cardiovascular disease prevention in clinical practice. European Heart Journal, 42(34), 3227–3337. https://doi.org/10.1093/eurheartj/ehab484

WHO. (2025, July 31). Cardiovascular diseases (CVDs). World Health Organization. https://www.who.int/news-room/fact-sheets/detail/cardiovascular-diseases-(cvds)

Whooley, M. A. (2006). Depression and Cardiovascular Disease: Healing the Broken-Hearted. JAMA, 295(24), Article 2874. https://doi.org/10.1001/jama.295.24.2874

World Health Organization. (2020). HEARTS technical package for cardiovascular disease management in primary health care: Risk based CVD MANAGEMENT (1st ed.). https://www.who.int/publications/i/item/9789240001367

World Health Organization and the United Nations Children’s Fund (UNICEF). (2018). A vision for primary health care in the 21st century: Towards universal health coverage and the sustainable development goals. https://iris.who.int/handle/10665/328065

 

 
 
Crossmark
  
 
 
https://doi.org/10.26697/ijsa.2026.1.7
  
 
 
Full Text
  
 

 

License
  
 

 

Information about the authors:

Peneva Yoanna Boyanova (Corresponding Author)https://orcid.org/0009-0004-8758-1086; This email address is being protected from spambots. You need JavaScript enabled to view it.; MD, MHBA, PhD Student in Public Health, Faculty of Public Health, Medical University – Sofia, Sofia, Bulgaria.

Gencheva Dolinahttps://orcid.org/0000-0001-7664-4329; MD, PhD, First Department of Internal Diseases, section of Cardiology, Medical University of Plovdiv, Plovdiv, Bulgaria.

Genchev Genchohttps://orcid.org/0000-0003-0561-029X; Eng., PhD, Professor of Biostatistics and Medical Informatics, Medical University – Sofia, Sofia, Bulgaria.

Georgieva Lidia Mladenovahttps://orcid.org/0000-0002-9320-9203; Doctor of Medical Sciences, MD, Full Professor, Professor of Social Medicine, Healthcare Organization and Management, Faculty of Public Health, Medical University – Sofia, Sofia, Bulgaria.

 

 
 
Cite this article as:

APA


Peneva, Y. B., Gencheva, D., Genchev, G., & Georgieva, L. M. (2026). Health literacy, mental health and medication adherence among adult primary care patients: A comparative study between Bulgaria and Germany. International Journal of Science Annals, 9(1), 01–08. https://doi.org/10.26697/ijsa.2026.1.7  

Harvard


Peneva, Y. B., Gencheva, D., Genchev, G., & Georgieva, L. M. "Health literacy, mental health and medication adherence among adult primary care patients: A comparative study between Bulgaria and Germany". International Journal of Science Annals, [online] 9(1), pp. 01–08. viewed 30 June 2026, https://culturehealth.org/ijsa_archive/ijsa.2026.1.7.pdf

Vancouver


Peneva, Y. B., Gencheva, D., Genchev, G., & Georgieva, L. M. Health literacy, mental health and medication adherence among adult primary care patients: A comparative study between Bulgaria and Germany. International Journal of Science Annals [Internet]. 2026 [cited 30 June 2026]; 9(1): 01–08. Available from: https://culturehealth.org/ijsa_archive/ijsa.2026.1.7.pdf https://doi.org/10.26697/ijsa.2026.1.7

  © 2018 – 2026 International Journal of Science Annals
DOI: https://doi.org/10.26697/ijsa