Abstract
BackgroundSeveral measurement tools have been developed to measure health literacy. The tools vary in their approach and design, but few have focused on comprehensive health literacy in populations. This paper describes the design and development of the European Health Literacy Survey Questionnaire (HLS-EU-Q), an innovative, comprehensive tool to measure health literacy in populations.MethodsBased on a conceptual model and definition, the process involved item development, pre-testing, field-testing, external consultation, plain language check, and translation from English to Bulgarian, Dutch, German, Greek, Polish, and Spanish.ResultsThe development process resulted in the HLS-EU-Q, which entailed two sections, a core health literacy section and a section on determinants and outcomes associated to health literacy. The health literacy section included 47 items addressing self-reported difficulties in accessing, understanding, appraising and applying information in tasks concerning decisions making in healthcare, disease prevention, and health promotion. The second section included items related to, health behaviour, health status, health service use, community participation, socio-demographic and socio-economic factors.ConclusionsBy illuminating the detailed steps in the design and development process of the HLS-EU-Q, it is the aim to provide a deeper understanding of its purpose, its capability and its limitations for others using the tool. By stimulating a wide application it is the vision that HLS-EU-Q will be validated in more countries to enhance the understanding of health literacy in different populations.
Highlights
Several measurement tools have been developed to measure health literacy
Other tools aim at measuring a broader concept of health literacy, with a view to provide an in-depth assessment of the dimensions of health literacy, or to explore its relationships with social determinants, health behavior, health status or healthy service use such as the National Assessment of Adult Literacy survey (NAAL) [13], the Critical Health Competence Test (CHC) [14], the Swiss Health Literacy Survey [15], the Health Literacy Management Scale (HeLMS) [16] and the Health Literacy Questionnaire (HLQ) [17]
The most apparent shortcomings of most tools are that they fail to capture all relevant aspects of health literacy and only focus on one or a few dimensions of the concept; that they have a primary focus on personal attributes at the cost of population aspects; that they have an unclear relationship to current definitions and conceptual frameworks of health literacy; and that they show only weak associations with causes and outcomes of health literacy [20]
Summary
The results of each of the eight development steps are described in the following and the items included in the final questionnaire are presented in the Additional file 1. With regard to the structure, participants suggested to change the order of items from focusing on the competencies related to information processing to a focus on the domains of healthcare, disease prevention and health promotion. Another comment with regard to the structure of the questionnaire concerned its repetitiveness. Field test The qualitative analysis of field test data derived from logbooks, observations by the interviewers and general comments from both the Irish and Dutch participants pointed out that the content of the questions was well-understood and considered as appropriate, the questionnaire was seen as too lengthy, too comprehensive, too repetitive, and too expert biased in terms of language (e.g., use of the word “hypertension” instead of “blood pressure”).
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