Abstract Background The Health Literacy Questionnaire (HLQ) is used to inform programs and policies in more than 80 countries. It is a key needs assessment in the Ophelia (Optimising Health Literacy and Access) process, a codesign process to build effective interventions. Ophelia is applied in the European Commission Joint Action on Cardiovascular Diseases and Diabetes initiative (25 projects/13 countries). Given growing demand, an Ophelia digital platform is being developed, and confirmation of robust HLQ psychometric evidence is needed for user confidence in the interpretation and use of HLQ scores in their contexts. This study is a review of the HLQ. Methods Developed in Australia in 2013, the HLQ measures nine health literacy domains and is translated to 40 languages. A March 2024 PRISMA systematic search (PROSPERO CRD42022361966) identified 257 articles, which were screened for evidence about internal structure and reliability. Results Across 15 countries/languages, 22 articles were included. Study samples included diverse groups, settings and contexts. Out of the 18 studies that used factor analysis, three used the Bayesian approach. All 15 classical factor analysis studies reported satisfactory fit indices in restricted 9-factor models (range CFI=0.841 to 0.995, TLI=0.826 to 0.969, RMSEA=0.048 to 0.084), except two required correlated residuals for acceptable fit indices. Factor loadings were significant except for five items across five studies (range .20 to .99). Three studies used Rasch modelling and found all domains had unidimensionality except for Domain 9 in one study. Most studies reported Cronbach’s alpha (range .57 to .95) across all domains, with only three studies reporting α<.7. Conclusions The HLQ has exceptional robust psychometric properties across cultures and languages, paving the way for users to have confidence in HLQ psychometric validity evidence on the upcoming Digital Ophelia platform to support scaling up of health literacy development. Key messages • The HLQ has robust psychometric properties across countries and languages. • The HLQ 9-domain profiles can inform intervention development for equitable health outcomes.
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