Development and Validation of the HLS-EU-Q Health Literacy Questionnaire

Starting from the conceptual model of health literacy,⁹ (link) a Delphi process among the HLS-EU Consortium members was conducted to generate items for assessing health literacy: the way people access, understand, appraise and apply information to make decisions regarding health care, disease prevention and health promotion. The resulting draft questionnaire was pre-tested for face validity in three focus groups (in Greece, Ireland and the Netherlands) and field-tested with 50 computer-assisted face-to-face interviews in two countries (n = 99 in Ireland and the Netherlands). Following the results of a principal component analysis and reliability analysis of the data, as well as inputs from consultations with external experts, a pre-final version of the questionnaire was achieved through a consensus-based item selection process. The pre-final version was subjected to a ‘plain language’ assessment by literacy experts to obtain the final version, which is known as HLS-EU-Q47 because it includes 47 items across 12 subdomains. For each item, respondents rated the perceived difficulty of a given task on a four-category Likert scale (i.e. very easy, easy, difficult and very difficult). This kind of operationalisation follows the tradition of subjective assessments of health literacy¹³ (link) and reflects the interactive or relational nature of health literacy by measuring the fit of personal competences with contextual or situational demands of social systems.¹⁴ (link) More details about the questionnaire’s development and the specific items of the HLS-EU-Q47 are presented in Sorensen et al.¹¹ (link)
For the purpose of the HLS-EU survey the HLS-EU-Q47 was supplemented with an additional section, which contained 39 items referring to antecedents and precedents outlined in the conceptual model.⁹ (link) They included inter alia indicators for the respondents’ health service use, health behaviour, subjective health status and socio-demographic and socio-economic situations supplemented with the Newest Vital Sign, which is a quick assessment of literacy.¹⁵ (link) Examples of items include gender, age, education (using score cards and answers were transformed to international standard classification of education (ISCED) levels, social status, financial deprivation, self-assessed health (SF-36), long term illness, visit to general practitioner, hospital admission, alcohol consumption, smoking, exercise, work experience in health sector and insurance coverage. The final version of the questionnaire for the HLS-EU survey included the 47 health literacy items and the additional 39 items and was named the HLS-EU-Q86.