Measuring health literacy in populations: illuminating the design and development process of the European Health Literacy Survey Questionnaire (HLS-EU-Q)

TLDR

Health literacy has been measured by various tools, yet few focus on comprehensive population‑level assessment. The study aims to detail the design and development of the HLS‑EU‑Q, clarify its purpose, capabilities, and limitations, and promote its wider validation across countries. The HLS‑EU‑Q was developed through a conceptual model, item creation, pre‑testing, field‑testing, external consultation, plain‑language review, and translation into six languages, comprising a 47‑item core health‑literacy section and a second section covering determinants and outcomes. The resulting HLS‑EU‑Q contains a core health‑literacy section and a determinants‑and‑outcomes section.

Abstract

Several 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. Based 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. The 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. By 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.