Measuring health literacy among very low literate people: a feasibility study with the HLS-EU questionnaire

Abstract

Introduction As health care is becoming more patient-centered, patients are increasingly expected to make health care decisions. Therefore, detecting people with limited health literacy (HL) is crucial. Limited HL is associated with lower levels of education. A relatively new instrument, HLS-EU-Q47, underwent a comprehensibility test, allowing inclusion of low literate people. However, its shorter form ‘HLS-EU-Q16’ did not. In this study suitability of HLS-EU-Q16 for use in a population of people with low literacy was examined. Methods Purposive sampling of adults with low (yearly) income (< €16,965.47, for one person) and limited education (maximum high school), with Dutch language proficiency. Excluding criteria were: psychiatric and/or neurodegenerative diseases or impairments. To determine suitability (length, comprehension and layout) participants were randomly distributed either HLS-EU-Q16 or a simplified version and were interviewed directly afterwards by one researcher. Qualitative and quantitative analyses were performed on respectively interviews and questionnaires. Findings Thirteen participants completed the HLS-EU-Q16 (n = 7) or the simplified version (n = 6). Questions about ‘disease prevention’ (domain) or ‘appraisal’ of information (competency) are frequently reported to be incomprehensible. Difficulties are attributed to comprehension (vocabulary, sentence structure) and decision process (abstraction, distinguishing “appraising” from “applying” information, indecisive on the appropriate response). Non-responses were highest and HL was predominantly scored ‘inadequate’ for HLS-EU-Q16 questionnaire. Conclusions HLS-EU-Q16 is a suitable instrument to determine HL in people with limited literacy. However, to facilitate the use and interpretation, some questions would benefit from minor adjustments and from the provision of explanatory, contextual information.