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BMC Public Health
Published in: BMC Public Health 1/2023

Open Access 01-12-2023 | Research

Validity and reliability of the swedish versions of the HLS-EU-Q16 and HLS-EU-Q6 questionnaires

Authors: Lina Bergman, Ulrica Nilsson, Karuna Dahlberg, Maria Jaensson, Josefin Wångdahl

Published in: BMC Public Health | Issue 1/2023

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Abstract

Background

Health Literacy is a crucial factor for health. In Europe, many people have limited health literacy (i.e. difficulties with accessing, understanding, appraising and using health information). This study aimed to evaluate the psychometrics of the Swedish versions of the HLS-EU-Q16 and HLS-EU-Q6, instruments that aims to assess health literacy.

Methods

In this prospective psychometric study convenience sampling was used, which gave a study population of 347 Swedish-speaking adults. The psychometric evaluation included item distributional statistics, construct validity testing, and principal component analysis to assess structural validity. Internal consistency and test-retest reliability was also investigated.

Results

For the Swedish version of HLS-EU-Q16, no floor effects were detected but a ceiling effect was noted among 28% of the respondents. Construct validity was supported as four out of five expected correlations was confirmed (educational level, self-perceived health, electronic health literacy and HLS-EU-Q6). In terms of structural validity, the principal component analysis yielded a four-factor structure with most items loading significantly only to one factor. The Swedish version of HLS-EU-Q16 had acceptable internal consistency (Cronbach’s α = 0.89, split-half reliability = 0.93) and test-retest reliability showed stability over time (Cohen’s κ = 0.822). For the Swedish version of HLS-EU-Q6, neither floor nor ceiling effects were observed. Construct validity was supported as HLS-EU-Q6 correlated as our a priori stated hypothesis. The principal component analysis did not support the unidimensionality of the scale as a two-factor structure was identified. The Swedish version of HLS-EU-Q6 had acceptable internal consistency (Cronbach’s α = 0.77, split-half reliability = 0.80) and test-retest reliability showed stability over time (Cohen’s κ = 0.812). According to the Swedish version of the HLS-EU-Q16, 71% of the participants were classified as having sufficient comprehensive health knowledge (CHL), while only 33% were classified as having this when the HLS-EU-Q6 was used.

Conclusions

The Swedish versions of the HLS-EU-Q16 and HLS-EU-Q6 have acceptable psychometric properties, and based on the results we recommend its use to measure CHL. However, we are hesitant to use Sw-HLS-EU-Q6 in estimating different CHL levels and further studies need to be conducted to establish validity and accuracy of the thresholds of HLS-EU-Q6.
Literature
1.
Nutbeam D, Lloyd JE. Understanding and responding to health literacy as a Social Determinant of Health. Annu Rev Public Health. 2021;42:159–73.CrossRefPubMed
2.
World Health Organization (WHO). Shanghai declaration on promoting health in the 2030 agenda for Sustainable Development. Health Promot Int. 2017;32(1):7–8.CrossRef
3.
Sørensen K, Van den Broucke S, Fullam J, Doyle G, Pelikan J, Slonska Z, et al. Health literacy and public health: a systematic review and integration of definitions and models. BMC Public Health. 2012;12(1):80.CrossRefPubMedPubMedCentral
4.
Baccolini V, Rosso A, Di Paolo C, Isonne C, Salerno C, Migliara G, et al. What is the prevalence of low health literacy in European Union Member States? A systematic review and Meta-analysis. J Gen Intern Med. 2021;36(3):753–61.CrossRefPubMedPubMedCentral
5.
Sørensen K, Pelikan JM, Röthlin F, Ganahl K, Slonska Z, Doyle G, et al. Health literacy in Europe: comparative results of the european health literacy survey (HLS-EU). Eur J Public Health. 2015;25(6):1053–8.CrossRefPubMedPubMedCentral
6.
Stormacq C, Van den Broucke S, Wosinski J. Does health literacy mediate the relationship between socioeconomic status and health disparities? Integrative review. Health Promot Int. 2019;34(5):e1–e17.CrossRefPubMed
7.
Peltzer S, Hellstern M, Genske A, Jünger S, Woopen C, Albus C. Health literacy in persons at risk of and patients with coronary heart disease: a systematic review. Soc Sci Med. 2020;245:112711.CrossRefPubMed
8.
Turhan Z, Dilcen HY, Dolu İ. The mediating role of health literacy on the relationship between health care system distrust and vaccine hesitancy during COVID-19 pandemic. Curr Psychol. 2022;41(11):8147–56.CrossRefPubMed
9.
Friis K, Pedersen MH, Aaby A, Lasgaard M, Maindal HT. Impact of low health literacy on healthcare utilization in individuals with cardiovascular disease, chronic obstructive pulmonary disease, diabetes and mental disorders. A danish population-based 4-year follow-up study. Eur J Public Health. 2020;30(5):866–72.CrossRefPubMedPubMedCentral
10.
Shah JM, Ramsbotham J, Seib C, Muir R, Bonner A. A scoping review of the role of health literacy in chronic kidney disease self-management. J Ren Care. 2021;47(4):221–33.CrossRefPubMed
11.
Visscher BB, Steunenberg B, Heijmans M, Hofstede JM, Devillé W, van der Heide I, et al. Evidence on the effectiveness of health literacy interventions in the EU: a systematic review. BMC Public Health. 2018;18(1):1–12.CrossRef
12.
Berkman ND, Sheridan SL, Donahue KE, Halpern DJ, Viera A, Crotty K et al. Health literacy interventions and outcomes: an updated systematic review.Evid Rep Technol Assess (Full Rep). 2011;(199):1–941.
13.
Liu H, Zeng H, Shen Y, Zhang F, Sharma M, Lai W, et al. Assessment tools for health literacy among the general population: a systematic review. Int J Environ Res Public Health. 2018;15(8):1711.CrossRefPubMedPubMedCentral
14.
Pelikan JM, Ganahl K, Van den Broucke S, Sørensen K. Measuring health literacy in Europe: introducing the european health literacy Survey Questionnaire (HLS-EU-Q). Bristol: Policy Press; 2019.
15.
Pelikan J, Röthlin F, Ganahl K. Introduction to HL measurement procedures of the HLS-EU study. In: 2nd European HL Conference. Aarhus; 2014.
16.
Gustafsdottir SS, Sigurdardottir AK, Arnadottir SA, Heimisson GT, Mårtensson L. Translation and cross-cultural adaptation of the European Health literacy Survey Questionnaire, HLS-EU-Q16: the icelandic version. BMC Public Health. 2020;20(1):1–11.CrossRef
17.
Bas-Sarmiento P, Poza-Méndez M, Fernández-Gutiérrez M, González-Caballero JL, Falcón Romero M. Psychometric Assessment of the European Health literacy Survey Questionnaire (HLS-EU-Q16) for Arabic/French-Speaking Migrants in Southern Europe. Int J Environ Res Public Health. 2020;17(21):8181.CrossRefPubMedPubMedCentral
18.
Lorini C, Lastrucci V, Mantwill S, Vettori V, Bonaccorsi G. Measuring health literacy in Italy: a validation study of the HLS-EU-Q16 and of the HLS-EU-Q6 in italian language, conducted in Florence and its surroundings. Ann Ist Super Sanita. 2019;55(1):10–8.PubMed
19.
Dsouza JP, Van den Broucke S, Pattanshetty S. Validity and reliability of the Indian Version of the HLS-EU-Q16 Questionnaire. Int J Environ Res Public Health. 2021;18(2):495.CrossRefPubMedPubMedCentral
20.
Maie A, Kanekuni S, Yonekura Y, Nakayama K, Sakai R. Evaluating short versions of the European Health literacy Survey Questionnaire (HLS-EU-Q47) for health checkups. Health Evaluation and Promotion. 2021;48(4):351–8.CrossRef
21.
Rouquette A, Nadot T, Labitrie P, Van den Broucke S, Mancini J, Rigal L, et al. Validity and measurement invariance across sex, age, and education level of the french short versions of the European Health literacy Survey Questionnaire. PLoS ONE. 2018;13(12):e0208091.CrossRefPubMedPubMedCentral
22.
Guillemin F, Bombardier C, Beaton D. Cross-cultural adaptation of health-related quality of life measures: literature review and proposed guidelines. J Clin Epidemiol. 1993;46(12):1417–32.CrossRefPubMed
23.
Dahlman D, Ekefäll M, Garpenhag L. Health literacy among swedish patients in opioid substitution treatment: a mixed-methods study. Drug Alcohol Depend. 2020;214:108186.CrossRefPubMed
24.
Wångdahl J, Jaensson M, Dahlberg K, Nilsson U. The Swedish Version of the Electronic Health literacy scale: prospective psychometric evaluation study including thresholds levels. JMIR mHealth and uHealth. 2020;8(2):e16316.CrossRefPubMedPubMedCentral
25.
Wångdahl J, Dahlberg K, Jaensson M, Nilsson U. Arabic Version of the Electronic Health literacy scale in arabic-speaking individuals in Sweden: prospective psychometric evaluation study. J Med Internet Res. 2021;23(3):e24466.CrossRefPubMedPubMedCentral
26.
Bergman L, Nilsson U, Dahlberg K, Jaensson M, Wångdahl J. Health literacy and e-health literacy among arabic-speaking migrants in Sweden: a cross-sectional study. BMC Public Health. 2021;21(1):2165.CrossRefPubMedPubMedCentral
27.
Wangdahl JM, Dahlberg K, Jaensson M, Nilsson U. Psychometric validation of swedish and arabic versions of two health literacy questionnaires, eHEALS and HLS-EU-Q16, for use in a swedish context: a study protocol. BMJ Open. 2019;9(9):e029668.CrossRefPubMedPubMedCentral
28.
29.
VanVoorhis CW, Morgan BL. Understanding power and rules of thumb for determining sample sizes. Tutorials in Quantitative Methods for Psychology. 2007;3(2):43–50.CrossRef
30.
Bujang MA, Baharum N. A simplified guide to determination of sample size requirements for estimating the value of intraclass correlation coefficient: A review.Archives of Orofacial Science. 2017;12(1).
31.
Pelikan JM, Ganahl K. Die europäische Gesundheitskompetenz-Studie: Konzept, Instrument und ausgewählte Ergebnisse. Health Literacy Forschungsstand und Perspektiven Bern: Hogrefe. 2017:93–126.
32.
Mokkink LB, Prinsen CA, Patrick DL, Alonso J, Bouter LM, de Vet HC et al. COSMIN Study Design checklist for Patient-reported outcome measurement instruments. Amsterdam, The Netherlands; 2019.
33.
De Vet HC, Terwee CB, Mokkink LB, Knol DL. Measurement in medicine: a practical guide. Cambridge university press; 2014.
34.
Polit DF, Yang F. Measurement and the measurement of change: a primer for the health professions. Philadelphia: Wolters Kluwer Health; 2016.
35.
Mokkink LB, Terwee CB, Patrick DL, Alonso J, Stratford PW, Knol DL, et al. The COSMIN study reached international consensus on taxonomy, terminology, and definitions of measurement properties for health-related patient-reported outcomes. J Clin Epidemiol. 2010;63(7):737–45.CrossRefPubMed
36.
37.
Karnoe A, Kayser L. How is eHealth literacy measured and what do the measurements tell us? A systematic review. Knowl Manage E-Learning: Int J. 2015;7(4):576–600.
38.
Schober P, Boer C, Schwarte LA. Correlation coefficients: appropriate use and interpretation. Anesth Analg. 2018;126(5):1763–68.CrossRefPubMed
39.
Coman MA, Forray AI, Van den Broucke S, Chereches RM. Measuring health literacy in Romania: validation of the HLS-EU-Q16 Survey Questionnaire. Int J Public Health. 2022;67:1604272.CrossRefPubMedPubMedCentral
40.
Hair JF. Multivariate data analysis: a global perspective. 7th ed. Upper Saddle River, N.J.: Pearson Education; 2010.
41.
Terwee CB, Bot SD, de Boer MR, van der Windt DA, Knol DL, Dekker J, et al. Quality criteria were proposed for measurement properties of health status questionnaires. J Clin Epidemiol. 2007;60(1):34–42.CrossRefPubMed
42.
Mialhe FL, Moraes KL, Bado FMR, Brasil VV, Sampaio HADC, Rebustini F. Psychometric properties of the adapted instrument european health literacy Survey Questionnaire short-short form. Rev Lat Am Enfermagem. 2021;29:e3436.CrossRefPubMedPubMedCentral
43.
The HLS19 Consortium of the WHO Action Network M-POHL. International Report on the methodology, results, and recommendations of the European Health literacy Population Survey 2019–2021 (HLS19) of M-POHL. Austrian National Public Health Institute, Vienna; 2021.
44.
Rouquette A, Rigal L, Mancini J, Guillemin F, Van den Broucke S, Allaire C, Azogui-Levy S, Ringa V, Hassler C. Health literacy throughout adolescence: invariance and validity study of three measurement scales in the general population. Patient Educ Couns. 2021;105(4):996–1003.CrossRefPubMed
45.
Cacciamani GE, Dell’Oglio P, Cocci A, Russo GI, Abreu ADC, Gill IS, et al. Asking “Dr. Google” for a second opinion: the Devil is in the details. Eur Urol Focus. 2021;7(2):479–81.CrossRefPubMed
46.
Storms H, Claes N, Aertgeerts B, Van den Broucke S. Measuring health literacy among low literate people: an exploratory feasibility study with the HLS-EU questionnaire. BMC Public Health. 2017;17(1):475.CrossRefPubMedPubMedCentral
47.
Bowling A. Mode of questionnaire administration can have serious effects on data quality. J Public Health (Oxf). 2005;27(3):281–91.CrossRefPubMed
48.
Cornett S. Assessing and addressing health literacy.Online J Issues Nurs2009;14(3).
Metadata
Title
Validity and reliability of the swedish versions of the HLS-EU-Q16 and HLS-EU-Q6 questionnaires
Authors
Lina Bergman
Ulrica Nilsson
Karuna Dahlberg
Maria Jaensson
Josefin Wångdahl
Publication date
01-12-2023
Publisher
BioMed Central
Published in
BMC Public Health / Issue 1/2023
Electronic ISSN: 1471-2458
DOI
https://doi.org/10.1186/s12889-023-15519-9

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