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Health literacy is an important construct in population health and healthcare requiring rigorous measurement. The Health Literacy Questionnaire (HLQ), with nine scales, measures a broad perception of health literacy. This study aimed to adapt the HLQ to the Danish setting, and to examine the factor structure, homogeneity, reliability and discriminant validity. The HLQ was adapted using forward–backward translation, consensus conference and cognitive interviews (n = 15). Psychometric properties were examined based on data collected by face-to-face interview (n = 481). Tests included difficulty level, composite scale reliability and confirmatory factor analysis (CFA). Cognitive testing revealed that only minor re-wording was required. The easiest scale to respond to positively was ‘Social support for health’, and the hardest were ‘Navigating the healthcare system’ and ‘Appraisal of health information’. CFA of the individual scales showed acceptably high loadings (range 0.49–0.93). CFA fit statistics after including correlated residuals were good for seven scales, acceptable for one. Composite reliability and Cronbach’s α were >0.8 for all but one scale. A nine-factor CFA model was fitted to items with no cross-loadings or correlated residuals allowed. Given this restricted model, the fit was satisfactory. The HLQ appears robust for its intended application of assessing health literacy in a range of settings. Further work is required to demonstrate sensitivity to measure changes.

BackgroundHealth literacy is a multidimensional concept covering a range of cognitive and social skills necessary for participation in health care. Knowledge of health literacy levels in general populations and how health literacy levels impacts on social health inequity is lacking. The primary aim of this study was to perform a population-based assessment of dimensions of health literacy related to understanding health information and to engaging with healthcare providers. Secondly, the aim was to examine associations between socio-economic characteristics with these dimensions of health literacy.MethodsA population-based survey was conducted between January and April 2013 in the Central Denmark Region. Postal invitations were sent to a random sample of 46,354 individuals >25 years of age. Two health literacy dimensions were selected from the Health Literacy Questionnaire (HLQ™): i) Understanding health information well enough to know what to do (5 items), and ii) Ability to actively engage with health care providers (5 items). Response options ranged from 1 (very difficult) to 4 (very easy). We investigated the level of perceived difficulty of each task, and the associations between the two dimensions and socio-economic characteristics.ResultsA total of 29,473 (63.6%) responded to the survey. Between 8.8%, 95% CI: 8.4-9.2 and 20.2%, 95% CI: 19.6-20.8 of the general population perceived the health literacy tasks as difficult or very difficult at the individual item level. On the scale level, the mean rating for i) understanding health information was 3.10, 95% CI: 3.09-3.10, and 3.07, 95% CI: 3.07-3.08 for ii) engagement with health care providers. Low levels of the two dimensions were associated with low income, low education level, living alone, and to non-Danish ethnicity. Associations with sex and age differed by the specific health literacy dimension.ConclusionEstimates on two key dimensions of health literacy in a general population are now available. A substantial proportion of the Danish population perceives difficulties related to understanding health information and engaging with healthcare providers. The study supports previous findings of a socio-economic gradient in health literacy. New insight is provided on the feasibility of measuring health literacy which is of importance for optimising health systems.

Nonresponse appears related to linguistic and/or educational limitations, to alienation generated by the questions' focus on disease and cultural assumptions, or mistrust regarding anonymity. Ethnic minorities seem particularly affected by such barriers. To increase survey participation, questions could be sensitized to reflect multicultural traditions, and the impact of sender and setting considered.