BackgroundRecent advances in the measurement of health literacy allow description of a broad range of personal and social dimensions of the concept. Identifying differences in patterns of health literacy between population sub-groups will increase understanding of how health literacy contributes to health inequities and inform intervention development. The aim of this study was to use a multi-dimensional measurement tool to describe the health literacy of adults in urban and rural Victoria, Australia.MethodsData were collected from clients (n = 813) of 8 health and community care organisations, using the Health Literacy Questionnaire (HLQ). Demographic and health service data were also collected. Data were analysed using descriptive statistics. Effect sizes (ES) for standardised differences in means were used to describe the magnitude of difference between demographic sub-groups.ResultsMean age of respondents was 72.1 (range 19–99) years. Females comprised 63 % of the sample, 48 % had not completed secondary education, and 96 % reported at least one existing health condition. Small to large ES were seen for mean differences in HLQ scales between most demographic groups. Compared with participants who spoke English at home, those not speaking English at home had much lower scores for most HLQ scales including the scales ‘Understanding health information well enough to know what to do’ (ES −1.09 [95 % confidence interval (CI) -1.33 to −0.84]), ‘Ability to actively engage with healthcare providers’ (ES −1.00 [95 % CI −1.24, −0.75]), and ‘Navigating the healthcare system’ (ES −0.72 [95 % CI −0.97, −0.48]). Similar patterns and ES were seen for participants born overseas compared with those born in Australia. Smaller ES were seen for sex, age group, private health insurance status, number of chronic conditions, and living alone.ConclusionsThis study has revealed some large health literacy differences across nine domains of health literacy in adults using health services in Victoria. These findings provide insights into the relationship between health literacy and socioeconomic position in vulnerable groups and, given the focus of the HLQ, provide guidance for the development of equitable interventions.

BackgroundThe need for healthcare strengthening to enhance equity is critical, requiring systematic approaches that focus on those experiencing lesser access and outcomes. This project developed and tested the Ophelia (OPtimising HEalth LIteracy and Access) approach for co-design of interventions to improve health literacy and equity of access. Eight principles guided this development: Outcomes focused; Equity driven, Needs diagnosis, Co-design, Driven by local wisdom, Sustainable, Responsive and Systematically applied. We report the application of the Ophelia process where proof-of-concept was defined as successful application of the principles.MethodsNine sites were briefed on the aims of the project around health literacy, co-design and quality improvement. The sites were rural/metropolitan, small/large hospitals, community health centres or municipalities. Each site identified their own priorities for improvement; collected health literacy data using the Health Literacy Questionnaire (HLQ) within the identified priority groups; engaged staff in co-design workshops to generate ideas for improvement; developed program-logic models; and implemented their projects using Plan-Do-Study-Act (PDSA) cycles. Evaluation included assessment of impacts on organisations, practitioners and service users, and whether the principles were applied.ResultsSites undertook co-design workshops involving discussion of service user needs informed by HLQ (n = 813) and interview data. Sites generated between 21 and 78 intervention ideas and then planned their selected interventions through program-logic models. Sites successfully implemented interventions and refined them progressively with PDSA cycles. Interventions generally involved one of four pathways: development of clinician skills and resources for health literacy, engagement of community volunteers to disseminate health promotion messages, direct impact on consumers’ health literacy, and redesign of existing services. Evidence of application of the principles was found in all sites.ConclusionsThe Ophelia approach guided identification of health literacy issues at each participating site and the development and implementation of locally appropriate solutions. The eight principles provided a framework that allowed flexible application of the Ophelia approach and generation of a diverse set of interventions. Changes were observed at organisational, staff, and community member levels. The Ophelia approach can be used to generate health service improvements that enhance health outcomes and address inequity of access to healthcare.Electronic supplementary materialThe online version of this article (doi:10.1186/s12889-017-4147-5) contains supplementary material, which is available to authorized users.

The Health Literacy Questionnaire (HLQ), developed in Australia in 2012 using a ‘validity-driven’ approach, has been rapidly adopted and is being applied in many countries and languages. It is a multidimensional measure comprising nine distinct domains that may be used for surveys, needs assessment, evaluation and outcomes assessment as well as for informing service improvement and the development of interventions. The aim of this paper is to describe the German translation of the HLQ and to present the results of the validation of the culturally adapted version. The HLQ comprises 44 items, which were translated and culturally adapted to the German context. This study uses data collected from a sample of 1,058 persons with chronic conditions. Statistical analyses include descriptive and confirmatory factor analyses. In one-factor congeneric models, all scales demonstrated good fit after few model adjustments. In a single, highly restrictive nine-factor model (no cross-loadings, no correlated errors) replication of the original English-language version was achieved with fit indices and psychometric properties similar to the original HLQ. Reliability for all scales was excellent, with a Cronbach’s Alpha of at least 0.77. High to very high correlations between some HLQ factors were observed, suggesting that higher order factors may be present. Our rigorous development and validation protocol, as well as strict adaptation processes, have generated a remarkable reproduction of the HLQ in German. The results of this validation provide evidence that the HLQ is robust and can be recommended for use in German-speaking populations.Trial Registration: German Clinical Trial Registration (DRKS): DRKS00000584. Registered 23 March 2011.

The nine HLQ scales are robust, providing a fine-grained assessment of health literacy. The revised response options improve psychometric properties and are recommended for future studies.

Objectives:Health literacy refers to the ability of individuals to gain access to, use, and understand health information and services in order to maintain a good health. The assessment of health literacy profiles in a population is potentially crucial to respond to health needs. The Health Literacy Questionnaire explores nine dimensions of health literacy and has been shown to display robust psychometric properties. The aim was to test the validity of the multidimensional Health Literacy Questionnaire and to describe the health literacy profiles in a French population at risk of cardiovascular disease.Methods:Data were collected using self-administered questionnaires from 175 participants attending health education and support programmes in local associations of patients in Paris. Analysis included scale reliability, confirmatory factor analysis, and health literacy profiles via descriptive statistics.Results:In confirmatory factor analysis, the nine-factor structure was close to the original Health Literacy Questionnaire. A nine-factor confirmatory factor analysis model was fitted to the 44 items with no cross-loadings or correlated residuals allowed. Given the restricted nature of the model, the fit was satisfactory: χ2WLSMV(866 df) = 1383.81, p = 0.0000, comparative fit index = 0.925, Tucker–Lewis index = 0.918, root mean square error of approximation = 0.058, weighted root mean square residual = 1.175. Composite reliability ranged from 0.77 to 0.91. Among the 9 scales of the Health Literacy Questionnaire, the highest scores were found for scale 1 ‘Feeling understood and supported by healthcare professionals’ and scale 9 ‘Understand health information enough to know what to do’ and the lowest for scale 2 ‘Having sufficient information to manage my health’ and scale 7 ‘Navigating the healthcare system’.Conclusion:The French version of the Health Literacy Questionnaire was shown to be psychometrically robust with good reliability. In the context of France, the 9 scales of Health Literacy Questionnaire allow a thorough assessment of health literacy strengths and weaknesses to respond to health literacy needs and improve the accessibility of health information and services.

ObjectiveValidity refers to the extent to which evidence and theory support the adequacy and appropriateness of inferences based on score interpretations. The health sector is lacking a theoretically-driven framework for the development, testing and use of health assessments. This study used the Standards for Educational and Psychological Testing framework of five sources of validity evidence to assess the types of evidence reported for health literacy assessments, and to identify studies that referred to a theoretical validity testing framework.MethodsA systematic descriptive literature review investigated methods and results in health literacy assessment development, application and validity testing studies. Electronic searches were conducted in EBSCOhost, Embase, Open Access Theses and Dissertations and ProQuest Dissertations. Data were coded to the Standards’ five sources of validity evidence, and for reference to a validity testing framework.ResultsCoding on 46 studies resulted in 195 instances of validity evidence across the five sources. Only nine studies directly or indirectly referenced a validity testing framework. Evidence based on relations to other variables is most frequently reported.ConclusionsThe health and health equity of individuals and populations are increasingly dependent on decisions based on data collected through health assessments. An evidence-based theoretical framework provides structure and coherence to existing evidence and stipulates where further evidence is required to evaluate the extent to which data are valid for an intended purpose. This review demonstrates the use of the Standards’ theoretical validity testing framework to evaluate sources of evidence reported for health literacy assessments. Findings indicate that theoretical validity testing frameworks are rarely used to collate and evaluate evidence in validation practice for health literacy assessments. Use of the Standards’ theoretical validity testing framework would improve evaluation of the evidence for inferences derived from health assessment data on which public health and health equity decisions are based.

Background As health resources and services are increasingly delivered through digital platforms, eHealth literacy is becoming a set of essential capabilities to improve consumer health in the digital era. To understand eHealth literacy needs, a meaningful measure is required. Strong initial evidence for the reliability and construct validity of inferences drawn from the eHealth Literacy Questionnaire (eHLQ) was obtained during its development in Denmark, but validity testing for varying purposes is an ongoing and cumulative process. Objective This study aims to examine validity evidence based on relations to other variables—using data collected with the known-groups approach—to further explore if the eHLQ is a robust tool to understand eHealth literacy needs in different contexts. A priori hypotheses are set for the expected score differences among age, sex, education, and information and communication technology (ICT) use for each of the 7 eHealth literacy constructs represented by the 7 eHLQ scales. Methods A Bayesian mediated multiple indicators multiple causes model approach was used to simultaneously identify group differences and test measurement invariance through differential item functioning across the groups, with ICT use as a mediator. A sample size of 500 participants was estimated. Data were collected at 3 diverse health sites in Australia. Results Responses from 525 participants were included for analysis. Being older was significantly related to lower scores in 4 eHLQ scales, with 3. Ability to actively engage with digital services having the strongest effect (total effect –0.37; P<.001), followed by 1. Using technology to process health information (total effect –0.32; P<.001), 5. Motivated to engage with digital services (total effect –0.21; P=.01), and 7. Digital services that suit individual needs (total effect –0.21; P=.02). However, the effects were only partially mediated by ICT use. Higher education was associated with higher scores in 1. Using technology to process health information (total effect 0.22; P=.01) and 3. Ability to actively engage with digital services (total effect 0.25; P<.001), with the effects mostly mediated by ICT use. Higher ICT use was related to higher scores in all scales except 2. Understanding health concepts and language and 4. Feel safe and in control. Either no or ignorable cases of differential item functioning were found across the 4 groups. Conclusions By using a Bayesian mediated multiple indicators multiple causes model, this study provides supportive validity evidence for the eHLQ based on relations to other variables as well as established evidence regarding internal structure related to measurement invariance across the groups for the 7 scales in the Australian community health context. This study also demonstrates that the eHLQ can be used to gain valuable insights into people’s eHealth literacy needs to help optimize access and use of digital health and promote health equity.

Definitions of health literacy have evolved from notions of health-related literacy to a multidimensional concept that incorporates the importance of social and cultural knowledge, practices and contexts. This evolution is evident in the development of instruments that seek to measure health literacy in different ways. Health literacy measurement is important for global health because diverse stakeholders, including the WHO, use these data to inform health practice and policy, and to understand sources of inequity. In this Practice paper, we explore the potential for negative consequences, bias and epistemic injustice to occur when health literacy instruments are used across settings without due regard for the lived experiences of people in various contexts from whom data are collected. A health literacy measurement approach that is emic-sensitive, strengths based and solution oriented is needed to minimise biased data interpretation and use and to avoid epistemic injustice.