Adapting the European Health Literacy Survey for Fourth-Grade Students in Germany: Questionnaire Development and Qualitative Pretest

Abstract

Background: Promoting health literacy in early life is regarded as an important means of sustaining health literacy and health over the life course. However, little evidence is available on children's health literacy, partly due to a scarcity of suitable measurement tools. Although there are 18 tools to measure specific items of health literacy for people younger than age 13 years, there is a lack of comparable, valid, and ageappropriate measures of generic health literacy. Objective: This study aimed to develop and qualitatively test an age-adapted version of the European Health Literacy Survey Questionnaire (HLS-EU-Q) for Germanspeaking children age 9 and 10 years. Although validated for adults and adolescents, the HLS-EU-Q has never been age-adapted or used with children. Methods: The content and language of HLS-EU-Q items were adapted for this age range. The literature was consulted to inform this process, and adaptations were developed and selected based on consensus among authors. From an item pool of 102 adapted items, 37 were given to 30 fourth-grade students in a cognitive pretest, which is a standard procedure in questionnaire development aiming to explore how items are interpreted. Participants (18 girls, 12 boys) were mostly age 9 or 10 years (range, 9-11 years). Key Results: Problems with misinterpretation were identified for some items and participants (e.g., items designed to assess participants' perceived difficulty in accessing and appraising health information were partly answered on the basis of knowledge and experience). A final selection of 26 wellperforming items corresponded to the underlying HLS-EU-Q framework. Conclusions: This is the first ageadapted version of the HLS-EU-Q. A preliminary 26-item questionnaire was successfully developed that performed well in a cognitive pretest. However, further research needs to verify its validity and reliability. The present findings help to advance the measurement of generic self-reported health literacy in children and highlight the need for cognitive pretesting as an essential part of questionnaire development. [HLRP: Health Literacy Research and Practice. 2020;4(2):e119-e128.] Plain Language Summary: The European Health Literacy Survey Questionnaire is used for testing adults' health literacy. It was adapted for German-speaking children age 9 and 10 years. Based on a review of the original items and the literature, 26 questionnaire items were developed and tested in interviews with 30 children. Although problems with understanding could be identified, the questionnaire was mostly well understood.

Adapting the European Health Literacy Survey Questionnaire for Fourth-Grade Students in Germany: Validation and Psychometric Analysis

“…This article focuses only on the quantitative study and explores the quality of the instrument regarding its psychometric properties. The questionnaire development process as well as the results of cognitive testing are reported elsewhere (Bollweg et al, 2020). The pilot study was carried out as a cross-sectional survey in school classes using a written, self-administered questionnaire.…”

“…We measured self-reported HL, operationalized as the perceived difficulty in accessing, understanding, appraising, and applying health-related information in the contexts of health care, disease prevention, and health promotion ( Sørensen et al, 2012 ), with adapted HLS-EU-Q items (see HLS-EU Consortium, 2012 , for the original items). We had developed 26 adapted items in a previous phase of this study, described in greater detail in Bollweg et al ( 2020 ). The original HLS-EU-Q item format and response categories were retained with slight changes in wording.…”

“…For instance, the present questionnaire is an age-adapted version of the HLS-EU-Q that was developed originally for use in adults. Although we have adapted the questionnaire specifically for the target group of fourth-grade students in Germany (for more details on the development process see Bollweg et al ( 2020 ), it was developed neither from scratch to meet their specific needs and idiosyncrasies, nor with their active participation. Accordingly, the questionnaire might be appropriate but not necessarily optimal for use in this age range.…”

Dimensionen der Gesundheitskompetenz von Viertklässler*innen

“…a.) bei Kindern messen [10,14,15,18] (für eine Übersicht s. [2]), sind es für Deutschland nur 3 Studien 1 : 4 Wallmann et al [27] untersuchen gesundheitsbezogenes Wissen, 4 Schmidt et al [21] erheben Wissen, Kommunikation und Einstellungen und 4 Bollweg et al [3] erfassen selbstberichtete sowie funktionale GK.…”

“…Die von Bollweg et al [3] gesammelten Daten wurden bislang nur hinsichtlich der Entwicklung eines Instruments zur Erfassung der GK von Kindern ausgewertet [3,4]. Im Rahmen dieses Beitrags erfolgt daher erstmalig eine inhaltliche Darstellung der gesammelten Daten im Bereich der selbstberichteten GK, des Gesundheitswissens, sowie gesundheitsbezogener schriftsprachlicher und numerischer Fähigkeiten von Viertklässler*innen, um potenzielle Forschungsund Interventionsbedarfe aufzuzeigen.…”