The Health Literacy Questionnaire (HLQ) at the patient-clinician interface: a qualitative study of what patients and clinicians mean by their HLQ scores

Abstract

BackgroundThe Health Literacy Questionnaire (HLQ) has nine scales that each measure an aspect of the multidimensional construct of health literacy. All scales have good psychometric properties. However, it is the interpretations of data within contexts that must be proven valid, not just the psychometric properties of a measurement instrument. The purpose of this study was to establish the extent of concordance and discordance between individual patient and clinician interpretations of HLQ data in the context of complex case management.MethodsSixteen patients with complex needs completed the HLQ and were interviewed to discuss the reasons for their answers. Also, the clinicians of each of these patients completed the HLQ about their patient, and were interviewed to discuss the reasons for their answers. Thematic analysis of HLQ scores and interview data determined the extent of concordance between patient and clinician HLQ responses, and the reasons for discordance.ResultsHighest concordance (80%) between patient and clinician item-response pairs was seen in Scale 1 and highest discordance (56%) was seen in Scale 6. Four themes were identified to explain discordance: 1) Technical or literal meaning of specific words; 2) Patients’ changing or evolving circumstances; 3) Different expectations and criteria for assigning HLQ scores; and 4) Different perspectives about a patient’s reliance on healthcare providers.ConclusionThis study shows that the HLQ can act as an adjunct to clinical practice to help clinicians understand a patient’s health literacy challenges and strengths early in a clinical encounter. Importantly, clinicians can use the HLQ to detect differences between their own perspectives about a patient’s health literacy and the patient’s perspective, and to initiate discussion to explore this. Provision of training to better detect these differences may assist clinicians to provide improved care.The outcomes of this study contribute to the growing body of international validation evidence about the use of the HLQ in different contexts. More specifically, this study has shown that the HLQ has measurement veracity at the patient and clinician level and may support clinicians to understand patients’ health literacy and enable a deeper engagement with healthcare services.

Application of validity theory and methodology to patient-reported outcome measures (PROMs): building an argument for validity

“…the cognitive processes that occur when respondents formulate answers to the items) [5, 11]. Given the extensive and clear item intents for each HLQ item, cognitive interviews to investigate response processes would provide information, for example, about whether or not respondents in the target language formulate their responses to the items in line with the item intents and construct criteria [10, 56]. Castillo-Diaz and Padilla used cognitive interviews within the argument-based approach framework in order to obtain validity evidence about response processes [16].…”

“…Items are scored from 1 to 4 in the first 5 scales (Strongly Disagree, Disagree, Agree, Strongly Agree), and from 1 to 5 in scales 6–9 (Cannot Do or Always Difficult, Usually Difficult, Sometimes Difficult, Usually Easy, Always Easy). The HLQ has been in use since 2013 [56, 57, 64–72] and was designed to furnish evidence that would help to guide the development and evaluation of targeted responses to health literacy needs [64, 73]. Typical decisions made from interpretations of HLQ data are those to do with changes in clinical practice (e.g.…”

“…For example, Maindal et al [60] conducted interviews to test the cognitive processes of target respondents when answering the Danish HLQ items, which was a way to test if the translated items were understood as intended. Another example of cognitive testing, although not a study of translated HLQ items, is that done by Hawkins et al [56] to determine concordances/discordances between patient and clinician HLQ responses about the patient, and to match these with the HLQ item intents. This could be a useful method to determine if the intent of translated items and scales is understood in the same way by both patients and clinicians in a new cultural setting.…”

“…apply source language construct-relevant criteria) when interpreting scores, and that these processes match the intended interpretation of scoresEvidence that the cognitive processes of PROM users when evaluating respondents’ scores from a translated PROM are consistent with the source language construct criteria and with the interpretation of scores as intended by developers of the source language PROMIn-depth cognitive interviews with target PROM users, and content analysis to compare narrative data from interviews with source language PROM item intents and construct definitions, and to compare narrative data with the data from cognitive interviews with source language PROM users. For example, the Hawkins et al study [56] shows how important it is that clinicians apply the same/similar construct criteria when interpreting HLQ scores as patients have applied when answering the items. Cognitive interviews to test response processes of the target audience of the translated PROM should also be conducted with the users of the PROM data who will interpret and use the scores to make decisions about those target audience members 3.…”

Barriers to Breast Cancer Screening among Diverse Cultural Groups in Melbourne, Australia

“…A four-point response scale is used to assess domains 1 to 5 (strongly disagree to strongly agree), and a five-point scale is used to assess domains 6 to 9 (cannot do or always difficult to always easy). The HLQ has a strong and reproducible theoretical structure that has been found to be robust in several studies [33,34,35,36]. The HLQ was translated using a formal forward and (blind) back translation procedure, with the forward translators guided by a detailed item intent document.…”