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Table 4 The characteristics of the design and development of HLS-EU-Q

From: Measuring health literacy in populations: illuminating the design and development process of the European Health Literacy Survey Questionnaire (HLS-EU-Q)


The rationale for the HLS-EU-Q is to address the lack of European data on health literacy in populations by providing an adequate instrument for collection of data, which can generate insights on national perspectives as well as a comparative analysis of the state of the art of health literacy in Europe.

Research question

The aim of the questionnaire is to measure health literacy in (European) populations with reference to the HLS-EU definition and conceptual model on health literacy as outlined by Sorensen et al. [23]

Scale and response format

Likert-type scales with a four choice format “Very easy, easy, difficult, very difficult”; “Don’t know” only to be ticked by interviewer.

Generation of items

Items generated by a Delphi procedure among consortium members, expert consultation, and literature review with reference to the HLS-EU conceptual model and a deducted matrix suggesting 12 sub-domains of health literacy.

47 core items were generated, placed first in order of the four information processing dimensions (accessing, understanding, appraising and applying health information to take decisions), then changed to be ordered in relation to the three health domains in focus: healthcare, disease prevention and health promotion. Within these sub-domains, items were placed in logic order according to content and purpose.

A subsequent second section focused on antecedents and consequences of health literacy related to the HLS-EU conceptual model operationalized as 39 items on personal information; health service use, health behaviour, community participation and socio-economic factors.

Test and pilot of items

Pre-test concerning face validity was made in three focus groups in Greece, Ireland and the Netherlands, respectively.

Field test was conducted as face-to-face interviews in Ireland (n = 50) and in the Netherlands (n = 49) to measure quantitative and qualitative aspects of the measurement.

Amendments based on item analysis or related techniques

Amendments were made based on

 - pre-test

 - field test

 - consultation process

 - plain language examination

 - translations

HLS-EU-Q versions

HLS-EU-Q47 (core health literacy related items only); HLS-EU-Q86 (measuring health literacy as well as antecedents and consequences according to the HLS-EU conceptual model).

Creation of an independent data set

The HLS-EU-Q86 was applied as part of the European Health Literacy Survey (HLS-EU) in a sample of 8000 participants from the general populations in Austria, Bulgaria, Germany, Ireland, the Netherlands, Poland and Spain [28].