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ACDC
AdultCognitiveDeclineConscientiousnessProject
2017-1-IT02-KA204-036825
HealthliteracyinEurope
ACDCprojectisfundedwithsupportfromtheEuropeanCommissionThisresearchanditscontentreflecttheviewsonlyoftheauthor,andtheCommissioncannotbeheldresponsibleforanyusewhichmaybemadeoftheinformationcontainedtherein.
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Index
I. Background
II. Searchingforevidence
- Methodology
- Results
a) Measurementtoolsforhealthliteracy
b) HealthliteracyinEuropeancountries
III. Conclusions
IV. Conflictofinterestsandfunding
V. References
VI. Annexes:
a) Annex1:Figure1.PRISMAFlow-chart
b) Annex2:Table1.CharacteristicsofIncludedStudies
c) Annex3:Table2.Individuals’self-assessmentofeHealthSkills
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I. Background
Inrecentyears,theinterestin‘healthliteracy’(HL)hasnotablyincreasedacrossmodernhealthsocieties.
Almosteverypeoplelifeaspectdealswithissuesabouthealthandcitizenswhomareexpectedtoactivelytakeawide
range of health decisions for themselves and their families; this includes decisions on health behaviors, nutrition,
medication,choiceofprovidersandtreatments[1,2,3].
Inthiscontext,severalstudieshavebeenpublishedonthistopicbutthereisnounanimouslyaccepteddefinitionof
theconcept.Accordingtoasystematicreview,acomprehensivedefinitioncapturingtheessenceofthe17definitions
identified in the literature couldbeas follows: “Health literacy is linked to literacyandentails people’s knowledge,
motivation and competences to access, understand, appraise, and apply health information in order to make
judgments and take decisions in everyday life concerning healthcare, disease prevention and health promotion to
maintainorimprovequalityoflifeduringthelifecourse”[3].
Many studies have also focused on developing and validating generic measurement instruments to assess Health
literacyintheEuropeanandextra-Europeanarea.
Aliteraturereviewpublishedin2014showsthat,fromanoverallperspective,almostallidentifiedinstrumentsapplya
multi-dimensionalmeasurement(oftenprintandnumeracyliteracy)andmostofthemutilizeamixedmeasurement
approach (objective and subjective measurement) with a multidimensional construct enhancing the
comprehensivenessoftoolsmeasuringhealthliteracy[4].
Whyishealthliteracysoimportant?Becauselowhealthliteracyisassociatedwithseveraladversehealthoutcomes,
includinglowhealthknowledge,increasedincidenceofchronicillness,poorerintermediatediseasemarkers,andless
thanoptimaluseofpreventivehealthservices.
Particularly, in a recently updated review, limited health literacy has been “consistently associatedwith increased
hospitalizations,greateremergencycareuse,loweruseofmammography,lowerreceiptofinfluenzavaccine,poorer
abilitytodemonstratetakingmedicationsappropriately,poorerabilitytointerpretlabelsandhealthmessages,and,
amongseniors,pooreroverallhealthstatusandhighermortality”[5].
Given these relevant implications, the concept of health literacy has remarkably gained recognition aswell as the
importantconsiderationtodesignmaterialsandtailoredprogramsforaddressinggapsandimprovinghealth,bothat
theglobalandlocallevel.
Indeed,asthesametimeasbuildingpoliciesandplanninginterventionstosupportthestrengtheningoflimitedhealth
literacy,anappropriateandvalidmeasurementofhealthliteracyinmedical-epidemiologicalresearchisessential[2].
Inthisresearch,weaimedtoprovideacomprehensivemeasurementofthehealthliteracyintheEuropeancountries
andthenhighlightthemainneedsforinterventions.
II. Searchingforevidence
Methodology
Thesearchprocesswascarriedoutintwosteps.
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Thefirststepconsistedofasystematicreviewoftheliteratureinordertoidentifyalltheavailabledataonthetopic.
The literature reviewwas performed betweenMarch 2018 and April 2018 through themain electronic databases
PubMedandScopus.
Thesearchstringusedwas[(healthliteracy*)OR(health*ANDliteracy*)ANDeurop*].
Forthedetailedsearchstrategy,seeAnnex1:FlowchartPRISMA.
Eligibility criteria. Articles were considered eligible if the study focused on measuring the health literacy level in
EuropeancountriesandwereinEnglishlanguage. Norestrictionswereappliedtotypeofpublication(e.g.editorials
papers,shortreports,systematicreview,conferenceproceedings,commentaries,booksreviews,dataset).
Studyselection.Atotalof1126articleswereretrievedfromelectronicdatabasesandrecordspublishedafter2000.
After removing duplicates, 656 articles were screened for titles/abstracts and 627 were excluded because not
relevant.
Twoauthors reviewedabstractsand full textsof the resulting29articlesand8articleswere furtherexcludedwith
reasons(outoftopic,notprovidingsufficientdetails).
Disagreementswereresolvedbyathirdreviewerwhoapprovedthefinallistof21articles.
Datacollection. Inthesecondstep,twoauthorsindependentlyextracteddataandresultsfromtheincludedarticles
usingasummarytabletoidentifythekeypointsofeacharticle;themostrelevantthemeswerediscussedwithathird
researcher.
Results
Attheendofourliteraturesearch,21articleswereincludedinthissystematicreview.
WiththeaimofillustratingthehealthliteracylevelinEuropeancountries,theanalysisoftheincludedstudiesfocused
onthecountry/countriesconsideredinthestudy,thecharacteristicsofthepopulation(i.e.generalpopulation),the
instrumentusedtomeasurehealthliteracyandtheresultsofeachstudy[Table1].
a) Measurementtoolsforhealthliteracy
Health literacycanbemeasuredandassessedatdifferent levels,but it isdifficulttostructureatoolthattakes into
accountthefullsetofskillsandknowledgeassociatedwithit;avalidmeasureofhealthliteracy,indeed,shouldallow
comparisonacrosscultures,populationgroupsandlivingenvironment.
Most of the developed instruments are commonly used to directly measure an individual’s literacy in relation to
health outcomes and almost all instruments apply a multi-dimensional measurement and a mixed measurement
approach(objectiveandsubjectivemeasurement).
Recently, some researchers have attempted to evaluate health literacy with simple screening questions or
health-related oral literacy rather than administering entire questionnaires. On the other hand, computer-assisted
testing is a promising tool because it allows more accurate measurement of individual capacity and it is
comprehensiveofthecoreliteracyskills(reading,writing,speaking,listening).
Giventhevarietyandheterogeneityofavailableinstruments,anoverviewofthemostpopulartoolsisshowedbelow.
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TheEuropeanHealthliteracysurveytool(HLS-EU)
TheEuropeanHealthliteracysurveytool[6] isasurveyavailable inmoreversions.Thecoreversionincludesthe47
matrixitemsrelatedto12subdomainsanditiscalledHLS-EU-Q47.TheversionHLS-EU-Q86includestheHLS-EUQ47
as well as a background section with items relating to selected health literacy determinants and outcomes as
described intheHLS-EUconceptualmodel. Italsoentails the itemsfromtheNewestVitalSign inordertomeasure
functionalhealthliteracy.
AshorterversionhasbeenpreparedasaresultoftheanalysisoftheEuropeanHealthLiteracySurveydata.Itcontains
16selecteditemswhichiscalledHLS-EU-Q16.Another25-itemversionhasbeenproposedandusedrecentlyanditis
calledHLS-EU-Q25.
Allthedifferentversionsareusedtoassessfourdimensionsofhealth literacy:access,understanding,appraisaland
application of health information in three different situations/domains: health promotion, disease prevention and
cureofdisease.Participantsareaskedtoassess,inascalerangingfrom1(unable,implyingleasthealthliteracyscore)
to 5 (without any difficulty, maximal health literacy score), their level of difficulty with regard to access,
understanding,appraisalandapplicationofhealthinformation.
TheGeneralHealthLiteracyScoreiscalculatedasfollows:0-25“inadequate”;25-33“problematic”;33-42“sufficient”;
42-50“excellent”anditisusedtoassessthegeneralHLlevel.
TheHealthliteracyQuestionnaire(HLQ)
The Health literacy Questionnaire (HLQ) [7] consists of 44 questions and can be either self-administered or orally
administered. The HLQ assesses nine dimensions and provides nine scale scores. Each score gives insight into the
strengths and limitations of the respondent, but the scores aremost powerfulwhen viewed together to show the
‘healthliteracyprofile’oftherespondent.
TestofFunctionalHealthLiteracyinAdults(TOFHLA)
TheTOFHLA[8]isa2-parttestthatisavailableinbothEnglishandSpanish.
The first part provides participants with medical information or instructions about various scenarios, such as
instructionsonaprescriptionlabelor instructionsaboutpreparationforadiagnosticprocedure.Participantsreview
thescenariosandthenanswerquestionsthattesttheirunderstandingoftheinformationinthescenarios.
ThesecondpartoftheTOFLHAisbasedontheClozemethodinwhichparticipantsaregivenpassagesoftextabout
medical topicswith selectedwords deleted and replacedwith blank spaces. The participantsmust fill in the blank
spaces using words selected from amultiple-choice list of options, identifying the wordsmost appropriate to the
contextofthepassage.TOFHLAscorescanrangefrom0to100,withhigherscoresindicatingbetterliteracy.
Scoreof<60represents‘inadequate’ literacy,60to74represents‘marginal’ literacy,and>75represents‘adequate’
literacy.
RapidEstimateofAdultLiteracyinMedicine(REALM)
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TheREALM[9] isaword-recognitiontest inwhichpatientsarepresentedwitha listof66medicalwordsbeginning
witheasywords (e.g. fat, flu,pill) andprogressing tomoredifficultwords (e.g.osteoporosis, impetigo,potassium).
Patientsareaskedtoreadthroughthelistandpronounceeachwordoutloud.
Theexaminerscoresthepatientonthenumberofwordspronouncedcorrectly.Noattemptismadetodetermineif
patientsactuallyunderstandthemeaningofthewords.Thenumberofcorrectlypronouncedwords isthenusedto
assignagrade-equivalentreading level.Scores0to44indicatereadingskillsatorbelowthe6thgradelevel,scores
from45to60representskillsatthe7thor8thgradelevel,andscoresabove60indicateskillsatthehigh-schoollevel
orhigher.Becausesomanypatienthandoutsandformsarewrittenatthehigh-schoollevelorhigher,patientswith
scores≤60areconsideredatriskformisunderstandingwritteninformationprovidedtothem.
NewestVitalSign(NVS)
This tool [8] was developed from a series of scenarios. Patients were given health-related information, which the
patientsreadandthendemonstratedtheirabilitytousetheinformationbyansweringquestionsaboutthescenarios.
Thequestionswerescoredaseithercorrectorincorrectaccordingtoascoringkeyprovidedtotheinterviewers.The
scoreassociatedwith thecorrectanswers, ranging from0 (minimum) to6 (maximum), indicate theoverall levelof
healthliteracyofthesubject.
SetofBriefScreeningQuestions(SBSQ)
This tool [10] consistsof three statements.Responsesare scoredona5-point Likert scale from0 to4,added,and
averaged. The responseof ‘somewhat’or lessprovidedoptimumsensitivity and specificity and is consideredas an
optimal screening threshold in most studies. This means that an average score of 2 indicates inadequate health
literacy,andascore>2 indicatesadequatehealth literacy.Severalversionsofthis instrumenthavebeendeveloped
andadoptedrecently,eachwithonlyonequestion.chosentodetectaninadequatelevelofHL.
FunctionalCommunicativeandCriticalHealthLiteracyscale(FCCHL)
Communicativehealthliteracyreferstothecognitiveandliteracyskillswhich,togetherwithsocialskills,canbeused
to actively participate in everyday activities, to extract information and derive meaning from different forms of
communicationand toapplynew information tochangingcircumstances.Criticalhealth literacy refers to themore
advancedcognitiveskillswhich,togetherwithsocialskills,canbeappliedtocriticallyanalyzeinformation,andtouse
this information to exert greater control over life events and situations. The FCCHL [11] measures these three
constructsby14statementsusing4-pointLikertscales(1–4)asresponseoptions.
Thetotalscoreisobtainedbysummingitemscoresanddividingbythetotalnumberoritems.
TheShortAssessmentofHealthLiteracyforSpanishSpeakingAdults(SAHLSA)
The SAHLSA [12] includes 50 items that explore recognition and comprehension of commonmedical terms, using
multiple-choicequestionsdesignedbyanexpertpanel. TheSAHLSA-50 score is associatedwith thephysicalhealth
statusofSpanish-speakingparticipantsandhasshowngoodinternalreliabilityandtest-retestreliability.
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TheSAHLSAscorerangesfrom0to50andahigherscoreindicateshigherHL.
ShortAssessmentofHealthLiteracyforBrazilianPortuguese-speakingAdults(SAHLPA)
ItisashorterandtranslatedversionoftheSAHLSA.Allthecorrectresponsesscore1pointandalltheotherresponses
score 0 points, thus SAHLPA-18 and SAHLPA-23 scores range between 0 and 18 points and 0 and 23 points,
respectively[13].
b) HealthliteracyinEuropeancountries
Mostof the21studies included in thissystematic reviewfocusedonthehealth literacyassessmentofonecountry
each,exceptfortwolargesurveys[15,16]thatwereconductedinmorecountriesatthesametime.
Only one study [16] concerned eHealth literacy instead of general health literacy and therefore its results are
describedseparately.
Fortheotherstudies,theresultsarereportedbycountry.
Albania.Toci et al. [17], in 2014used a questionnaire to assessHL level in a sampleof 239 individuals inAlbania,
consistingof threeparts:generaldemographicandsocioeconomic information;HLquestionnairebasedonHLS-EU-
Q47 instrument; HL questionnaire based on the TOFHLA instrument. Overall, mean value of TOFHLA was 76.32
(‘adequate’)andmeanvalueofgeneralHLS-EU-Qwas32.8(‘problematic’).In2015,thesameauthors[18]evaluated
theHLlevelinalargersampleof1154individualsaged≥18yearsandshowedthatthiscountryhada‘sufficient’level
of HL (mean: 34.4) according to theGeneral Health Literacy score of the EuropeanHealth Literacy surveywith 47
items(HLS-EU-Q47).
Austria.Soresenetal.[15],describingtheresultsofthehugeEuropeanHealthLiteracyprojectwhichinvolved8EU
countries,showedthatAustriahadan‘inadequate’levelofHL(mean:31.95)accordingtoHLS-EU-Q86.
Belgium. Vandenbosch et al. [19] used the HLS-EU-Q16 tool to assess HL level in Belgium. A score of 0 to 8 is
consideredasindicating‘insufficient’healthliteracy,ascorebetween9and12as‘limited’healthliteracy,andascore
of13ormoreas‘sufficient’healthliteracy.Onasampleof9617individuals,themajorityofpeople(58.5%,N=5629)
hada‘sufficient’HLlevel.
Bulgaria.Bulgariawasoneofthe8EUcountriesinvolvedintheEuropeanHealthLiteracyProject.Soresenetal.[15]
reported that this country had an ‘inadequate’HL level (mean: 30.50) according toHLS-EU-Q86; itwas the lowest
meanofthe8countriesinvestigatedintheproject.
Denmark. In 2015, Emtekær Hæsum et al. [20] assessed the HL level in Danish patients with chronic obstructive
pulmonarydiseaseusingTOHFLAtool: these42patientswerecategorizedashavingan ‘inadequate’ levelofhealth
literacywithameanscoreof47.09(26.2%,N=11),ashavinga‘marginal’levelofhealthliteracywithameanscoreof
67.38 (19.0%,N=8)and themajorityof themashavingan ‘adequate’ levelofhealth literacywithamean scoreof
86.30(54.8%,N=23).Afewyearslater,AabyA.[21]assessedHLlevelin3116individualswithcardiovasculardiseases.
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OnlytwooftheninesubscalesofHLQtoolwere included inthesurvey,namely“Understandinghealth information
well enough to know what to do” and “Ability to actively engage with healthcare providers”. Scale scores were
calculated as themean score of the number of items answered in that particular subscale: “Understanding health
informationwellenoughtoknowwhattodo”meanwas2.92;“Abilitytoactivelyengagewithhealthcareproviders”
meanwas2.97.Bothofthemindicatean‘adequate’levelofHL.
Germany.Soresenetal.[15]in2015showedthatgloballythegeneralpopulationinGermanyhada‘sufficient’(mean:
34.49)HLlevelaccordingtoHLS-EU-Q86and46.3%ofthesamplehadalimitedHLlevel.Twoyearslater,SchaefferD.
[22]usedtheHLS-EU-Q47tooltoassessagaintheHL level in2000Germanpeopleand inhisstudythispercentage
washigher,around54.3%.
Greece.Soresenetal.[15]showedintheirsurveythattheGreekgeneralpopulationhada‘sufficient’(mean:33.57)
HLlevelandthat13.9%ofthesamplehad‘inadequate’levelofHLaccordingtotheHLS-EU-Q86tool.Similartothat
result Efthymiou et al. [23], in 2017, showed that only the 8.4% of a sample of 107 older Greek people had an
‘inadequate’HLlevel.
Italy.In2015,Palumboetal.[24]validatedtheHLS-EU-Q86surveyintheItaliancontextandshowedthattheHLlevel
inasampleoftheItaliangeneralpopulation(N=1000)was‘inadequate’in17,3%,‘problematic’in37,3%,‘sufficient’
in39,5%and‘excellent’in5,9%.ThemeanHLscorewas31.6,belowtheEuropeanscore.
Kosovo.Tocietal.[25],in2014,useda25-itemquestionnairederivedfromtheHLS-EU-Q47toassesstheHLlevelina
sampleof1730peopleaged>65years.Themeanvalueoftheoverallhealthliteracyscorewas76.5(minimum:25-
maximum:125) indicatinga lowhealth literacy level;moreover,all subscalescores (access,understanding,appraisal
andapplication)weresignificantlyloweramongindividualswhoperceivedapoorerhealthstatusorwithapresence
ofchronicconditions.
Ireland. This country resulted to have a ‘sufficient’ HL level (mean: 35.16) in the HLS-EU-Q86 survey described by
Soresenetal.[15]in2015whereitwasrankedamongthecountrieswiththehighesthealthliteracylevel.
Netherlands.Fransenetal.[26],in2011,enrolled289patients,201withcoronaryarterydisease(CAD)and88with
type2diabetesmellitus(T2DM),tomeasuretheirHLlevelusingseveraltoolsatthesametime.
AccordingtotheREALM-Dscores,only19%ofthepatientshaddifficultyreading(definedasa7-8thgrade-equivalent
readinglevel).Italsoshowedaceilingeffectwith23%ofthepatientsexhibitingthemaximumscoreof66.
In theNVS-D test, 56%of the patients scored one or no items correctly,which suggested a high likelihood of low
healthliteracy.Moreover,31%ofthepatientsdidnotansweranyofthesixitemscorrectly,indicatingaflooreffect.
IntheFCCHL-Dtest,72%ofthepatientsscored3pointsorless,indicatinglowsubjectivehealthliteracy.
IntheSBSQ-Dtest,5%ofthepatientsscoredlow,indicatinglowsubjectivehealthliteracyasdefinedbythismeasure.
Inthiscase,theSBSQ-Dshowedaceilingeffectwith42.5%ofthepatientsexhibitingthemaximumscore.
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Twoyearslater,vanderHeideetal.[27],in2013,usedHLS-EU-Q47toassessHLlevelintheNetherlands.Concerning
thefourcompetencesofaccessing,understanding,appraisingandapplyinghealthinformation,themeanscoreswere
considered ‘sufficient’ except for applying that registered a ‘problematic’ score. The mean scores per item were
howeverallcloseto3(equaltobeingperceivedaseasy).
Inlinewiththeseresults,Soresenetal.[15]reportedtheNetherlandsasthecountrywiththehighestmean(37.06)in
the HLS-EU-Q86 survey compared to the other seven EU countries and the lowest percentage of people with
‘inadequate’HL(1.7%).Inthesameyear,Hussonetal.[28]confirmedagainthesefindings:assessingtheprevalence
ofhealth literacy(HL)among1626colorectalcancer (CRC)survivors, theyshowedthatonly224patients (14%)had
lowsubjectiveHL,725patients(45%)hadmediumHLand677patientshadahighHL(42%).
Poland.Soresenetal.[15]in2015showedthatthePolishgeneralpopulationhada‘sufficient’HLlevel(mean=34.45)
comparedtotheothersevenEUcountries.Slonskaetal.[29],inthesameyear,analyzeddatacomingfromthispart
oftheHLS-EU-Q86ProjecttoassesstheHLlevelinelderlypeople.Theyfoundthattheelderlyaged65andmorewere
athighest riskof lowhealth literacy. In fact, thehighestpercentage (61.3%)ofpeoplewith ‘limited’health literacy
wasfoundintheelderlyaged65andmore.
Portugal.In2016,Espanhaetal.[30]validatedtheHLS-EU-Q86surveyusedintheEuropeanHealthLiteracyProject.
TheyshowedthatinthecaseoftheGeneralHealthLiteracyIndex,Portugalwascharacterizedbythepresenceof11%
of respondents with an ‘inadequate’ level of health literacy, around 38% with a ‘problematic’ HL, 8.6% with an
excellentHLand41.4%witha‘sufficient’ levelofhealth literacy.ComparedtotheHLS-EUdata,Portugal issituated
belowtheaverageforthecountriesintheEuropeanstudy.Inaccordancewiththisresult,oneyearlater,PaivaetL.
[31] assessed the HL level in Portugal using the Portuguese adapted version of the instrument NVS. The sample
analyzedincludedphysicians(N=53),healthresearchers(N=45),otherresearchers(N=50)andthegeneralpopulation
(N=101).Theyfoundthatwhilephysician,healthresearchersandotherresearchershadan‘adequate’HLlevel(100%
and 88.9%, respectively), only the 18.8% of the general population had that same HL level and the 57.4% were
classifiedashavingan‘highlikelihoodoflimitedHL’.ThesamefindingswereshowedalsobyPiresC.etal.[32]in2018
whentheyassessedHL level inasampleof484Portugueseadults,showingthataroundhalf theparticipants (53%)
wereclassifiedashaving‘inadequate’healthliteracywiththeSAHLPA-23.
Spain. Soresen et al. [15] in 2015 showed that Spain in theHLS-EU-Q86 Project had globally a ‘sufficient’ HL level
(mean=32.88) compared to the other seven EU countries with one of the lowest percentages of ‘inadequate’ HL
(7.5%).
Switzerland.Franzenetal. [33], in2013,usedonequestionof theSBSQ (‘‘Whenyougetwritten informationona
medicaltreatmentoryourmedicalcondition,howoftendoyouhaveproblemsunderstandingwhatitistellingyou?’’)
to assess functionalHL level in 493patientswith type 2 diabetes. The results showed that half of theparticipants
declared “never having problems in understanding written information” related to their medical condition. In
contrast,7.3%of theparticipantsoftenoralwayshadproblemsunderstandingwritten information.Similar findings
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wereshowedalsobyZuercheretal.[34],twoyearsafter,usingthesametoolusedtoassessfunctionalHLlevelina
similar sample. Again, half of the participants (52.5%) reported never having problems understanding medical
information(goodFHL),whereas40.7%reportedhavingproblemsoccasionallyorsometimes(mediumFHL)and6.8%
oftenoralways(poorFHL).
UnitedKingdom. In2007VonWagner et al. [35]used theTOFHLA tool in a sampleof 719participants; only5.7%
(N=41)wereclassifiedashaving‘inadequate’HLlevelandonly5.7%(N=41)ashaving‘marginal’HLlevel,whileallthe
otherparticipantsashaving‘adequate’HLlevel.
eHealth literacy. eHealth literacy (alternatively known as eHealth skills or digital health literacy) is a concept
consideredseparatelyfromthegeneralhealthliteracybyscientificresearchers;inparticular,itincludes“theabilityto
searchandlocatehealthinformationonline,andalsotounderstand,applyandusethisinformation”[36].
Inthiscontext,thecoreproblemistheincapacityofdistinguishingbetweenbiasednon-evidence-basedinformation
andunbiasedevidence-basedinformationsources.
Thisstudy[16]reportstheresultsofamultinationalsurveyconductedamongthe28EUMemberStateswhere26566
participantswereinterviewedbyCATL(computer-assistedtelephoneinterviews).
eHealthwasmeasuredvia fivequestionswhich largelymatched theeHEALS scale, thewide-spread tool commonly
used to assess individual’s self-perceived skills at finding, evaluating and applying electronic health information to
healthproblems[37].
These fivequestionswere: (i) knowinghow to seek the Internet forhealth information; (ii) knowingwhere to find
reliable health online sources; (iii) understanding the terminology of health online information; (iv) being able to
identifythequalityofthehealthinformation;and(v)knowinghowtouseit.
Eachitemwasmeasuredona4-pointscaleform1=totallydisagreethrough4=totallydisagree.
Consideringtheindividuals’self-assessmentofeHealthskillsresultsonknowinghowtonavigatetheInternettofind
health information, substantialvariationsappearacrossMemberStates.Cyprus reported thehighestpercentageof
people totally agreeingonhaving this search skill (72%) followedbySweden (69%).Meanwhile,Poland, Latviaand
Italyshowedthe lowestpercentages,the latterofwhichwithabouthalfpercentageofthe leadingcountries(30%).
(Forthedetailedresultsbycountry,seeAnnex3:Table2.Individuals’self-assessmentofeHealthSkills).
For the other questions, the results revealed a quite complex pattern in which only Internet experience and self-
reportedhealth status influence all skills in a similarmanner. Themore frequently people seekhealth information
online, the more likely they report themselves as high-skilled. Moreover, people with better self-reported health
statusalsoindicatedhigherskills.Astosocioeconomiccharacteristics,thepatterndifferedacrossskills.Inparticular,
younger respondents tended to report higher levels of skills compared to older people for three skill categories
considered.Nevertheless,olderrespondentswerebetterabletounderstandhealthterminology.
More educated respondents appeared to achieve better self-reported skills; the ability to search, distinguish
informationqualityandunderstandtechnology.
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Tosum,thissurveyhighlightedthatthemostvulnerablegroupswithineachcountryarethesick,leasteducatedand
eldest.
III. Conclusions
It iswell-knownthatincreasingthelevelofHLinthepopulationcanbeaneffectivestrategytoimprovethecorrect
useofhealthcareservices,toenhancetheeffectivenessoftreatment,andthustoimprovepeople’shealthstatusand
outcomes.
Theaimofthissystematicreviewwastoprovideacomprehensivemeasurementof thehealth literacy inEuropean
countriesandaninitialinsightinthemorecriticalgroupsinordertoidentifypromisingareasofintervention.
Regarding the 20 articles assessing general health literacy, a huge variety of questionnaires have been adopted to
measure it. Indeed, themost used tool was the HLS-EU instrument in all the available versions; particularly, four
studiesincludingtheEuropeansurveyadoptedthelongestquestionnaireHLS-EU-Q87[15,24,29,39],fourstudiesused
theHLS-EU-Q47version[17,18,22,27],twostudiesemployedtheshortestHLS-EU-Q16[19,23]andonestudyadapted
a versionwith 25 items (HLS-EU-Q25) [25].On theother hand, four studies assessed the health literacy through a
subjectivemeasure,theSBSQs,generallymadeofthreestatements,butonlyonestudyusedall thequestions[26];
theother threeemployedonequestioneach [28,33,34]. Finally, three studiesadopted theTOFHLA test [17,20,35],
twostudiestheNVS[26,31],onestudyanadaptedversionoftheHLQ[21],onestudytheREALM[26]andonestudy
theFCCHL[26].
Onlytwostudiesusedatthesametimemorethanonetest[17,26].
Most of the studies investigated the general population without particular characteristics
[15,17,18,19,22,24,27,29,30,32,35],twoofwhichwerefocusedontheolderpeople.[23,25]
The others enrolled specific patients’ groups with relevant diseases (e.g. cardiovascular diseases, type 2 diabetes
mellitus,colorectalcancer)[20,21,26,28,33,34].Onlytwostudiesinvolvedmorethanonegroupofpeopleinthesame
survey[26,31].
Thelargestsurvey[15]focusedoneightEuropeancountriesanditsmethodologywasreplicatedafterwardsinother
threecountries[24,29,30]inordertoexpandthecomparabilityoftheseresults.
However, given theheterogeneityof themethodsused to assessHL across the countries and in the same country
wheremorestudiestookplace,thedifferencesinthetargetpopulationorsettingandthedifferencesintheHLscales,
itisdifficulttoprovideadetailedcomparisonoftheEuropeancountries.
Surely,therearecountriessuchasTheNetherlandsandIrelandwheretheproportionofpeoplewith‘limited’HLlevel
(inadequate or problematic) is considerably lower thanother States in Europe. AlsoDenmark, BelgiumandUnited
Kingdomrecorded ‘adequate’scoresofHL.Notably,Switzerlandregisteredahigh levelofHL inmorethanhalf the
patientsoftwostudies.
Bycontrast,Italy,Austria,PortugalandBulgariaregisteredthehighestpercentagesof‘limited’HL.
KosovowasanothercountrywithalowlevelofHL.
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Spainwasparticular;itrecordedalowproportionofpeoplewith‘inadequate’HLbutmorethan50%ofpeoplewith
‘problematic’HL.
Poland,GermanyandGreecerecordedasimilarscoreof‘limited’HLslightlybelowthe50%intheEuropeansurvey:
only Polandmaintained the same finding in a following study, while the other two registered a worsening in the
limitedhealthliteracycategoryof5-10%.
In general, the distribution of health literacy varies considerably across countries, with only few states with an
‘adequate’ level ofHL.A similar findingwas foundalso in theeHealth literacy survey,where substantial variations
appearedacrossMemberStatesandwherethereareonlyfewleadingcountries.Nevertheless,acommonpatternof
vulnerabilityforthesick,theleasteducatedandeldestwasfoundinallthesurveyedcountries.
Therefore,thereisastrongneedtoaddressthesedeficitandinequalitiesbyEuropeanandnationalhealthplannersor
policymakers.Fundamentalisthesupportofappropriateandtargetedpublichealthandhealthpromotionstrategies
of interventiontostrengthencitizens’andpatients’personalknowledge,motivationandcompetencestotakewell-
informedhealthdecisions.
IV. Conflictofinterestsandfunding
Theauthorsdeclarethattheresearchwasconductedintheabsenceofanycommercialorfinancialrelationshipsthat
couldbeconstruedasapotentialconflictofinterests.
ThisresearchwasfundedbytheACDCAdultCognitiveDeclineConsciousness(Erasmus+projectnumber:2017-1-IT02-
KA204-036825).
V. References
[1] Kickbusch,Ilona,andDanielaMaag."Healthliteracy."(2008):204-211.
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15
VI. Annexes
Figure1.PRISMAFlow-chart
Research,selectionandanalysisFLOWCHARTofthearticlesincludedinthesystematicreview.
searchstring:[(healthliteracy*)OR(health*ANDliteracy*)ANDeurop*]
RecordsidentifiedthroughPUBMED
(N=483)
Screening
Included
Eligibility
Identification
RecordsidentifiedthroughScopus(N=643)
Recordsafterduplicatesremoved(N=656)
Recordsscreened(N=656)
Recordsexcluded(N=627)
Full-textarticlesassessedforeligibility
(N=29)
Full-textarticlesexcluded,withreasons
(N=8)
Studiesincludedinqualitativesynthesis
(N=21)
16
Table1.CharacteristicsofIncludedStudies
FirstAuthor,YearofPublication Country SettingandN Methods Results
SoresenK,2015[15]
AustriaBulgariaGermanyGreeceIrelandNetherlandsPolandSpain
Generalpopulation(N=8000)
HLS-EU-Q86Score:0–25:inadequate25–33:problematic33–42:sufficient42-50:excellent
Inadequate Problematic Sufficient Excellent MeanAustria 18.2% 38.2% 33.7% 9.9% 31.95Bulgaria 26.9% 35.2% 26.6% 11.3% 30.50Germany 11.0% 35.3% 34.1% 19.6% 34.49Greece 13.9% 30.9% 39.6% 15.6% 33.57Ireland 10.3% 29.7% 38.7% 21.3% 35.16theNetherlands 1.8% 26.9% 46.3% 25.1% 37.06Poland 10,2% 34.4% 35.9% 19.5% 34.45Spain 7.5% 50.8% 32.6% 9.1% 32.88
ErvinT,2014[17] Albania Generalpopulationaged>18years(N=239)
HLS-EU-Q47Score:0–25:inadequate25–33:problematic33–42:sufficient42-50:excellentTOFHLAScore:0-59:inadequate60-74:marginal75-100:adequate
HLS-EU-Q47Meanvalue:32.8TOFHLAMeanvalue:76.32
TociE,2015[18] Albania Generalpopulation(N=1154)
HLS-EU-Q47Score0–25:inadequate25–33:problematic33–42:sufficient42-50:excellent
Mean=34.4HLlevelwassignificantlyhigheramongyounger,highlyeducatedandbetter-offparticipants.
17
VandenboschJ,2015[19]
Belgium Generalpopulation(N=9617)
HLS-EU-Q16Score:0-8insufficient9-12:limited>13:sufficient
InsufficientHL:11.5%(N=1111)LimitedHL:29.6%(N=2847)SufficientHL:58.5%(N=5629)
KorsbakkeEmtekærHæsumL,2014[20]
Denmark Patientswithchronicobstructivepulmonarydisease(N=42)
TOFHLAScore:0-59:inadequate60-74:marginal75-100:adequate
InadequateHL:26.2%(N=11)MarginalHL:19.0%(N=8)AdequateHL:54.8%(N=23)
AabyA,2017[21] Denmark Patientswithcardiovasculardiseases(N=3116)
HLQ-2dimensionsScore:<2:InadequateHL>2:AdequateHL
Understandinghealthinformationwellenoughtoknowwhattodo:mean2.92Abilitytoactivelyengagewithhealthcareproviders:mean2.97
SchaefferD,2017[22]
Germany Generalpopulation(N=2000)
HLS-EU-Q47Score0–25:inadequate25–33:problematic33–42:sufficient42-50:excellent
LimitedHL:54.3%(N=1086)Inadequate:9.7%(N=194)Problematic:44.6%(N=892)NotlimitedHL:45.7%(N=914)Sufficient:38.4%(N=768)Excellent:7.3%(N=146)
EfthymiouA,2017[23]
Greece Generalpopulationolderpeople(N=107)
HLS-EU-Q16Score:0-8insufficient9-12:limited>13:sufficient
SufficientHL:45.8%(N=49)ProblematicHL:45.8%(N=49)InadequateHL:8.4%(N=9)
PalumboR,2015[24]
Italy Generalpopulation(N=1000)
HLS-EU-Q86Score:0–25:inadequate25–33:problematic33–42:sufficient42-50:excellent
InadequateHL:17.3%(N=173)ProblematicHL:37.3%(N=373)SufficientHL:39.5%(N=395)ExcellentHL:5.9%(N=59)MeanHL:31.6
18
TociE,2014[25] Kosovo Generalpopulationaged>65years(N=1730)
HLS-EU-Q2525:minimumscore125:maximumscore
MeanHL:76.5ThemeanvalueofHLwassignificantlyloweramongparticipantswhitapoorerself-perceivedhealthstatusandwiththepresenceofchronicconditions.
FransenMP,2011[26]
theNetherlands Patients(N=289):-withcoronaryarterydisease(N=201)-withtype2diabetesmellitus(N=88)
REALM-DScore:0-18:<3rdgradeeducation19-44:4-6thgradeeducation45-60:7-8thgradeeducation61-66:highschooleducationNVS-DScore:0-1: high likelihood oflimitedHL2-3:possibilityoflimitedHL4-6:adequateHLSBSQ-DScore:<2:InadequateHL>2:AdequateHLFCCHL-DScore:<3:InadequateHL>3:AdequateHL
NVS-D TOT CAD T2DMHighlikelihoodoflimitedHL 56%(N=159) 52%(N=103) 68%(N=57)
PossibilityoflimitedHL 23%(N=65) 24%(N=48) 20%(N=17)
AdequateHL 21%(N=58) 24%(N=48) 12%(N=10)SBSQ-D TOT CAD T2DMInadequateHL 5%(N=11) 5%(N=11) notassessedAdequateHL 95%(N=190) 95%(N=190) notassessed
FCCHL-D TOT CAD T2DMInadequateHL 73%(N=146) 73%(N=146) notassessedAdequateHL 27%(N=55) 27%(N=55) notassessed
REALM-D TOT CAD T2DM<3rdgrade 0%(N=0) 0%(N=0) 2%(N=1)4-6thgrade 2%(N=5) 1%(N=2) 3%(N=3)7-8thgrade 17%(N=50) 17%(N=33) 18%(N=17)Highschool 81%(N=228) 82%(N=164) 77%(N=64)
vanderHeideI,2013[27]
theNetherlands Generalpopulationaged>15years(N=925)
HLS-EU-Q47Score0–25:inadequate25–33:problematic33–42:sufficient
Concerning the four competencesof assessing, understanding, appraising andapplyinghealthinformation,themeanscoreswereconsideredsufficientexceptforapplyingthatregisteredaproblematicscore.Accessing:mean35.2Understanding:mean36.8
19
42-50:excellent Appraising:mean36.7Applying:mean28.9
HussonO,2015[28]
theNetherlands Patientswithcolorectalcancer(N=1643)
1-itemofSBSQ
LowHL:14%(N=224)MediumHL:45%(N=725)HighHL:42%(N=677)
SlonskaZA,2015[29]
Poland Generalpopulationaged>15years(N=1000)
HLS-EU-Q86Score:0–25:inadequate25–33:problematic33–42:sufficient42-50:excellent
LimitedHL:44.6%SufficientHL:35.9%ExcellentHL:19.5%
EspanhaR,2016[30]
Portugal Generalpopulation(N=2104)
HLS-EU-Q86Score:0–25:inadequate25–33:problematic33–42:sufficient42-50:excellent
LimitedHL:49%Inadequate: 11%Problematic:38%NotlimitedHL:51%Sufficient:41.4%Excellent:8.6%
PaivaD,2017[31] Portugal Participants:N=249Physicians(N=53)Healthresearchers(N=45)Otherresearchers(N=50)Generalpopulation(N=101)
NVS-PTScore:0-1: high likelihood oflimitedHL2-3:possibilityoflimitedHL4-6:adequateHL
Physicians Healthresearchers
Otherresearchers
Generalpopulation
HighlikelihoodoflimitedHL
0%(N=0) 0%(N=0) 0%(N=0) 57.4%(N=58)
PossibilityoflimitedHL
0%(N=0) 11.1%(N=5) 8%(N=4) 23.8%(N=24)
AdequateHL 100%(N=53) 88.9%(N=40) 92%(N=46) 18.8%(N=19)
PiresC,2018[32] Portugal Generalpopulation(N=484)
SAHLPA-23Score:0-19:inadequateHL20-23:adequateHL
InadequateHL:52.8%(N=256)AdequateHL:47.2%(N=228)
20
FranzenJ,2013[33]
Switzerland Patientsaged35–70yearswithtype2diabetes(N=493)
1-itemofSBSQ
LowHL:7.3%(N=36)MediumHL:42.0%(N=207)HighHL:50.7%(N=250)
ZuercherE,2017[34]
Switzerland Non-institutionalizedpatientswithdiabetes(N=381)
1-itemofSBSQ
LowHL:6.8%(N=26)MediumHL:40.7%(N=155)HighHL:52.5%(N=200)
vonWagnerC,2007[35]
UnitedKingdom Generalpopulation(N=719)
TOFHLAScore:0-59:inadequate60-74:marginal75-100:adequate
InadequateHL:5.7%(N=41)MarginalHL:5.7%(N=41)AdequateHL:88.6%(N=637)
21
Table2.Individuals’self-assessmentofeHealthSkills.FirstAuthor,
Yearofpublication
Country SettingandN Methods Results
VincenteMR,2017[16]
AustriaBelgiumBulgariaCyprusCzechRepublicGermanyDenmarkEstoniaSpainFinlandFranceUnitedKingdomGreeceCroatiaHungaryIrelandItalyLithuaniaLuxembourgLatviaMaltaNetherlandsPolandPortugalRomaniaSwedenSloveniaSlovakia
Generalpopulationaged>14years(N=26566)
Score:Category1:TotallydisagreeTendtodisagreeCategory2:TendtoagreeCategory3:Totallyagree
Q:DoyouknowhowtoseektheInternetforhealthinformation?
Category1 Category2 Category3
Austria 7% 36% 57%Belgium 6% 44% 51%Bulgaria 4% 33% 64%Cyprus 5% 23% 72%CzechRepublic 7% 45% 48%Germany 9% 40% 51%Denmark 5% 33% 62%Estonia 4% 42% 55%Spain 6% 44% 49%Finland 8% 51% 41%France 7% 46% 47%UnitedKingdom 3% 37% 60%Greece 8% 43% 49%Croatia 5% 48% 47%Hungary 8% 38% 54%Ireland 6% 40% 54%Italy 6% 64% 30%Lithuania 5% 34% 61%Luxembourg 8% 49% 43%Latvia 11% 52% 37%Malta 10% 31% 59%Netherlands 6% 40% 54%Poland 5% 55% 39%Portugal 6% 34% 60%Romania 6% 33% 62%Sweden 2% 29% 69%
22
Slovenia 12% 38% 50%Slovakia 5% 51% 44%
