Open Access Highly Accessed Research article

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

Kristine Sørensen1*, Stephan Van den Broucke2, Jürgen M Pelikan3, James Fullam4, Gerardine Doyle5, Zofia Slonska6, Barbara Kondilis78, Vivian Stoffels1, Richard H Osborne9, Helmut Brand1 and on behalf of the HLS-EU Consortium

Author Affiliations

1 Department of International Health, CAPHRI, Faculty of Health, Medicine and Life Sciences, Maastricht University, P.O. Box 616, 6200, Maastricht, MD, the Netherlands

2 Department of Psychology, Catholic University of Louvain, Leuven, Belgium

3 Ludwig Boltzmann Institute Health Promotion Research, Vienna, Austria

4 School of Public Health, Physiotherapy and Population Science and School of Business, University College Dublin, Dublin, Ireland

5 School of Business, University College Dublin, Dublin, Ireland

6 The Cardinal Wyszyński Institute of Cardiology, Warsaw, Poland

7 Hellenic American University, Manchester, NH, USA

8 Hellenic American Education Center, Athens, Greece

9 Public Health Innovation, Deakin Population Health Strategic Research Centre, Deakin University, VIC 3125, Melbourne, Australia

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BMC Public Health 2013, 13:948  doi:10.1186/1471-2458-13-948

Published: 10 October 2013



Several measurement tools have been developed to measure health literacy. The tools vary in their approach and design, but few have focused on comprehensive health literacy in populations. This paper describes the design and development of the European Health Literacy Survey Questionnaire (HLS-EU-Q), an innovative, comprehensive tool to measure health literacy in populations.


Based on a conceptual model and definition, the process involved item development, pre-testing, field-testing, external consultation, plain language check, and translation from English to Bulgarian, Dutch, German, Greek, Polish, and Spanish.


The development process resulted in the HLS-EU-Q, which entailed two sections, a core health literacy section and a section on determinants and outcomes associated to health literacy. The health literacy section included 47 items addressing self-reported difficulties in accessing, understanding, appraising and applying information in tasks concerning decisions making in healthcare, disease prevention, and health promotion. The second section included items related to, health behaviour, health status, health service use, community participation, socio-demographic and socio-economic factors.


By illuminating the detailed steps in the design and development process of the HLS-EU-Q, it is the aim to provide a deeper understanding of its purpose, its capability and its limitations for others using the tool. By stimulating a wide application it is the vision that HLS-EU-Q will be validated in more countries to enhance the understanding of health literacy in different populations.

Health literacy; Survey; Measurement; Tool; Population