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

Melanie Hawkins, Stephen D Gill, Roy Batterham, Gerald R Elsworth, Richard H Osborne

The 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. Sixteen 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. Highest 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. This 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.