Measuring general health literacy using the HLS19-Q12 in specialty consultations in Spain | BMC Public Health

This study used the HLS₁₉-Q12 to calculate HL score and determine general HL of a patient population attending specialty consultations in the region of Aragon, Spain. It further created a sociodemographic profile and examined relationships between those variables and HL scores. It is believed that this was the first time the HLS₁₉-Q12 has been used in Spain, and in the Spanish language.

The comprehensive project describing results of the HLS₁₉-Q12 across large general populations in 17 countries reported a median HL score of 64 with a mean of 65 [16]. This study population had a median score of 67 and mean score of 66, which is in alignment with the findings from the 17 country study. Our results showed that 59% of respondents had HL categorized as inadequate or problematic, while 41% had sufficient or excellent HL. In comparison, a study using the HLS₁₉-Q12 in Portugal reported notably higher HL with only 30% of the population categorized as inadequate or problematic, and 70% possessing sufficient or excellent HL [20].

The study found a statistically significant difference in the HL between patients with different work situations. The category of “studying” was included in the choices of work situation. Patients who were currently studying recorded the highest HL scores. This could be that individuals who are already in learning mode and are actively exploring new ideas and concepts are more open or receptive to processing current and new health information.

The ANOVA results showed that income had a relationship to HL score. A study in Valencia, Spain found that population subgroups such as low-income individuals presented with a higher degree of inadequate or problematic HL [8]. Our findings support this and other studies that suggest a relationship between low-income levels and limited HL [7, 9, 11].

Numerous studies cite the relationship between age and HL, stating that older individuals generally have lower scores [8, 21,22,23]. Our results did not support previous findings. The influence of older age could have been diminished by the presence of younger family members and caregivers at the appointment during which the survey was completed. The principal researcher noted that older participants frequently deferred to the opinions or help of the person accompanying them during the visit when completing the survey.

As shown in Table 4, individuals who reported their health status as ‘very good’ had significantly higher HL than those who reported their health status as any of the inferior categories. This finding is in keeping with a large European study by Sorensen et al. (2015) which found that people who reported their health status as ‘very bad’ or ‘bad’ experienced the highest proportion of limited HL.

In total, 56% of participants found it difficult or very difficult to decide how to ‘protect themselves from illness using information from the mass media.’ This was the survey item with the second lowest mean score. These findings are in line with research that shows public uncertainty and distrust with “fake news,” social media, and artificial intelligence [11, 24,25,26], and highlights the need to ensure that individuals are equipped to identify health misinformation received from mass media sources.

There was no statistically significant relationship between the number of times the patient had visited the specialty consultation and their HL score, except in the case of those who had 5–6 prior appointments. Patients who had 5–6 appointments had a significantly lower HL score than those who had > 6. This is noteworthy, as it suggests that the quantity of visits does not necessarily reflect the quality of those encounters. A mere visit does not necessarily mean that patients are understanding, learning, and better equipped to manage and act upon healthcare information.

Results further showed that patients who self-reported as having diabetes had significantly higher mean HL scores than those who reported having cardiovascular disease, digestive illness, hypertension, cancer, or respiratory conditions. This is not surprising, as people with diabetes often require quarterly condition management appointments, and many attend educational sessions regarding medication management, nutrition, and lifestyle practices. It is also a condition that normally requires lifelong management [27]. This suggests that frequent interactions with healthcare providers where health information is exchanged over long periods of time may improve patient HL.

Limitations and future research

This study presents both valuable opportunities as well as weaknesses. The sample size for this study was small, and we recommend the additional use of the HLS₁₉-Q12 in Spain on a sample size similar to those in the 17 country validation studies (n > 1,000) [16]. We surveyed a non-randomized sample of patients in a specialized care setting. The HLS₁₉-Q12 should further be administered to a randomized sample of patients in a more general care setting. Finally, as no other studies could be found that specifically measured the HL of patients in specialty consultations, our ability to make direct comparisons was limited.

While various studies have measured general HL, reinforced that HL is often low, and determined that a relationship exists between certain sociodemographic variables and general HL, more studies are needed to explore the solutions to these identified problems [7, 9, 11, 21, 22, 28]. One worthy direction for future research is to explore the HL awareness and skills of healthcare providers themselves. This is essential to determine if healthcare providers understand the concept of HL, the role it plays in health outcomes, and whether they possess the necessary skills to transmit health information in ways that are understandable and meaningful to patients [4, 29,30,31].

Since it has been shown that HL affects populations, further research is warranted on what countries can do at the systems level to increase general HL. Health policies, literacy campaigns, amending or creating service design and healthcare delivery should continue to be explored [6, 32]. In the private sector, hospitals and care networks are often more agile and able to restructure services to meet users’ needs in innovative and alternative ways. Thus, studies should determine how HL is or can be addressed in these private care settings [33].

Given the rapidly increasing use of virtual care settings and telemedicine, it is necessary to continue to analyze how these venues affect general HL, as well as how a person’s general HL influences their use of such care settings. When healthcare providers choose these care mediums, the actual HL of patients, in addition to opportunities to improve general HL, should be considered in the design, functionality and ease of use.

Finally, increasing numbers of people are looking to the internet and even using social media to diagnose and treat their medical concerns. Our results showed that people struggled with trusting health information from mass media. Therefore, while the study of e-health literacy has become more frequent, we recommend continued research that identifies ways to minimize disinformation and improve both general and e-health literacy when using the internet [34, 35].