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InternationalJournalof
EnvironmentalResearch
andPublicHealth
Article
HealthLiteracyinPortugal:ResultsoftheHealthLiteracy
PopulationSurveyProject2019–2021
MiguelArriaga1,2,*,RitaFrancisco2,PauloNogueira3,4,JorgeOliveira5,CarlotaSilva1,GiseleCâmara6,
KristineSørensen7,ChristinaDietscher8andAndreiaCosta3,6
1DivisãodeLiteracia,SaúdeeBem-Estar,Direção-GeraldaSaúde,1049-005Lisbon,Portugal;
.******@
2CatólicaResearchCentreforPsychological—FamilyandSocialWellbeing(CRC-W),FaculdadedeCiências
Humanas,UniversidadeCatólicaPortuguesa,1649-023Lisbon,Portugal;******@
3InstitutodeSaúdeAmbiental(ISAMB),FaculdadedeMedicina,UniversidadedeLisboa,
1649-028Lisboa,Portugal;paulo.******@(.);******@(.)
4LaboratóriodeBiomatemática,InstitutodeMedicinaPreventivaeSaúdePública,FaculdadedeMedicina,
UniversidadedeLisboa,1649-028Lisbon,Portugal
5DigitalHuman-EnvironmentandInteractionLab(HEI-Lab),SchoolofPsychologyandLifeSciences,
UniversityLusófona,1749-024Lisbon,Portugal;jorge.******@
6NursingResearch,InnovationandDevelopmentCentreofLisbon(CIDNUR),NursingSchoolof
Lisbon(ESEL),1990-096Lisbon,Portugal;******@
7GlobalHealthLiteracyAcademy,8240Risskov,Denmark;******@
8AustrianMinistryofHealth,HealthPromotionandDiseasePrevention,1010Vienna,Austria;
christina.******@
*Correspondence:******@-

Abstract:Healthliteracyentailstheknowledge,motivation,andcompetenciestoaccess,understand,
Citation:Arriaga,M.;Francisco,R.;appraise,andapplyhealthinformationinordertomakejudgmentsanddecisionsineverydaylife
Nogueira,P.;Oliveira,J.;Silva,C.;concerninghealthcare,diseaseprevention,andhealthpromotiontomaintainorimprovequalityof
Câmara,G.;Sørensen,K.;
Dietscher,C.;Costa,
modiflabledeterminantofhealthdecisions,healthbehaviors,health,
LiteracyinPortugal:Resultsofthe

Project2019–.
PublicHealth2022,19,://ThisstudyaimedtodescribetheprocessofadaptationtoPortugaloftheshort-formversionofthe
/ijerph19074225HealthLiteracySurvey(HLS19-Q12)fromtheHealthLiteracyPopulationSurveyProject2019–2021,

AcademicEditor:
,

plustheHLS19-Q12questionnaireandthespeciflchealthliteraciespackagesondigitalhealthliteracy,
Received:4February2022navigationalhealthliteracy,
Accepted:30March2022inPortugal(mainland)havehighhealthliteracylevelsandsupporttheresultsofotherstudies
Published:,theresults
Publisher’sNote:MDPIstaysneutralsuggestthat“navigationinthehealthsystem”tasksarethemostchallengingtasksregardingspeciflc
-Q12asafeasiblemeasuretoassesshealth
publishedmapsandinstitutionalaffll-,itcanbeusedinPortugaltoassessthepopulation’s

societal,environmental,personal,andsituationalmodiflabledeterminantfactors.
Keywords:healthliteracy;HealthLiteracySurvey;digitalhealthliteracy;navigationalhealthliteracy;
Copyright:©2022bytheauthors.
vaccinationhealthliteracy;psychometry
LicenseeMDPI,Basel,Switzerland.
Thisarticleisanopenaccessarticle
distributedunderthetermsand
conditionsoftheCreativeCommons
Attribution(CCBY)license(
,beingdebatedinhealth
/).careandpublichealthcontexts,andhasevolvedsincethenasatheoreticalconcept,leading
,19,:///ijerph19074225:.
,19,42252of15
tothedevelopmentofdifferentmeasuringinstrumentsandinterventionstopromotehealth
literacy[1].Facingthelackofaconsensusaboutthedeflnitionofhealthliteracyorits
conceptualdimensions,Sørensenandcolleagues,fromtheConsortiumoftheEuropean
HealthLiteracyProject(HLS-EU2009–2012),conductedastudycapturingevidence-based
dimensionsofhealthliteracyandproposedanintegrateddeflnitionandacomprehensive
modelofhealthliteracy[1].Thisstudyanditsproductsservedasabasisfordevel-
opingamultidimensional,comprehensivequestionnairetomeasurehealthliteracyin
thegeneralpopulation,theHLS-EU-Q47,containing47itemsacross12subdomains[2].
TheHLS-EU-Q47,supplementedwithanadditionalsectionwith39itemsreferringtode-
terminantsandconsequencesoutlinedintheconceptualmodel(HLS-EU-Q86),wasused
toconducttheflrstcomparativeEuropeanHealthLiteracySurvey(HLS-EU)in2011[3].
ThisflrstHLS-EUwasconductedineightofthe27EuropeanUnioncountries:Austria,
Bulgaria,Germany,Greece,Ireland,theNetherlands,Poland,andSpain,comprising

(general)%ofthetotalsurveyedpopulation
hadaninadequatelevelofhealthliteracy,%inthe
%%ofcitizensshowedlimitedhealthliteracy
(inadequateorproblematic),%%in
,lowsocialstatus,
loweducation,oroldagehadhigherproportionsoflimitedhealthliteracy[3].
Threeyearslater,PortugalconductedasurveyusingtheHLS-EU-
demonstratedthatthegeneralhealthliteracylevelsofthePortuguesepopulation(mainland)
,11%of
respondentsshowedinadequatehealthliteracylevels,andaround38%showedproblematic
,amongthe50%ofrespondentswithadequatehealthliteracy
levels,%showedexcellentones[4].
AsstatedbyHLS-EUConsortium,monitoringhealthliteracycansupportprofes-
sionalandpoliticaldecisionmakingtoimprovehealthliteracytobenefltthepopulation’s
health[3].Forthispurpose,undertheumbrellaoftheWorldHealthOrganization’sEu-
ropeanHealthInformationInitiative,theActionNetworkonMeasuringPopulationand
OrganizationalHealthLiteracy(M-POHL)
PopulationSurveyProject2019–2021(HLS19)istheM-POHL’
collectcomparativedataonthepopulation’shealthliteracyinasmanymemberstatesof
theWorldHealthOrganizationEuropeanRegionaspossible[5].
HLS19buildsupontheflrstEuropeanHealthLiteracySurveyandtheWorldHealth
Organization’sbooklet“Healthliteracy:thesolidfacts”,andistheresultofasystematic
,it
considersasitsconceptualframeworktheintegrativeconceptdevelopedbytheEuropean
HealthLiteracyConsortium[5]:“Healthliteracyiscloselylinkedtoliteracyandentailsthe
knowledge,motivationandcompetenciestoaccess,understand,appraise,andapplyhealth
informationinordertomakejudgmentsandtakedecisionsineverydaylifeconcerning
healthcare,diseasepreventionandhealthpromotiontomaintainorimprovequalityoflife
throughoutthelifecourse”[1]().Thisintegrativeconceptisbasedonapreviousstudy
thatproposesacomprehensivehealthliteracymodelthatconsiders12domainsofhealth
literacy,proximalanddistalfactorsthatimpacthealthliteracy,aswellasthepathways
linkinghealthliteracytohealthoutcomes[1].
ThegenericHLS19questionnairewasbuiltontheHLS-EU-
theperceivedlengthimplementationofHLS-EU-Q47intoaccount,thenewversionof
HLS19alsoconsiderstwoshortformsof12and16items(HLS19-Q12andHLS19-Q16,
respectively),besidestheHLS19-
generalhealthliteracy(HL),threespeciflcdomainsofhealthliteracy—healthpromotion,
diseaseprevention,andhealthcare(ormanagingdisease)—aswellasfouraspectsof
health-relatedinformationmanagement,toflnd/access,understand,evaluate,andapply
informationrelevantforhealth[5].:.
,19,42253of15
InPortugal,weoptedtoadaptthecorehealthliteracymeasurementquestions(HLS19-
Q12version)andthreeoptionalpackages—DigitalHealthLiteracy(HLS19-DIGI),Nav-
igationalHealthLiteracy(HLS19-NAV),andVaccinationHealthLiteracy(HLS19-VAC).
Upto20countrieshavealreadycommittedthemselvestoparticipatinginHLS19,and
Portugalisoneofthem[5].Therefore,aspartoftheM-POHLandcomplyingwithwhat
wassuggestedinthePortugueseHealthLiteracyActionPlan[6],theDirectorate-General
ofHealthconductedanewassessmentofthehealthliteracyofthePortuguesepopulation
(mainland),whoseresultswillcontributetodevelopingpoliciesandinitiativestopro-
motehealthliteracy,monitoringtheirimplementation,andcomparingresultswithother
,which
aimedto:
translateandadaptHLS19tools(HLS19-Q12andthreeoptionalpackages)forassessing
personalhealthliteracyinPortugal;
explorepsychometriccharacteristicsofthePortugueseHLS19Questionnaire(HLS19-Q12);
establishhealthliteracylevelsinthePortuguesepopulation;
measurenewtopicsonhealthliteracy,speciflcallydigitalhealthliteracy(HL-DIGI),
navigationalhealthliteracy(HL-NAV),andvaccinationhealthliteracy(HL-VAC)in
thePortuguesepopulation;
exploreassociationsbetweenhealthliteracylevelsandsomehealthliteracycorrelates
(determinantsandconsequences)inthePortuguesepopulation.

ThestudypopulationconsistedoftheinhabitantsofPortugal(mainland),above
16yearsold,
basedonstratifledrandomsampling,withreplacement,accordingtothedistributionof
thePortuguesepopulationonthefollowingvariables:(i)numberofresidentsbyNUTS
III(NUTS—NomenclatureofTerritorialUnitsforStatistics),(ii)gender,and(iii)large
agegroups.
DatacollectionwasconductedaccordingtotheformatofComputerAssistedTele-
phoneInterviewsforindividualslivinginPortugal(mainland)throughatelephoneline

averagetimeofthecallswas20min.
Toachieve1247validinterviews,atotalnumberof6749phonecallsweremade.
Fromthese,4492werenotanswered,
1555surveys,30werenotsuccessfullyvalidated(percentagehigherthan20%ofdata
incomplete).Therefore,theparticipationrateinthissurveywas69%.
Thequestionnaireusedinthisstudycomprisedthecorehealthliteracymeasure-
mentquestions(HLS19-Q12),alongwith31corecorrelatesitems(relevanthealthinfor-
mation;determinants;supportfromothers;biometricvariables;healthhabits;health
perception;anduseofemergencyservices)andthreeoptionalpackages(DigitalHealth
Literacy,—16additionalitems;NavigationalHealthLiteracy,—12additionalitems;and
VaccinationHealthLiteracy,—14additionalitems),asshowninTable1.
.
HLMeasurementHLCorrelates
HLSCoreHLS-Q12ShortVersionwith12ItemsMandatoryCorrelatesforGeneral
1919HLMeasurement(31Items)
forMeasuringGeneralSuchasAge,Education,
HealthLiteracySocioeconomicStatus,etc.
DigitalHealthLiteracySub-scalewith16itemsformeasuringdigitalhealthliteracy
(HLS19-DIGI)
OptionalpackagesNavigationalHealthSub-scalewith12itemsformeasuringnavigationalhealthliteracy
Literacy(HLS19-NAV)
VaccinationHealthSub-scalewith14itemsformeasuringvaccinationhealthliteracy
Literacy(HLS19-VAC):