This study validated the Asante Twi (Local Ghanaian language) version of the HLQ in a sample of 1234 mothers with children under five years. This target group was selected because we needed the HLQ to assess the impact of a community malaria programme for children under five years on the health literacy levels of caregivers. The interpretation of the findings from this study is discussed in the context of previous HLQ validation studies in other languages and in the context of the current study.
The results of the nine-factor CFA show that the model has a good fit. However, in the one-factor analysis, the scale 9 ‘Understanding health information well enough to know what to do´ seemed to have high point estimates for RMSEA > 0.1 and low estimates for CFI and TLI ≤ 0.95, which means the model fits less well. Debussche et al.(22) reported a similar finding in the validation study of the French version of HLQ, where all scales had a good fit except scale 9. Furthermore, we observed that some question items of scale 9 loaded negatively on the scale although close to zero, a finding that stands out from other studies. This means the items negatively influence the scale or do not contribute to the understanding of health information well enough to know what to do. The items included the questions how easy or difficult do you find it to: 1) accurately follow the instructions from healthcare providers? and 2) understand what health providers are asking you to do? Both questions reveal how people respond to instructions from health providers and should load well on understanding health information; this was, however, not the case in this context. This could be attributed to the translation and how the translated questions may have altered the intended meaning. As noted from the consensus meeting, many deliberations and discussions were assigned to these two questions, because the backward translations sounded stronger, exaggerating the intended meaning of the original version. However, the forward translations were approved as the panel agreed that they fitted the meaning of the original English version. Nonetheless, it is likely that the accepted forward translations might have had stronger meanings than the original version, and thus the exaggerations resulting from the translations might have shifted the focus from understanding to applying the information. This means that respondents may have focused on their ability to apply the information when answering these two questions. This could explain why they did not load well on the scale intended to measure understanding of health information. We therefore call for a re-examination of scale 9, especially the translations of the two questions of interest since this was not observed in other validation studies (9, 19–21).
The difficulty levels of the scales appear to be higher than other validation studies except the Chinese(23), which was quite similar. However, the high difficulty levels in the Chinese study could be due to the sample consisting of older adults (60 years and above)(23). This is supported by a similar finding by Bo et al, reporting that older adults are more likely to lack sufficient health literacy skills(3). A high range of difficulty levels was primarily found in the second part of the questionnaire (scales 6 to 9), which is in line with findings from other validation studies on the HLQ (9, 19–21, 23). However, the range of difficulty level for scales 6–9 from our findings is also higher (0.21–0.68) compared with the original English version (0.08–0.42), but in line with the French version of the HLQ (0.32–0.69). The higher difficulty levels found for HLQ part 2 indicates a larger health literacy gap and suggests that most caregivers in this study need some form of support to empower them in their engagements with the health system for better health care and health outcomes.
Within HLQ Part 1, scale 1 ‘Feeling understood and supported by healthcare providers’ shows high difficulty levels for all of the four items ranging from 0.50–0.54. Comparatively, the difficulty levels for the items in this scale were higher than that recorded in the other validation studies(9, 19–23) with the lowest levels ranging from 0.10–0.19 for the Australian version (original version). Considering the differences in development among the referenced countries, this result is expected from a relatively low resource setting such as Ghana.
The lack of health personnel in the Ghanaian health system may partly explain that as many as 60% of respondents report not having health provider support. Ghana has low provider to population ratios for both doctors (1 to 8481) and nurses(1 to 627) (27), thus, patients are likely not to get enough time with their healthcare providers. Furthermore, the low provider-patient ratios lead to pressure on the health workers that may negatively impact on their reliability and responsiveness(28). This makes it difficult to have at least one healthcare provider to consistently support patients making health decisions. Thus, health provider support might not be a strong feature of the health system, and it is not surprising to see low scores in this study. In a better-resourced health system with good coverage and access, the scale ‘Feeling supported by healthcare providers’ would to a larger extent reveal individual competences in benefitting from the support from the health system compared with low resource settings, where access to such support is more limited. Thus, although the scale shows the ability of an individual to engage with health providers, it is likely also to reflect how the health system is responsive to the needs of the individuals depending on the setting. Any intervention to address low levels of health literacy in this dimension might differ between low and high resource settings, with focus on individual competences in the well-resourced system, as opposed to a focus on health system gaps and organisational responsiveness to health literacy in poorly resourced systems.
Almost 90% of the respondents in our study spoke a local language at home and only 10% spoke English at home. The difference in mean scores between these two groups in Table 4 showed that the English speakers scored higher in especially the last four scales, including navigating the health system. In this paragraph, we discuss language as a barrier (10, 11, 29) to navigating health systems especially when the official language is different from the local language(s). As English serves as the official language in Ghana, most written health information is in English, including labels on medications. This works well for English speakers at the detriment of most of the population. It is not surprising that for items 9.3 and 9.4 (read and understand written health information; read and understand medication labels) most respondents (68% and 64%, respectively; Table 2) had low scores, and thus found the task to be difficult. Such low scores were not evident in the other validation studies (19, 21–23), probably because their official language was predominantly the most spoken language in the country. Contrary to these low scores, the majority (> 70%) of respondents found it easy to understand and follow health information given orally (items 9.2 and 9.5). Such information is most likely presented in the local language. Hence, apart from the difference between oral and written information per se, respondents may also find it relatively easy to understand health information in the local language compared with the official language.
Discussions on language barriers to access and use of healthcare systems have led to changes in policies in western countries concerning adding interpreters or providing language courses for the target population who do not speak the official language(10, 11), e.g. immigrants and the Inuit population may not be good at speaking the official language of the country(11, 29). Sometimes the ability of an individual to read and write does not necessarily mean that the person can comprehend the meaning of the words(30). Although English is known by almost all groups across Ghana, it is not the day to day spoken language by most people and may thus hinder access to and effective use of the health system. Although healthcare providers speak the local languages, some messages might be lost in translation(11) and it becomes more problematic when the inscriptions on medications, medical forms and the information to navigate the health system are also in the official language. The challenge might be to provide written health information in all languages and dialects because of non-documentation of some of the dialects. Nevertheless, there is good reason to raise such discussions in countries facing similar language issues to find policies and approaches to curb this problem. The above also emphasises the importance of translating the questionnaire even in settings with English as the official language. Even if the questionnaire could be maintained in English, cultural and contextual adaptation might be necessary, e.g. perception of a health care provider and nuances of emphasis on certain meanings.
Strengths and limitations
Although the HLQ is one of the recommended tools by WHO(12) in low and middle income countries, this is the first validation study on the HLQ in Africa and thus serves as a first-hand information on how this tool works in an African context. We translated the HLQ to the most commonly spoken Ghanaian language and validated it using a relatively large sample. The validated Twi version of the HLQ can now be considered for assessment of health literacy in Ghana and other neighbouring countries such as Benin and Côte D'Ivoire, which have sub-populations speaking Twi. This could also be useful in countries with a higher number of residents of Ghanaian origin to describe their health literacy profiles.
However, the interpretations of findings are limited to a special group of the Ghanaian population being caregivers with children under five years, because the HLQ was needed to assess the impact of a malaria programme for children under five on the health literacy levels of their caregivers. Caregivers, especially mothers, influence the health status of their families and are thus key people to target to improve health literacy. Our interest in this special group, however, limits the generalisability of the findings. Hence, we recommend testing the questionnaire in other population groups to improve its usefulness in the general population. Another limitation is the potential response bias, as a questionnaire on malaria preceded the HLQ. The sequence might have steered responses to reflect health literacy in managing malaria in children under five rather than managing general health as intended. It might be easier for a caregiver to agree to a statement like “I feel I have enough information to manage my health”, if the person has malaria in mind. This is because the high prevalence of malaria has led to much familiarity with health information on the disease(31). However, we expect that a caregiver, who is for example confident in having sufficient information and in navigating the health system when reflecting on malaria, is in general likely to be more confident and be able to navigate the health system. Therefore, we believe that this potential bias is minor and would not likely alter the findings. Furthermore, malaria is the most common health condition accounting for 40% of all outpatient cases at health facilities (32). Using it as a proxy for health literacy is thus appropriate.