Validity and reliability of the Turkish version of the HLS-EU-Q6 questionnaire

Validity and reliability of the Turkish version of the HLS-EU-Q6 questionnaire | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Validity and reliability of the Turkish version of the HLS-EU-Q6 questionnaire Müjdat YEŞİLDAL This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5145103/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 02 Aug, 2025 Read the published version in BMC Public Health → Version 1 posted 17 You are reading this latest preprint version Abstract Background Health literacy plays an important role in the effectiveness of health services by affecting individuals' ability to access, understand, and use health information. Many people in Turkey have limited health literacy. This study aimed to determine the psychometric validity and reliability of the Turkish version of the HLS-EU-Q6. Methods This psychometric study was conducted in two phases with 475 Turkish adults between January and March 2024. In the first stage, the scale was adapted into Turkish. Content validity indices were used for content validity, and exploratory factor analysis (EFA) and confirmatory factor analysis (CFA) were used for construct validity. Discriminant analysis was used for reliability analysis, and Cronbach's alpha coefficient was used for internal consistency. Results The mean age of the 475 participants was 28.82 ± 9.75 years, and 65.5% were female. The health literacy level of 75.6% of the participants was determined as “problematic.” The content validity index of the scale was found to be 0.92. In exploratory factor analysis, factor loadings ranged between 0.664 and 0.853, and in confirmatory factor analysis, model fit indices were acceptable (x²/df=2.95, RMSEA=0.07, SRMR=0.07, TLI=0.92, GFI=0.95). In the reliability analysis, Cronbach's alpha coefficient was 0.82. Conclusions The Turkish version of HLS-EU-Q6 consistently showed acceptable psychometric reliability and validity characteristics. HLS-EU-Q Health Literacy Psychometric Validity Reliability Turkish Background Health literacy is a critical concept in public health and individual health management that refers to the ability of individuals to access, understand, evaluate, and use health-related information to make healthy decisions [1]. The level of health literacy has a direct impact on individuals' capacity to protect their health, prevent diseases, and maintain a healthy lifestyle, and low levels of health literacy are associated with adverse outcomes such as incorrect treatment decisions, inadequate disease management, and unnecessary use of health services [2, 3]. Therefore, measuring the population's health literacy level is critical for improving public health and increasing the effectiveness of health services. The Health Literacy Survey Europe (HLS-EU) is a comprehensive tool developed to measure levels of health literacy across Europe [4]. This questionnaire was developed to measure the capacity of individuals to acquire, understand, evaluate, and use health information. It is widely used to determine the level of health literacy in societies. The HLS-EU-Q6, the short form of the HLS-EU questionnaire, is designed to assess health literacy more quickly and practically and has become an important measurement tool, especially for researchers and health professionals. The questionnaire includes questions assessing individuals' access to health-related information, how they understand it, and their interactions with health services [5, 6]. Adaptation studies conducted in different countries have shown that the HLS-EU-Q6 is a reliable and valid instrument [7–10]. Studies conducted in Turkey show that the health literacy level of society is generally low, and this situation negatively affects the effective use of health services [11, 12]. Especially those living in rural areas, the elderly, individuals with low education levels, and those living with chronic diseases are defined as risk groups in terms of health literacy [13, 14]. In addition, low health literacy negatively affects individuals' access to health services and their ability to recognize disease symptoms early and evaluate health information [11, 15]. Such findings make the necessity of Turkish adaptation of the HLS-EU-Q6 and the potential of this tool to respond to the community's health needs even more important. When the literature was examined, it was determined that HLS-EU-Q47 and HLS-EU-Q16 versions were adapted into Turkish [16, 17]. However, the shorter length of the HLS-EU-Q6 is important for ease of use. The Turkish adaptation of the HLS-EU-Q6 will provide a reliable tool for health service providers, researchers, and policymakers to measure health literacy, enabling them to assess the population's access to health-related information and their ability to understand and use information. Methods Aim This study aims to determine the psychometric validity and reliability of the Turkish version of HLS-EU-Q6. Study Design and Participants This psychometric study used a cross-sectional design. The data were collected in Konya province, located in the Central Anatolia region of Turkey. In validity and reliability studies, the sample size should be 5 to 10 times the number of items, and according to the sample size recommended for psychometric validation studies, it should consist of 300 participants. Accordingly, the original scale consists of 6 items, and at least 300 samples should be reached [18–20]. Data collected from 475 people were used within the research scope. Instruments Personal information form It consists of six questions about the demographic characteristics of the participants, including age, gender, educational status, income, marital status, and the number of applications to health institutions in the last year. HLS-EU-Q6 The HLS-EU questionnaire consists of 4 versions, HLS-EU-Q86, HLS-EU-Q47, HLS-EU-Q16, and HLS-EU-Q6, within the European Health Literacy Project scope between 2009 and 2012 [21]. The HLS-EU-Q6 was created using the six items from the HLS-EU test. To make the HLS-EU-Q6 score, the categories and scores of the HLS-EU-Q47 were considered: “very easy” = 4; ‘fairly easy’ = 3; ‘fairly difficult’ = 2; ‘very difficult’ = 1; ‘don't know/refused’ = missing. The scale score is the mean value and ranges from 1 to 4. Only respondents who answered at least five items were included in the evaluation [22]. The scores obtained were evaluated as follows. All participants received scores ranging from 1 to 4. The scores were inadequate (HLS-EU-Q6 score ≤2), problematic (HLS-EU-Q6 score >2 and ≤3), and adequate (HLS-EU-Q6 score >3). Translation and Cultural Adaptation The translation process started after obtaining permission from the responsible author who developed the scale via e-mail. The translation and cultural adaptation stages were as follows: Translation, synthesis of translations, back translation, expert panel, piloting and cognitive review, and creation of the final version [23, 24]. The translation committee consisted of 3 fluent English-speaking native Turkish speakers, one public health specialist, one independent translator, and one psychological counselor with PhD degrees. In the first stage, the committee members translated the questionnaire into Turkish. In the second stage, the translations made by the committee were synthesized by the researcher and an expert fluent in both languages. In the synthesis stage of the translations, the errors were corrected, and the first version of the Turkish adaptation was created. In the third stage, three native English-speaking public health experts translated Turkish into English. In the fourth stage, the original version of the scale, the Turkish adaptation, and the retranslation into the original language were evaluated by a panel of 10 experts, including academicians and public health experts. The purpose of the expert panel was to assess the scale in terms of content and content validity by evaluating the inadequacy of the expressions in the translation and the inconsistencies between the two languages. The experts assessed the items as “Appropriate,” “Appropriate but should be corrected,” and “Should be removed.” In the fifth stage, it was presented to a group of 45 graduate students in the health sciences field to evaluate the statements' comprehensibility. TR-HLS-EU-Q6 was created with the suggestions from the pilot application group. Data collection The study data were collected online via Google Forms between January and March 2024. After obtaining ethics committee permission, the survey link was sent to the participants via social media groups. It took an average of 6 minutes for participants to complete one questionnaire. The questionnaire included an informed consent form, personal information form, and TR-HLS-EU-Q6. Data analysis The collected data were analyzed using Statistical Package for Social Sciences for Windows (SPSS) 27.0 and Analysis of Moment Structures (AMOS) 26.0 programs. The conformity of the data to normal distribution was evaluated according to the kurtosis and skewness results. Since Skewness and Kurtosis coefficients are between -1 and +1, the data are normally distributed [23, 25]. The participants' sociodemographic characteristics were summarized with descriptive analyses (number, percentage, mean, standard deviation). Content validity indices were used for content validity, and exploratory factor analysis (EFA) and confirmatory factor analysis (CFA) were used for construct validity. Discriminant analysis and internal consistency coefficient were used in reliability analyses. The internal consistency of the scale was evaluated using Cronbach's alpha. Principal component analysis and the varimax rotation method were utilized in EFA. In the evaluation of CFA, x2/df, RMSEA, SRMR, TLI, and GFI were used for goodness of fit. Acceptable values for goodness of fit were x 2 /df<5; RMSEA and SRMR0.9. [20, 26, 27]. The statistical significance level was set at 0.05. Ethical Considerations The Principles of the Declaration of Helsinki conducted the study. Before the study, approval was received from the Selçuk University Faculty of Health Sciences Non-Interventional Research Ethics Committee (Date: 29.11.2023 Decision No: 2023/1213). In addition, all participants read the consent form before filling out the survey and completed the study after checking the "I agree to participate in the research" box. Results Participants’ characteristics A total of 475 respondents participated. Table 1 shows the demographic characteristics of the participants, their frequency of applying to health institutions, and their health literacy levels. The mean age of the participants was 28.82 years (SD = 9.75), and 34.7% were 30 years of age or older. In gender distribution, 65.5% of the participants were female and 65.7% were single. Regarding education level, 27.6% were undergraduate graduates, and 34.9% were in the income group of 20,000₺ and below. The mean frequency of visits to health institutions in the last year was 7.29 (SD = 8.69), and 42.5% of the participants received health services 3-7 times, and 30.5% received health services eight or more times. This shows that the participants applied to health services frequently. The level of health literacy was measured with the TR-HLS-EU-Q6 index, and it was found that 75.6% of the participants had a problematic level of health literacy. In comparison, only 23.2% achieved adequate health literacy. The mean index score was 2.84 (SD = 0.38), ranging from 1.83 to 3.67. Table 1 Demographics of the test group (N = 475) Characteristics n (%) Age ≤ 22 163 (34.3) 23 – 29 147 (30.9) 30 ≥ 165 (34.7) Mean (SD) 28.82 (9.75) Sex Male 164 (34.5) Female 311 (65.5) Marital Status Married 163 (34.3) Single 312 (65.7) Education High school and below 108 (22.7) Associate degree 128 (26.9) Bachelor degree 131 (27.6) Postgraduate degree 108 (22.7) Monthly income (₺) ≤ 20.000 166 (34.9) 20.001 – 40.000 161 (33.9) 40001 ≥ 148 (31.2) Number of applications to health institutions in the last year ≤ 2 128 (26.9) 3 – 7 202 (42.5) 8 ≥ 145 (30.5) Mean (SD) 7.29 (8.69) TR-HLS-EU-Q6 Inadequate 6 (1.3) Problematic 359 (75.6) Sufficient 110 (23.2) Mean index score (SD) 2.84 (0.38) Range 1.83 – 3.67 Item distributional statistics Table 2 summarizes the distribution of responses to the items in the TR-HLS-EU-Q6 questionnaire. Regarding “getting a second opinion from another doctor,” 68.6% of the participants found it “easy,” while 17.7% found it “difficult.” In the item “Making decisions about the disease using the information provided by the doctor,” 77.3% of the participants found it “easy,” and 18.9% found it “very easy.” While 52.2% found it “easy” to find information about mental health problems, 29.3% found it “difficult.” Assessing the credibility of health risks in the media was the most challenging item; 48.4% found it “difficult,” and 20.6% found it “very difficult.” “Finding activities for mental well-being” was found ‘easy’ by 62.3%, while 58.1% found it ‘easy’ to understand health promotion information. In general, evaluating media sources was more difficult, while using physician information and finding activities for mental well-being were more accessible. Table 2 Distributional statistics for individual TR-HLS-EU-Q6 items Items, n (%) Very difficult Difficult Easy Very easy 1. Judge when you may need to get a second opinion from another doctor 0 (0) 84 (17.7) 326 (68.6) 65 (13.7) 2. Use information the doctor gives you to make decisions about your illness 0 (0) 18 (3.8) 367 (77.3) 90 (18.9) 3. Find information on how to manage mental health problems like stress or depression 23 (4.8) 139 (29.3) 248 (52.2) 65 (13.7) 4. Judge if the information on health risks in the media is reliable 98 (20.6) 230 (48.4) 122 (25.7) 25 (5.3) 5. Find out about activities that are good for your mental well-being 0 (0) 69 (14.5) 296 (62.3) 110 (23.2) 6. Understand information in the media on how to get healthier 8 (1.7) 98 (20.6) 276 (58.1) 93 (19.6) Validity analysis Table 3 presents the factor loadings of the TR-HLS-EU-Q6 and assesses the relationship between health literacy and the questionnaire items. The results of the expert panel review were used to assess the content validity of the TR-HLS-EU-Q6. The content validity of the TR-HLS-EU-Q6 was calculated using the content validity index (CVI). Lawshe's (1975) method was used to calculate the CVI [28]. As a result of the analysis, it was determined that the CGI coefficient, which was defined as 0.92 for the whole scale, ranged between 0.88 - 0.95 for the items. The content validity values of the scale were found to be above the acceptable value of 0.80. Before factor analysis, the Kaiser Meyer Olkin (KMO) sample measurement adequacy test and Barlett sphericity test were performed to test the suitability of the data for factor analysis. The KMO coefficient of 0.78 indicates that the data are suitable for EFA. Barlett's test result was x2=330.33; SD=15 (p<0.001). Based on these findings, the sample size is sufficient, and the data is normally distributed. To examine the factor structure of TR-HLS-EU-Q6, the exploratory factor analysis principal component analysis method was used, and the Varimax method, which is the orthogonal rotation method, was used as the rotation method. As a result of Principal Component Analysis (PCA), the relationship of the items with health literacy was shown with factor loadings ranging from 0.664 to 0.853. The questionnaire items measured individuals' ability to evaluate doctor's recommendations (factor loading: 0.768), use information to make health-related decisions (0.664), find information to manage mental health problems (0.722), question health risk information in media sources (0.684), learn about activities that promote mental well-being (0.768), and understand media information about healthy living (0.853). In particular, the item on understanding health information in the media had the highest factor loading, indicating a very strong relationship regarding health literacy. Table 3 Factor loadings of TR-HLS-EU-Q6 (PCA, N = 475) Items Factor load 1. Judge when you may need to get a second opinion from another doctor 0.768 2. Use information the doctor gives you to make decisions about your illness 0.664 3. Find information on how to manage mental health problems like stress or depression 0.722 4. Judge if the information on health risks in the media is reliable 0.684 5. Find out about activities that are good for your mental well-being 0.768 6. Understand information in the media on how to get healthier 0.853 Table 4 shows the model fit indices of TR-HLS-EU-Q6. In confirmatory factor analysis, x 2 /df=2.95, RMSEA=0.07, SRMR=0.07, TLI=0.92 and GFI=0.95 provided an acceptable fit. [20, 26, 27]. A good relationship was found between the items and the scale. No covariance was made between the items since the correction indices were not significantly loaded. Table 4 Model fit indices Fit indices Acceptable value Model x 2 /df < 5 2.95 RMSEA < 0.08 0.07 SRMR 0.90 0.92 GFI > 0.90 0.95 Reliability analysis Discriminant analysis was conducted to test the discrimination of the items with the highest (27%) and lowest (27%) scores. Accordingly, the student t-test compared the lower and upper cut-off groups. For each mean item score, there was a significant difference between the low-scoring group (n=125) and the high-scoring group (n=125) (p<0.001). Cronbach alpha coefficient for TR-HLS-EU-Q6 was 0.82. Based on this value, it is seen that TR-HLS-EU-Q6 is highly reliable [28] Discussion This study evaluated the validity and reliability of the new version of TR-HLS-EU-Q6 based on the data obtained from participants living in Konya, Turkey. Adapting the scale to Turkish is of great importance in health literacy culture studies as a valid and reliable instrument can be used to obtain national and international data to be compared. The study findings showed good internal consistency, content validity, and construct validity, indicating that the TR-HLS-EU-Q6 can measure the Turkish population's health literacy level. CFA results for the 6-item structure of the Turkish version supported a single-factor structure. In addition, each item contributed to its own expected scale, providing evidence for construct validity. The content validity of the TR-HLS-EU-Q6 was assessed using CVI. According to the CVI results, the equivalence of the items in the Turkish form was evaluated. Content validity indices are expected to be above 0.80 [29]. In this study, the content validity index was at an acceptable level. Therefore, no item regarding content validity was removed from the scale. The construct validity of the scale was assessed using CFA. CFA is a type of structural equation modeling that reveals the relationships between items and factors [26]. Confirmatory factor analysis results showed that x 2 /df, RMSEA, SRMR, TLI, and GFI values showed an acceptable fit [20, 26, 27]. Since the correction indices had no significant loading, no covariance was made between the items [29]. In addition, discriminant analyses showed that each item captured the difference between the highest and lowest scorers. A study examining the French version of the HLS-EU-Q6 found that good construct validity was not achieved through Confirmatory Factor Analysis (CFA) and that scores on this version correlated poorly with other measures of health literacy and physician assessments. This study suggests that there are limitations in distinguishing between the health literacy levels of participants with average and high levels of health literacy [30]. Evaluating the Brazilian Portuguese version, the researchers found that the original classification criteria of the HLS-EU-Q6 should be modified to determine health literacy levels in Brazilian adults more accurately, and this finding highlights the importance of the effectiveness of cultural adaptation in different populations [8]. The HLS-EU-Q6, which was psychometrically evaluated in Brazil, showed a unidimensional structure with a high explained variance of 71.23% and was recognized as a reliable instrument for measuring health literacy for different population groups with good factor loadings and item discrimination [9]. A study of the Italian version confirmed that the Italian versions of the HLS-EU-Q16 and HLS-EU-Q6 questionnaires present a valid construct and are reliable and valid in the Italian general population. In this study, the internal consistency of the questionnaires was reported to be relatively high, and Cronbach's alpha coefficient was acceptable, indicating that the questionnaires can provide consistent results over time [22]. It was determined that the fit model of the Bengali HLS-EU-Q6 form was low, and some items may differ in certain demographic groups [10]. Although the HLS-EU-Q6 is reliable in different settings, its validity may vary depending on the population and requires cultural adaptation to categorize health literacy levels accurately. Measuring health literacy through the HLS-EU-Q6 can help health professionals identify the real needs of healthcare users and redirect interventions accordingly. It is recommended that future studies expand the application of this tool in other samples and populations, aiming to reveal the classification of health literacy levels in different regions. Conclusion As a result of the literature review, this is the first study to examine the psychometric properties of the HLS-EU-Q6 in the Turkish population. Our findings confirm that the short version of the HLS-EU, TR-HLS-EU-Q6, offers sufficient psychometric properties to measure the health literacy level of the Turkish population. Based on these results, it can be used to measure health literacy. Further research is needed to investigate its psychometric properties for widely validated applications. Abbreviations CFA Confirmatory Factor Analysis CVI Content Validity Index EFA Exploratory Factor Analysis GFI Goodness of Fit Index HLS-EU-Q European Health Literacy Survey Questionnaire KMO Kaiser-Meyer-Olkin PCA Principal Component Analysis RMSEA Root-Mean-Square Error of Approximation SRMR Standardized Root Mean Square Residual TLI Tucker Lewis Index TR-HLS-EU-Q6 Turkish European Health Literacy Survey Questionnaire Declarations Acknowledgments I want to thank our respondents for participating in the study. Author Contribution Writing first draft: MY; Data collection: MY; interpretation of data and statistical analysis: MY; Study concept, design, and critical revision: MY. The author read and approved the final article. Funding None Data Availability Data sharing is not applicable. All available data was included in the study. Ethics approval The ethics committee approval of the research was obtained from the Selçuk University Faculty of Health Sciences Non-Interventional Research Ethics Committee (2023/1213). Informed consent to participate was obtained from all participants Consent for publication Not applicable. Competing Interests The author had no relevant conflicts of interest. Author details Müjdat YEŞİLDAL, Department of Healthcare Management, Faculty of Health Sciences, Selçuk University, Konya, Türkiye References Nutbeam D. The evolving concept of health literacy. Soc Sci Med. 2008;67:2072–8. Berkman ND, Sheridan SL, Donahue KE, Halpern DJ, Crotty K. Low health literacy and health outcomes: an updated systematic review. Ann Intern Med. 2011;155:97–107. Kickbusch I, Pelikan JM, Apfel F, Tsouros AD. Health Literacy, the solid facts. Geneva: World Health Organization; 2013. Sørensen K, Pelikan JM, Röthlin F, Ganahl K, Slonska Z, Doyle G, et al. 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The level of health literacy has a direct impact on individuals\u0026apos; capacity to protect their health, prevent diseases, and maintain a healthy lifestyle, and low levels of health literacy are associated with adverse outcomes such as incorrect treatment decisions, inadequate disease management, and unnecessary use of health services [2, 3]. Therefore, measuring the population\u0026apos;s health literacy level is critical for improving public health and increasing the effectiveness of health services.\u003c/p\u003e\n\u003cp\u003eThe Health Literacy Survey Europe (HLS-EU) is a comprehensive tool developed to measure levels of health literacy across Europe [4]. This questionnaire was developed to measure the capacity of individuals to acquire, understand, evaluate, and use health information. It is widely used to determine the level of health literacy in societies. The HLS-EU-Q6, the short form of the HLS-EU questionnaire, is designed to assess health literacy more quickly and practically and has become an important measurement tool, especially for researchers and health professionals. The questionnaire includes questions assessing individuals\u0026apos; access to health-related information, how they understand it, and their interactions with health services [5, 6]. Adaptation studies conducted in different countries have shown that the HLS-EU-Q6 is a reliable and valid instrument\u0026nbsp;[7\u0026ndash;10].\u003c/p\u003e\n\u003cp\u003eStudies conducted in Turkey show that the health literacy level of society is generally low, and this situation negatively affects the effective use of health services [11, 12]. Especially those living in rural areas, the elderly, individuals with low education levels, and those living with chronic diseases are defined as risk groups in terms of health literacy [13, 14]. In addition, low health literacy negatively affects individuals\u0026apos; access to health services and their ability to recognize disease symptoms early and evaluate health information [11, 15]. Such findings make the necessity of Turkish adaptation of the HLS-EU-Q6 and the potential of this tool to respond to the community\u0026apos;s health needs even more important.\u003c/p\u003e\n\u003cp\u003eWhen the literature was examined, it was determined that HLS-EU-Q47 and HLS-EU-Q16 versions were adapted into Turkish [16, 17]. However, the shorter length of the HLS-EU-Q6 is important for ease of use. The Turkish adaptation of the HLS-EU-Q6 will provide a reliable tool for health service providers, researchers, and policymakers to measure health literacy, enabling them to assess the population\u0026apos;s access to health-related information and their ability to understand and use information.\u0026nbsp;\u003c/p\u003e"},{"header":"Methods","content":"\u003ch2\u003eAim\u003c/h2\u003e\n\u003cp\u003eThis study aims to determine the psychometric validity and reliability of the Turkish version of HLS-EU-Q6.\u003c/p\u003e\n\u003ch2\u003eStudy Design and Participants\u003c/h2\u003e\n\u003cp\u003eThis psychometric study used a cross-sectional design. The data were collected in Konya province, located in the Central Anatolia region of Turkey. In validity and reliability studies, the sample size should be 5 to 10 times the number of items, and according to the sample size recommended for psychometric validation studies, it should consist of 300 participants. Accordingly, the original scale consists of 6 items, and at least 300 samples should be reached\u0026nbsp;[18\u0026ndash;20]. Data collected from 475 people were used within the research scope.\u003c/p\u003e\n\u003ch2\u003eInstruments\u003c/h2\u003e\n\u003ch3\u003ePersonal information form\u003c/h3\u003e\n\u003cp\u003eIt consists of six questions about the demographic characteristics of the participants, including age, gender, educational status, income, marital status, and the number of applications to health institutions in the last year.\u003c/p\u003e\n\u003ch3\u003eHLS-EU-Q6\u003c/h3\u003e\n\u003cp\u003eThe HLS-EU questionnaire consists of 4 versions, HLS-EU-Q86, HLS-EU-Q47, HLS-EU-Q16, and HLS-EU-Q6, within the European Health Literacy Project scope between 2009 and 2012 \u0026nbsp;[21]. The HLS-EU-Q6 was created using the six items from the HLS-EU test. To make the HLS-EU-Q6 score, the categories and scores of the HLS-EU-Q47 were considered: \u0026ldquo;very easy\u0026rdquo; = 4; \u0026lsquo;fairly easy\u0026rsquo; = 3; \u0026lsquo;fairly difficult\u0026rsquo; = 2; \u0026lsquo;very difficult\u0026rsquo; = 1; \u0026lsquo;don\u0026apos;t know/refused\u0026rsquo; = missing. The scale score is the mean value and ranges from 1 to 4. Only respondents who answered at least five items were included in the evaluation [22]. The scores obtained were evaluated as follows. All participants received scores ranging from 1 to 4. The scores were inadequate (HLS-EU-Q6 score \u0026le;2), problematic (HLS-EU-Q6 score \u0026gt;2 and \u0026le;3), and adequate (HLS-EU-Q6 score \u0026gt;3).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTranslation and Cultural Adaptation\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe translation process started after obtaining permission from the responsible author who developed the scale via e-mail. The translation and cultural adaptation stages were as follows: Translation, synthesis of translations, back translation, expert panel, piloting and cognitive review, and creation of the final version [23, 24]. The translation committee consisted of 3 fluent English-speaking native Turkish speakers, one public health specialist, one independent translator, and one psychological counselor with PhD degrees. In the first stage, the committee members translated the questionnaire into Turkish. In the second stage, the translations made by the committee were synthesized by the researcher and an expert fluent in both languages. In the synthesis stage of the translations, the errors were corrected, and the first version of the Turkish adaptation was created. In the third stage, three native English-speaking public health experts translated Turkish into English. In the fourth stage, the original version of the scale, the Turkish adaptation, and the retranslation into the original language were evaluated by a panel of 10 experts, including academicians and public health experts. The purpose of the expert panel was to assess the scale in terms of content and content validity by evaluating the inadequacy of the expressions in the translation and the inconsistencies between the two languages. The experts assessed the items as \u0026ldquo;Appropriate,\u0026rdquo; \u0026ldquo;Appropriate but should be corrected,\u0026rdquo; and \u0026ldquo;Should be removed.\u0026rdquo; In the fifth stage, it was presented to a group of 45 graduate students in the health sciences field to evaluate the statements\u0026apos; comprehensibility. TR-HLS-EU-Q6 was created with the suggestions from the pilot application group.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData collection\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study data were collected online via Google Forms between January and March 2024. After obtaining ethics committee permission, the survey link was sent to the participants via social media groups. It took an average of 6 minutes for participants to complete one questionnaire. The questionnaire included an informed consent form, personal information form, and TR-HLS-EU-Q6.\u003c/p\u003e\n\u003ch2\u003eData analysis\u003c/h2\u003e\n\u003cp\u003eThe collected data were analyzed using Statistical Package for Social Sciences for Windows (SPSS) 27.0 and Analysis of Moment Structures (AMOS) 26.0 programs. The conformity of the data to normal distribution was evaluated according to the kurtosis and skewness results. Since Skewness and Kurtosis coefficients are between -1 and +1, the data are normally distributed [23, 25]. The participants\u0026apos; sociodemographic characteristics were summarized with descriptive analyses (number, percentage, mean, standard deviation). Content validity indices were used for content validity, and exploratory factor analysis (EFA) and confirmatory factor analysis (CFA) were used for construct validity. Discriminant analysis and internal consistency coefficient were used in reliability analyses. The internal consistency of the scale was evaluated using Cronbach\u0026apos;s alpha. Principal component analysis and the varimax rotation method were utilized in EFA. In the evaluation of CFA, x2/df, RMSEA, SRMR, TLI, and GFI were used for goodness of fit. Acceptable values for goodness of fit were x\u003csup\u003e2\u003c/sup\u003e/df\u0026lt;5; RMSEA and SRMR\u0026lt;0.8; TLI and GFI \u0026gt;0.9. [20, 26, 27]. The statistical significance level was set at 0.05.\u003c/p\u003e\n\u003ch2\u003eEthical Considerations\u003c/h2\u003e\n\u003cp\u003eThe Principles of the Declaration of Helsinki conducted the study. Before the study, approval was received from the Sel\u0026ccedil;uk University Faculty of Health Sciences Non-Interventional Research Ethics Committee (Date: 29.11.2023 Decision No: 2023/1213). \u0026nbsp;In addition, all participants read the consent form before filling out the survey and completed the study after checking the \u0026quot;I agree to participate in the research\u0026quot; box.\u003c/p\u003e"},{"header":"Results","content":"\u003ch2\u003eParticipants\u0026rsquo; characteristics\u003c/h2\u003e\n\u003cp\u003eA total of 475 respondents participated. Table 1 shows the demographic characteristics of the participants, their frequency of applying to health institutions, and their health literacy levels. The mean age of the participants was 28.82 years (SD = 9.75), and 34.7% were 30 years of age or older. In gender distribution, 65.5% of the participants were female and 65.7% were single. Regarding education level, 27.6% were undergraduate graduates, and 34.9% were in the income group of 20,000₺ and below. The mean frequency of visits to health institutions in the last year was 7.29 (SD = 8.69), and 42.5% of the participants received health services 3-7 times, and 30.5% received health services eight or more times. This shows that the participants applied to health services frequently. The level of health literacy was measured with the TR-HLS-EU-Q6 index, and it was found that 75.6% of the participants had a problematic level of health literacy. In comparison, only 23.2% achieved adequate health literacy. The mean index score was 2.84 (SD = 0.38), ranging from 1.83 to 3.67.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 1\u003c/strong\u003e Demographics of the test group (N = 475)\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 73.5202%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCharacteristics\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26.4798%;\"\u003e\n \u003cp\u003e\u003cstrong\u003en (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 73.5202%;\"\u003e\n \u003cp\u003eAge\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26.4798%;\"\u003e\u0026nbsp;\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 73.5202%;\"\u003e\n \u003cp\u003e\u0026le; 22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26.4798%;\"\u003e\n \u003cp\u003e163 (34.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 73.5202%;\"\u003e\n \u003cp\u003e23 \u0026ndash; 29\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26.4798%;\"\u003e\n \u003cp\u003e147 (30.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 73.5202%;\"\u003e\n \u003cp\u003e30 \u0026ge;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26.4798%;\"\u003e\n \u003cp\u003e165 (34.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 73.5202%;\"\u003e\n \u003cp\u003eMean (SD)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26.4798%;\"\u003e\n \u003cp\u003e28.82 (9.75)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 73.5202%;\"\u003e\n \u003cp\u003eSex\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26.4798%;\"\u003e\u0026nbsp;\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 73.5202%;\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26.4798%;\"\u003e\n \u003cp\u003e164 (34.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 73.5202%;\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26.4798%;\"\u003e\n \u003cp\u003e311 (65.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 73.5202%;\"\u003e\n \u003cp\u003eMarital Status\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26.4798%;\"\u003e\u0026nbsp;\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 73.5202%;\"\u003e\n \u003cp\u003eMarried\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26.4798%;\"\u003e\n \u003cp\u003e163 (34.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 73.5202%;\"\u003e\n \u003cp\u003eSingle\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26.4798%;\"\u003e\n \u003cp\u003e312 (65.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 73.5202%;\"\u003e\n \u003cp\u003eEducation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26.4798%;\"\u003e\u0026nbsp;\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 73.5202%;\"\u003e\n \u003cp\u003eHigh school and below\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26.4798%;\"\u003e\n \u003cp\u003e108 (22.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 73.5202%;\"\u003e\n \u003cp\u003eAssociate degree\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26.4798%;\"\u003e\n \u003cp\u003e128 (26.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 73.5202%;\"\u003e\n \u003cp\u003eBachelor degree\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26.4798%;\"\u003e\n \u003cp\u003e131 (27.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 73.5202%;\"\u003e\n \u003cp\u003ePostgraduate degree\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26.4798%;\"\u003e\n \u003cp\u003e108 (22.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 73.5202%;\"\u003e\n \u003cp\u003eMonthly income (₺)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26.4798%;\"\u003e\u0026nbsp;\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 73.5202%;\"\u003e\n \u003cp\u003e\u0026le; 20.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26.4798%;\"\u003e\n \u003cp\u003e166 (34.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 73.5202%;\"\u003e\n \u003cp\u003e20.001 \u0026ndash; 40.000\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26.4798%;\"\u003e\n \u003cp\u003e161 (33.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 73.5202%;\"\u003e\n \u003cp\u003e40001 \u0026ge;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26.4798%;\"\u003e\n \u003cp\u003e148 (31.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 73.5202%;\"\u003e\n \u003cp\u003eNumber of applications to health institutions in the last year\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26.4798%;\"\u003e\u0026nbsp;\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 73.5202%;\"\u003e\n \u003cp\u003e\u0026le; 2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26.4798%;\"\u003e\n \u003cp\u003e128 (26.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 73.5202%;\"\u003e\n \u003cp\u003e3 \u0026ndash; 7\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26.4798%;\"\u003e\n \u003cp\u003e202 (42.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 73.5202%;\"\u003e\n \u003cp\u003e8 \u0026nbsp;\u0026ge;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26.4798%;\"\u003e\n \u003cp\u003e145 (30.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 73.5202%;\"\u003e\n \u003cp\u003eMean (SD)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26.4798%;\"\u003e\n \u003cp\u003e7.29 (8.69)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 73.5202%;\"\u003e\n \u003cp\u003eTR-HLS-EU-Q6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26.4798%;\"\u003e\u0026nbsp;\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 73.5202%;\"\u003e\n \u003cp\u003eInadequate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26.4798%;\"\u003e\n \u003cp\u003e6 (1.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 73.5202%;\"\u003e\n \u003cp\u003eProblematic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26.4798%;\"\u003e\n \u003cp\u003e359 (75.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 73.5202%;\"\u003e\n \u003cp\u003eSufficient\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26.4798%;\"\u003e\n \u003cp\u003e110 (23.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 73.5202%;\"\u003e\n \u003cp\u003eMean index score (SD)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26.4798%;\"\u003e\n \u003cp\u003e2.84 (0.38)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 73.5202%;\"\u003e\n \u003cp\u003eRange\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26.4798%;\"\u003e\n \u003cp\u003e1.83 \u0026ndash; 3.67\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003ch2\u003eItem distributional statistics\u003c/h2\u003e\n\u003cp\u003eTable 2 summarizes the distribution of responses to the items in the TR-HLS-EU-Q6 questionnaire. Regarding \u0026ldquo;getting a second opinion from another doctor,\u0026rdquo; 68.6% of the participants found it \u0026ldquo;easy,\u0026rdquo; while 17.7% found it \u0026ldquo;difficult.\u0026rdquo; In the item \u0026ldquo;Making decisions about the disease using the information provided by the doctor,\u0026rdquo; 77.3% of the participants found it \u0026ldquo;easy,\u0026rdquo; and 18.9% found it \u0026ldquo;very easy.\u0026rdquo; While 52.2% found it \u0026ldquo;easy\u0026rdquo; to find information about mental health problems, 29.3% found it \u0026ldquo;difficult.\u0026rdquo; Assessing the credibility of health risks in the media was the most challenging item; 48.4% found it \u0026ldquo;difficult,\u0026rdquo; and 20.6% found it \u0026ldquo;very difficult.\u0026rdquo; \u0026ldquo;Finding activities for mental well-being\u0026rdquo; was found \u0026lsquo;easy\u0026rsquo; by 62.3%, while 58.1% found it \u0026lsquo;easy\u0026rsquo; to understand health promotion information. In general, evaluating media sources was more difficult, while using physician information and finding activities for mental well-being were more accessible.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2\u003c/strong\u003e Distributional statistics for individual TR-HLS-EU-Q6 items\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" class=\"fr-table-selection-hover\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 51.5702%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eItems, n (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.2397%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eVery difficult\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.3967%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDifficult\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.3967%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eEasy\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.3967%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eVery easy\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 51.5702%;\"\u003e\n \u003cp\u003e1. Judge when you may need to get a second opinion from another doctor\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.2397%;\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.3967%;\"\u003e\n \u003cp\u003e84 (17.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.3967%;\"\u003e\n \u003cp\u003e326 (68.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.3967%;\"\u003e\n \u003cp\u003e65 (13.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 51.5702%;\"\u003e\n \u003cp\u003e2. Use information the doctor gives you to make decisions about your illness\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.2397%;\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.3967%;\"\u003e\n \u003cp\u003e18 (3.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.3967%;\"\u003e\n \u003cp\u003e367 (77.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.3967%;\"\u003e\n \u003cp\u003e90 (18.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 51.5702%;\"\u003e\n \u003cp\u003e3. Find information on how to manage mental health problems like stress or depression\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.2397%;\"\u003e\n \u003cp\u003e23 (4.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.3967%;\"\u003e\n \u003cp\u003e139 (29.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.3967%;\"\u003e\n \u003cp\u003e248 (52.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.3967%;\"\u003e\n \u003cp\u003e65 (13.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 51.5702%;\"\u003e\n \u003cp\u003e4. Judge if the information on health risks in the media is reliable\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.2397%;\"\u003e\n \u003cp\u003e98 (20.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.3967%;\"\u003e\n \u003cp\u003e230 (48.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.3967%;\"\u003e\n \u003cp\u003e122 (25.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.3967%;\"\u003e\n \u003cp\u003e25 (5.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 51.5702%;\"\u003e\n \u003cp\u003e5. Find out about activities that are good for your mental well-being\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.2397%;\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.3967%;\"\u003e\n \u003cp\u003e69 (14.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.3967%;\"\u003e\n \u003cp\u003e296 (62.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.3967%;\"\u003e\n \u003cp\u003e110 (23.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 51.5702%;\"\u003e\n \u003cp\u003e6. Understand information in the media on how to get healthier\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.2397%;\"\u003e\n \u003cp\u003e8 (1.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.3967%;\"\u003e\n \u003cp\u003e98 (20.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.3967%;\"\u003e\n \u003cp\u003e276 (58.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.3967%;\"\u003e\n \u003cp\u003e93 (19.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003ch2\u003eValidity analysis\u003c/h2\u003e\n\u003cp\u003eTable 3 presents the factor loadings of the TR-HLS-EU-Q6 and assesses the relationship between health literacy and the questionnaire items. The results of the expert panel review were used to assess the content validity of the TR-HLS-EU-Q6. The content validity of the TR-HLS-EU-Q6 was calculated using the content validity index (CVI). Lawshe\u0026apos;s (1975) method was used to calculate the CVI [28]. As a result of the analysis, it was determined that the CGI coefficient, which was defined as 0.92 for the whole scale, ranged between 0.88 - 0.95 for the items. The content validity values of the scale were found to be above the acceptable value of 0.80. Before factor analysis, the Kaiser Meyer Olkin (KMO) sample measurement adequacy test and Barlett sphericity test were performed to test the suitability of the data for factor analysis. The KMO coefficient of 0.78 indicates that the data are suitable for EFA. Barlett\u0026apos;s test result was x2=330.33; SD=15 (p\u0026lt;0.001). Based on these findings, the sample size is sufficient, and the data is normally distributed. To examine the factor structure of TR-HLS-EU-Q6, the exploratory factor analysis principal component analysis method was used, and the Varimax method, which is the orthogonal rotation method, was used as the rotation method. As a result of Principal Component Analysis (PCA), the relationship of the items with health literacy was shown with factor loadings ranging from 0.664 to 0.853. The questionnaire items measured individuals\u0026apos; ability to evaluate doctor\u0026apos;s recommendations (factor loading: 0.768), use information to make health-related decisions (0.664), find information to manage mental health problems (0.722), question health risk information in media sources (0.684), learn about activities that promote mental well-being (0.768), and understand media information about healthy living (0.853). In particular, the item on understanding health information in the media had the highest factor loading, indicating a very strong relationship regarding health literacy.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 3\u003c/strong\u003e Factor loadings of TR-HLS-EU-Q6 (PCA, N = 475)\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"100%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 84.8485%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eItems\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15.1515%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFactor load\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 84.8485%;\"\u003e\n \u003cp\u003e1. Judge when you may need to get a second opinion from another doctor\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15.1515%;\"\u003e\n \u003cp\u003e0.768\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 84.8485%;\"\u003e\n \u003cp\u003e2. Use information the doctor gives you to make decisions about your illness\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15.1515%;\"\u003e\n \u003cp\u003e0.664\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 84.8485%;\"\u003e\n \u003cp\u003e3. Find information on how to manage mental health problems like stress or depression\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15.1515%;\"\u003e\n \u003cp\u003e0.722\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 84.8485%;\"\u003e\n \u003cp\u003e4. Judge if the information on health risks in the media is reliable\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15.1515%;\"\u003e\n \u003cp\u003e0.684\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 84.8485%;\"\u003e\n \u003cp\u003e5. Find out about activities that are good for your mental well-being\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15.1515%;\"\u003e\n \u003cp\u003e0.768\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 84.8485%;\"\u003e\n \u003cp\u003e6. Understand information in the media on how to get healthier\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15.1515%;\"\u003e\n \u003cp\u003e0.853\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eTable 4 shows the model fit indices of TR-HLS-EU-Q6. In confirmatory factor analysis, x\u003csup\u003e2\u003c/sup\u003e/df=2.95, RMSEA=0.07, SRMR=0.07, TLI=0.92 and GFI=0.95 provided an acceptable fit. [20, 26, 27]. A good relationship was found between the items and the scale. No covariance was made between the items since the correction indices were not significantly loaded.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 4\u003c/strong\u003e Model fit indices\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 32.9457%;\"\u003e\n \u003cp\u003eFit indices\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47.6744%;\"\u003e\n \u003cp\u003eAcceptable value\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19.3798%;\"\u003e\n \u003cp\u003eModel\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 32.9457%;\"\u003e\n \u003cp\u003ex\u003csup\u003e2\u003c/sup\u003e/df\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47.6744%;\"\u003e\n \u003cp\u003e\u0026lt; 5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19.3798%;\"\u003e\n \u003cp\u003e2.95\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 32.9457%;\"\u003e\n \u003cp\u003eRMSEA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47.6744%;\"\u003e\n \u003cp\u003e\u0026lt; 0.08\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19.3798%;\"\u003e\n \u003cp\u003e0.07\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 32.9457%;\"\u003e\n \u003cp\u003eSRMR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47.6744%;\"\u003e\n \u003cp\u003e\u0026lt; 0.08\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19.3798%;\"\u003e\n \u003cp\u003e0.07\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 32.9457%;\"\u003e\n \u003cp\u003eTLI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47.6744%;\"\u003e\n \u003cp\u003e\u0026gt; 0.90\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19.3798%;\"\u003e\n \u003cp\u003e0.92\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 32.9457%;\"\u003e\n \u003cp\u003eGFI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47.6744%;\"\u003e\n \u003cp\u003e\u0026gt; 0.90\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19.3798%;\"\u003e\n \u003cp\u003e0.95\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003ch2\u003eReliability analysis\u003c/h2\u003e\n\u003cp\u003eDiscriminant analysis was conducted to test the discrimination of the items with the highest (27%) and lowest (27%) scores. Accordingly, the student t-test compared the lower and upper cut-off groups. For each mean item score, there was a significant difference between the low-scoring group (n=125) and the high-scoring group (n=125) (p\u0026lt;0.001). Cronbach alpha coefficient for TR-HLS-EU-Q6 was 0.82. Based on this value, it is seen that TR-HLS-EU-Q6 is highly reliable [28]\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study evaluated the validity and reliability of the new version of TR-HLS-EU-Q6 based on the data obtained from participants living in Konya, Turkey. Adapting the scale to Turkish is of great importance in health literacy culture studies as a valid and reliable instrument can be used to obtain national and international data to be compared.\u003c/p\u003e\n\u003cp\u003eThe study findings showed good internal consistency, content validity, and construct validity, indicating that the TR-HLS-EU-Q6 can measure the Turkish population\u0026apos;s health literacy level. CFA results for the 6-item structure of the Turkish version supported a single-factor structure. In addition, each item contributed to its own expected scale, providing evidence for construct validity.\u003c/p\u003e\n\u003cp\u003eThe content validity of the TR-HLS-EU-Q6 was assessed using CVI. According to the CVI results, the equivalence of the items in the Turkish form was evaluated. Content validity indices are expected to be above 0.80 [29]. In this study, the content validity index was at an acceptable level. Therefore, no item regarding content validity was removed from the scale. The construct validity of the scale was assessed using CFA. CFA is a type of structural equation modeling that reveals the relationships between items and factors [26]. Confirmatory factor analysis results showed that x\u003csup\u003e2\u003c/sup\u003e/df, RMSEA, SRMR, TLI, and GFI values showed an acceptable fit [20, 26, 27]. Since the correction indices had no significant loading, no covariance was made between the items [29]. In addition, discriminant analyses showed that each item captured the difference between the highest and lowest scorers.\u003c/p\u003e\n\u003cp\u003eA study examining the French version of the HLS-EU-Q6 found that good construct validity was not achieved through Confirmatory Factor Analysis (CFA) and that scores on this version correlated poorly with other measures of health literacy and physician assessments. This study suggests that there are limitations in distinguishing between the health literacy levels of participants with average and high levels of health literacy [30]. Evaluating the Brazilian Portuguese version, the researchers found that the original classification criteria of the HLS-EU-Q6 should be modified to determine health literacy levels in Brazilian adults more accurately, and this finding highlights the importance of the effectiveness of cultural adaptation in different populations [8]. The HLS-EU-Q6, which was psychometrically evaluated in Brazil, showed a unidimensional structure with a high explained variance of 71.23% and was recognized as a reliable instrument for measuring health literacy for different population groups with good factor loadings and item discrimination [9]. A study of the Italian version confirmed that the Italian versions of the HLS-EU-Q16 and HLS-EU-Q6 questionnaires present a valid construct and are reliable and valid in the Italian general population. In this study, the internal consistency of the questionnaires was reported to be relatively high, and Cronbach\u0026apos;s alpha coefficient was acceptable, indicating that the questionnaires can provide consistent results over time [22]. It was determined that the fit model of the Bengali HLS-EU-Q6 form was low, and some items may differ in certain demographic groups [10].\u003c/p\u003e\n\u003cp\u003eAlthough the HLS-EU-Q6 is reliable in different settings, its validity may vary depending on the population and requires cultural adaptation to categorize health literacy levels accurately. Measuring health literacy through the HLS-EU-Q6 can help health professionals identify the real needs of healthcare users and redirect interventions accordingly. It is recommended that future studies expand the application of this tool in other samples and populations, aiming to reveal the classification of health literacy levels in different regions.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eAs a result of the literature review, this is the first study to examine the psychometric properties of the HLS-EU-Q6 in the Turkish population. Our findings confirm that the short version of the HLS-EU, TR-HLS-EU-Q6, offers sufficient psychometric properties to measure the health literacy level of the Turkish population. Based on these results, it can be used to measure health literacy. Further research is needed to investigate its psychometric properties for widely validated applications.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 23.908%;\"\u003e\n \u003cp\u003eCFA\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76.092%;\"\u003e\n \u003cp\u003eConfirmatory Factor Analysis\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 23.908%;\"\u003e\n \u003cp\u003eCVI\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76.092%;\"\u003e\n \u003cp\u003eContent Validity Index\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 23.908%;\"\u003e\n \u003cp\u003eEFA\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76.092%;\"\u003e\n \u003cp\u003eExploratory Factor Analysis\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 23.908%;\"\u003e\n \u003cp\u003eGFI\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76.092%;\"\u003e\n \u003cp\u003eGoodness of Fit Index\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 23.908%;\"\u003e\n \u003cp\u003eHLS-EU-Q\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76.092%;\"\u003e\n \u003cp\u003eEuropean Health Literacy Survey Questionnaire\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 23.908%;\"\u003e\n \u003cp\u003eKMO\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76.092%;\"\u003e\n \u003cp\u003eKaiser-Meyer-Olkin\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 23.908%;\"\u003e\n \u003cp\u003ePCA\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76.092%;\"\u003e\n \u003cp\u003ePrincipal Component Analysis\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 23.908%;\"\u003e\n \u003cp\u003eRMSEA\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76.092%;\"\u003e\n \u003cp\u003eRoot-Mean-Square Error of Approximation\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 23.908%;\"\u003e\n \u003cp\u003eSRMR\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76.092%;\"\u003e\n \u003cp\u003eStandardized Root Mean Square Residual\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 23.908%;\"\u003e\n \u003cp\u003eTLI\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76.092%;\"\u003e\n \u003cp\u003eTucker Lewis Index\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 23.908%;\"\u003e\n \u003cp\u003eTR-HLS-EU-Q6\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76.092%;\"\u003e\n \u003cp\u003eTurkish European Health Literacy Survey Questionnaire\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"},{"header":"Declarations","content":"\u003ch2\u003eAcknowledgments\u003c/h2\u003e\n\u003cp\u003eI want to thank our respondents for participating in the study.\u003c/p\u003e\n\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\n\u003cp\u003eWriting first draft: MY; Data collection: MY; interpretation of data and statistical analysis: MY; Study concept, design, and critical revision: MY. The author read and approved the final article.\u003c/p\u003e\n\u003ch2\u003eFunding\u003c/h2\u003e\n\u003cp\u003eNone\u003c/p\u003e\n\u003ch2\u003eData Availability\u003c/h2\u003e\n\u003cp\u003eData sharing is not applicable. All available data was included in the study.\u003c/p\u003e\n\u003ch2\u003eEthics approval\u003c/h2\u003e\n\u003cp\u003eThe ethics committee approval of the research was obtained from the Sel\u0026ccedil;uk University Faculty of Health Sciences Non-Interventional Research Ethics Committee (2023/1213). Informed consent to participate was obtained from all participants\u003c/p\u003e\n\u003ch2\u003eConsent for publication\u003c/h2\u003e\n\u003cp\u003eNot applicable.\u0026nbsp;\u003c/p\u003e\n\u003ch2\u003eCompeting Interests\u003c/h2\u003e\n\u003cp\u003eThe author had no relevant conflicts of interest.\u003c/p\u003e\n\u003ch2\u003eAuthor details\u003c/h2\u003e\n\u003cp\u003eM\u0026uuml;jdat YEŞİLDAL, Department of Healthcare Management, Faculty of Health Sciences, Sel\u0026ccedil;uk University, Konya, T\u0026uuml;rkiye\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eNutbeam D. The evolving concept of health literacy. Soc Sci Med. 2008;67:2072\u0026ndash;8.\u003c/li\u003e\n\u003cli\u003eBerkman ND, Sheridan SL, Donahue KE, Halpern DJ, Crotty K. Low health literacy and health outcomes: an updated systematic review. Ann Intern Med. 2011;155:97\u0026ndash;107.\u003c/li\u003e\n\u003cli\u003eKickbusch I, Pelikan JM, Apfel F, Tsouros AD. Health Literacy, the solid facts. Geneva: World Health Organization; 2013.\u003c/li\u003e\n\u003cli\u003eS\u0026oslash;rensen K, Pelikan JM, R\u0026ouml;thlin F, Ganahl K, Slonska Z, Doyle G, et al. Health literacy in Europe: comparative results of the European health literacy survey (HLS-EU). Eur J Public Health. 2015;25:1053\u0026ndash;8.\u003c/li\u003e\n\u003cli\u003eS\u0026oslash;rensen K, Van Den Broucke S, Pelikan JM, Fullam J, Doyle G, Slonska Z, et al. Measuring health literacy in populations: illuminating the design and development process of the European Health Literacy Survey Questionnaire (HLS-EU-Q). BMC Public Health. 2013;13.\u003c/li\u003e\n\u003cli\u003ePelikan JM, Link T, Stra\u0026szlig;mayr C, Waldherr K, Alfers T, B\u0026oslash;ggild H, et al. Measuring Comprehensive, General Health Literacy in the General Adult Population: The Development and Validation of the HLS19-Q12 Instrument in Seventeen Countries. Int J Environ Res Public Health. 2022;19:14129.\u003c/li\u003e\n\u003cli\u003eDuong VT, Lin I-F, Sorensen K, Pelikan JM, Van Den Broucke S, Lin Y-C, et al. Health Literacy in Taiwan: A Population-Based Study. Asia Pac J Public Health. 2015;27:871\u0026ndash;80.\u003c/li\u003e\n\u003cli\u003eMialhe FL, Rebustini F. Evaluation of normative data of the instrument European Health Literacy Survey Questionnaire short-short form (HLS-EU-Q6) in Brazilian adults. Revista Eletr\u0026ocirc;nica Acervo Sa\u0026uacute;de. 2023;23:e12305.\u003c/li\u003e\n\u003cli\u003eMialhe FL, Moraes KL, Bado FMR, Brasil VV, Sampaio HADC, Rebustini F. Psychometric properties of the adapted instrument European Health Literacy Survey Questionnaire short-short form. Rev Latino-Am Enfermagem. 2021;29:e3436.\u003c/li\u003e\n\u003cli\u003eMousum S, Salwa M, Fatema K, Haque MA. Psychometric Validation of the Translated and Adapted Bengali Version of the HLS-EU-Q16/Q6 for Adults. Inquiry. 2024;61:00469580241248132.\u003c/li\u003e\n\u003cli\u003e\u0026Ouml;zdemir H, Alper Z, Uncu Y, Bilgel N. Health literacy among adults: a study from Turkey. Health Educ Res. 2010;25:464\u0026ndash;77.\u003c/li\u003e\n\u003cli\u003e\u0026Ouml;zturk FO, Ayaz-Alkaya S. Health Literacy and Health Promotion Behaviors of Adolescents in Turkey. J Pediatr Nurs. 2020;54:e31\u0026ndash;5.\u003c/li\u003e\n\u003cli\u003e\u0026Ouml;zcan G, \u0026Ouml;zkaraman A. Tip 2 Diabetes Mellitus Hastalarında Sağlık Okuryazarlığı D\u0026uuml;zeyi ve Etkileyen Fakt\u0026ouml;rler. Dokuz Eyl\u0026uuml;l \u0026Uuml;niversitesi Hemşirelik Fak\u0026uuml;ltesi Elektronik Dergisi. 2021;14:3\u0026ndash;16.\u003c/li\u003e\n\u003cli\u003eBozkurt H, Demirci H. Health Literacy Among Older Persons in Turkey. Aging Male. 2019;22:272\u0026ndash;7.\u003c/li\u003e\n\u003cli\u003eDurusu-Tanrı\u0026ouml;ver M, Yıldırım HH, Demiray-Ready FN, \u0026Ccedil;akır B, Akalın HE. T\u0026uuml;rkiye Sağlık Okuryazarlığı Araştırması. Birinci Baskı. Ankara: Sağlık-Sen Yayınları; 2014.\u003c/li\u003e\n\u003cli\u003eEmiral GO, Aygar H, Işıktekin B, G\u0026ouml;ktaş S, Dağtekin G, Arslantaş D, et al. Health literacy scale-European union-Q16: a validity and reliability study in Turkey. Int Res J Medical Sci. 6:1\u0026ndash;7.\u003c/li\u003e\n\u003cli\u003eAbacigil F, Harlak H, Okyay P, Kiraz DE, Gursoy Turan S, Saruhan G, et al. Validity and reliability of the Turkish version of the European Health Literacy Survey Questionnaire. Health Promot Int. 2019;34:658\u0026ndash;67.\u003c/li\u003e\n\u003cli\u003eWilson Van Voorhis CR, Morgan BL. Understanding Power and Rules of Thumb for Determining Sample Sizes. In: Tutorials in Quantitative Methods for Psychology. 2007. p. 43\u0026ndash;50.\u003c/li\u003e\n\u003cli\u003eIacobucci D. Structural equations modeling: Fit Indices, sample size, and advanced topics. Journal of Consumer Psychology. 2010;20:90\u0026ndash;8.\u003c/li\u003e\n\u003cli\u003eYaşlıoğlu MM. Sosyal Bilimlerde Fakt\u0026ouml;r Analizi ve Ge\u0026ccedil;erlilik: Keşfedici ve Doğrulayıcı Fakt\u0026ouml;r Analizlerinin Kullanılması. İstanbul \u0026Uuml;niversitesi İşletme Fak\u0026uuml;ltesi Dergisi. 2017;46:74\u0026ndash;85.\u003c/li\u003e\n\u003cli\u003ePelikan JM, Ganahl K, Van Den Broucke S, S\u0026oslash;rensen K. Measuring health literacy in Europe: Introducing the European Health Literacy Survey Questionnaire (HLS-EU-Q). In: Okan O, Bauer U, Levin-Zamir D, Pinheiro P, S\u0026oslash;rensen K, editors. International Handbook of Health Literacy. Policy Press; 2019. p. 115\u0026ndash;38.\u003c/li\u003e\n\u003cli\u003eLorini C, Lastrucci V, Mantwill S, Vettori V, Bonaccorsi G, Florence Health Literacy Research Group. Measuring health literacy in Italy: a validation study of the HLS-EU-Q16 and of the HLS-EU-Q6 in Italian language, conducted in Florence and its surroundings. Ann Ist Super Sanita. 2019;55:10\u0026ndash;8.\u003c/li\u003e\n\u003cli\u003eKarag\u0026ouml;z Y, Bardak\u0026ccedil;ı S. Bilimsel Araştırmalarda Kullanılan \u0026Ouml;l\u0026ccedil;me Ara\u0026ccedil;ları ve \u0026Ouml;l\u0026ccedil;ek Geliştirme. Ankara: Nobel Akademik Yayıncılık; 2020.\u003c/li\u003e\n\u003cli\u003e\u0026Ccedil;apık C, G\u0026ouml;z\u0026uuml;m S, Aksayan S. K\u0026uuml;lt\u0026uuml;rlerarası \u0026Ouml;l\u0026ccedil;ek Uyarlama Aşamaları, Dil ve K\u0026uuml;lt\u0026uuml;r Uyarlaması: G\u0026uuml;ncellenmiş Rehber. Florence Nightingale J Nurs. 2018;26:199\u0026ndash;210.\u003c/li\u003e\n\u003cli\u003eG\u0026uuml;rb\u0026uuml;z S, Şahin F. Sosyal Bilimlerde Araştırma Y\u0026ouml;ntemleri. 5. Baskı. Ankara: Se\u0026ccedil;kin Yayıncılık; 2018.\u003c/li\u003e\n\u003cli\u003eByrne BM. Structural equation modeling with AMOS: basic concepts, applications, and programming. 2. Edition. New York, NY: Routledge; 2010.\u003c/li\u003e\n\u003cli\u003e\u0026Ccedil;apık C. Ge\u0026ccedil;erlik ve G\u0026uuml;venirlik \u0026Ccedil;alışmalarında Doğrulayıcı Fakt\u0026ouml;r Analizinin Kullanımı. Anadolu Hemşirelik ve Sağlık Bilimleri Dergisi. 2014;17:196\u0026ndash;205.\u003c/li\u003e\n\u003cli\u003eKarag\u0026ouml;z Y. SPSS - AMOS - META Uygulamalı İstatistiksel Analizler. Ankara: Nobel Akademik Yayıncılık; 2019.\u003c/li\u003e\n\u003cli\u003eAlpar R. Uygulamalı İstatistik ve Ge\u0026ccedil;erlik-G\u0026uuml;venirlik: Spor, Sağlık Ve Eğitim Bilimlerinden \u0026Ouml;rneklerle. 2. Baskı. Ankara: Detay Yayıncılık; 2012.\u003c/li\u003e\n\u003cli\u003eRouquette A, Nadot T, Labitrie P, Van den Broucke S, Mancini J, Rigal L, et al. Validity and measurement invariance across sex, age, and education level of the French short versions of the European Health Literacy Survey Questionnaire. PLoS One. 2018;13:e0208091.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"HLS-EU-Q, Health Literacy, Psychometric, Validity, Reliability, Turkish","lastPublishedDoi":"10.21203/rs.3.rs-5145103/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5145103/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground \u003c/strong\u003eHealth literacy plays an important role in the effectiveness of health services by affecting individuals' ability to access, understand, and use health information. Many people in Turkey have limited health literacy. This study aimed to determine the psychometric validity and reliability of the Turkish version of the HLS-EU-Q6.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e This psychometric study was conducted in two phases with 475 Turkish adults between January and March 2024. In the first stage, the scale was adapted into Turkish. Content validity indices were used for content validity, and exploratory factor analysis (EFA) and confirmatory factor analysis (CFA) were used for construct validity. Discriminant analysis was used for reliability analysis, and Cronbach's alpha coefficient was used for internal consistency.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults \u003c/strong\u003eThe mean age of the 475 participants was 28.82 ± 9.75 years, and 65.5% were female. The health literacy level of 75.6% of the participants was determined as “problematic.” The content validity index of the scale was found to be 0.92. In exploratory factor analysis, factor loadings ranged between 0.664 and 0.853, and in confirmatory factor analysis, model fit indices were acceptable (x²/df=2.95, RMSEA=0.07, SRMR=0.07, TLI=0.92, GFI=0.95). In the reliability analysis, Cronbach's alpha coefficient was 0.82.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions\u003c/strong\u003e The Turkish version of HLS-EU-Q6 consistently showed acceptable psychometric reliability and validity characteristics.\u003c/p\u003e","manuscriptTitle":"Validity and reliability of the Turkish version of the HLS-EU-Q6 questionnaire","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-06-17 09:04:57","doi":"10.21203/rs.3.rs-5145103/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-07-03T08:39:43+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-04-01T06:32:02+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-11-18T07:59:35+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-11-17T19:54:53+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"25217856342053064516700049364389926185","date":"2024-11-14T13:09:11+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"180206755176617357715117734570010577499","date":"2024-11-12T16:26:55+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"314212226073305923022947976177622555787","date":"2024-11-12T09:07:47+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"332468712803120711841510878119438483358","date":"2024-11-12T09:02:47+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-11-10T13:21:02+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"124941897916913417651844292545116881281","date":"2024-11-07T12:28:40+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"242752917228392332390132206636394204945","date":"2024-11-05T10:40:16+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"39211538653806307098681054660909612389","date":"2024-10-28T07:52:12+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-10-28T07:45:52+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-10-21T13:00:04+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2024-09-27T04:48:18+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-09-26T07:53:19+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Public Health","date":"2024-09-26T07:52:08+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"5db7f004-d67f-4e7f-bb51-e975024edc2f","owner":[],"postedDate":"June 17th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-08-04T16:41:04+00:00","versionOfRecord":{"articleIdentity":"rs-5145103","link":"https://doi.org/10.1186/s12889-025-24081-5","journal":{"identity":"bmc-public-health","isVorOnly":false,"title":"BMC Public Health"},"publishedOn":"2025-08-02 16:21:05","publishedOnDateReadable":"August 2nd, 2025"},"versionCreatedAt":"2025-06-17 09:04:57","video":"","vorDoi":"10.1186/s12889-025-24081-5","vorDoiUrl":"https://doi.org/10.1186/s12889-025-24081-5","workflowStages":[]},"version":"v1","identity":"rs-5145103","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5145103","identity":"rs-5145103","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}