Translation and cultural adaptation of the health literacy questionnaire (HLQ) in Morocco

BACKGROUND: Health literacy is an established determinant of health and a key tool in the development of public health interventions. It plays an important role in improving the health and equity of individuals and populations. The Health Literacy Questionnaire (HLQ) is a widely used multidimensional instrument designed to assess various domains of health literacy across diverse populations. However, no culturally and linguistically adapted version of the HLQ is currently available for the Moroccan context, where Moroccan Arabic (Darija) is the primary language of everyday communication, including interactions with healthcare professionals. Therefore, the objective of this study was to carry out the socio-cultural and linguistic adaptation of the HLQ into Darija. METHODS: The HLQ was culturally and linguistically adapted for Morocco through a collaborative process with the HLQ developers, community members, healthcare professionals, and the project team from the Higher Institute of Health Sciences (ISSS). Forward and backward translation and cognitive interviews with 28 primary healthcare users recruited from two Moroccan provinces (Kenitra and Settat) maximized that each item reflected its intended meaning. Data were analyzed using thematic analysis to refine the adapted version for the Moroccan context. RESULTS: The 28 participants (71.4% women) were aged 18 to 70, with diverse educational backgrounds and resided in both urban and rural areas. Of the 44 translated items, 19 (43%) required further linguistic or cultural adaptation for Darija speakers (Moroccan Arabic dialect). Participants generally understood and responded to the items per each item's intent, but qualitative analysis highlighted important nuances. A marked dependence on medical authority appeared to limit participants' ability to manage their own health and was associated with persistent difficulties navigating the healthcare system and critically appraising health information. In contrast, items related to social support were more readily understood, highlighting the central role of family networks. Collectively, these findings underscore the interplay between cultural norms and structural barriers in shaping perceptions of health literacy in Morocco. CONCLUSION: The cognitive and cultural adaptation of the HLQ into Moroccan Darija supported the relevance of the nine scales and provided insight into locally grounded conceptions of health. This process highlights the importance of a participatory and context-sensitive approach to achieving conceptual fidelity and cultural appropriateness. However, it should be emphasized that this study represents an initial yet essential step in the overall validation process. While the adapted Darija version of the HLQ cannot yet be considered a fully validated instrument for use in the general population, it provides a robust foundation for subsequent psychometric evaluation. Further research is required to evaluate its psychometric properties, including internal structure and reliability, to determine its suitability for assessing health literacy in the Moroccan context. This study is important because health literacy development is critical to helping individuals and populations access and use health information and services to manage their health. The first step in measuring health literacy is to adapt tools to local languages and cultures. The study focuses on adapting the Health Literacy Questionnaire (HLQ) to the Darija language (Moroccan Arabic dialect) so that the health literacy needs of people in primary healthcare settings in Morocco can be assessed. The methods used in the study helped ensure that the Darija HLQ is relevant and understandable in the Moroccan context. The study found that the Darija HLQ was well understood by most users, though some with lower education levels found certain questions unclear. This means that the tool is adequate for use in Morocco, but further refinement may be needed for certain groups. The questionnaire was translated and adapted through a collaborative translation process to maximize its cultural and linguistic appropriateness for Moroccan users.