Introduction
In the last decades, enormous attention has been paid to health liter-
acy due to its influence on health behaviours and health outcomes and
there is a robust body of literature focusing on this relationship.1-4
However, two main aspects are still discussed by the research commu-
nity for this concept to be fully considered as an effective approach. One
concerns its conceptualization, as to date there is not a unique defini-
tion for it, and the other one its measurement.5 The most commonly
used measures have focused on assessing reading, writing, and numer-
acy skills.6 Although so far the tools measuring these functional skills
have shown a well-established relationship between health literacy and
health outcomes,3 these tools fail to capture more advanced health liter-
acy skills needed by individuals to function properly within a health care
context,7 including decision-making, analytical thinking, pondering
abilities, information use, informatics and communicative skills. These
advanced skills among others allow patients to be autonomous in navi-
gating the health care system, participate actively in their own and their
families’ health care, make informed decisions, and collaborate effi-
ciently with healthcare professionals. All this points towards the need to
develop reliable tools that can assess skills that go beyond these func-
tional abilities. Different attempts have been carried out to develop
other measures able to capture more advanced health literacy skills.
Chew et al.8 for instance developed a screening tool to assess individu-
als’ understanding of health material and the use of this; Ishikawa et al.9
went further and developed a screening tool assessing different dimen-
sions of health literacy such as individuals’ capabilities to extract health
information, derive meaning from it (communicative literacy), and crit-
ically use it (critical literacy). Despite these noticeable efforts to
advance health literacy measurement, findings from other studies using
these tools are inconclusive regarding their capacity to measure more
advanced health literacy dimensions.10,11 Another recent approach that
fits into the conceptualization of advanced health literacy skills has been
proposed by Schulz and Nakamoto.12 One of the dimensions of the
authors’ theoretical framework, known as judgment skills, focuses on
the individuals’ abilities to adapt and apply health information accord-
ing to the health context. These skills allow the individual to subtract
and generalize information, to build knowledge that can be applied dif-
ferently according to the situation.12 Thus, it has been hypothesized that
individual with higher judgment skills are able to respond better to a
particular health situation. The conceptualization of judgment skills has
been recently and successfully operationalized in a scenario based-tool
for the context of asthma self-management.13
The tool was developed in the asthma context because this chronic
condition poses high demands on patients’ self-care routines. Patients
need to follow strict medical regimens, use medicines properly, avoid
asthma triggers, and recognize symptoms. However, if asthma health
information is not properly understood and integrated by patients, a
proper asthma control is difficult to achieve, which is at the end the
final purpose for managing this condition. Therefore, the characteris-
tics present in asthma self-management make it an appropriate condi-
tion to develop and test the proposed judgment skills. In addition to
this, it has been pointed out by other authors that health literacy skills
should involve more content-specific skills and health-related knowl-
edge that depends on the health condition.7 Thus it is crucial to devel