Modelling variance in the multidimensional Health Literacy Questionnaire: Does a General Health Literacy factor account for observed interscale correlations?

Objectives: Self-report measures of health literacy frequently encompass a group of conceptually distinct but related domains scored as either a single scale or separately for each domain. Psychometric studies of the 44-item Health Literacy Questionnaire, scored as nine separate scales, typically report the results of correlated factors confirmatory factor analyses as validity evidence. However, some scales are quite strongly correlated, raising the question of whether there is sufficient discriminant validity to warrant separate scoring. This psychometric study aims to contrast the results of fitting higher-order and bifactor models as alternative options to illuminate the issue. Methods: Correlated factors, higher-order and bifactor confirmatory factor analysis models were fitted to an Australian sample of responses to the Health Literacy Questionnaire (N = 813) using Bayesian confirmatory factor analysis methods. Results: All models representing a nine-factor structure for the Health Literacy Questionnaire fitted well. The correlated factors model replicated previous findings, showing inter-factor correlations between 0.19 and 0.93. A higher-order model showed relatively high loadings of all nine first-order factors on the second-order factor with particularly high loadings (⩾0.97) for three. Two bifactor models showed that the majority of Health Literacy Questionnaire items were multifactorial, each containing systematic variance from both a General Health Literacy factor and a domain-specific factor. Seven items from four scales were identified as strongly associated with the General Health Literacy factor, with item content suggesting that this factor indexes a broad sense of agency and efficacy in interacting with health-related information and healthcare providers. Conclusion: Contrasting correlated factors, higher-order and bifactor models fitted to the Health Literacy Questionnaire suggest that constituent items in self-report health literacy questionnaires might be anticipated to represent at least two sources of reliable and substantive common factor variance: variance associated with General Health Literacy and variance associated with a more specific domain, suggesting that items may be 'irreducibly' heterogeneous. Implications for test development and validation practice are discussed.

Validity Evidence of the eHealth Literacy Questionnaire (eHLQ) Part 2: Mixed Methods Approach to Evaluate Test Content, Response Process, and Internal Structure in the Australian Community Health Setting.

BACKGROUND: Digital technologies have changed how we manage our health, and eHealth literacy is needed to engage with health technologies. Any eHealth strategy would be ineffective if users' eHealth literacy needs are not addressed. A robust measure of eHealth literacy is essential for understanding these needs. On the basis of the eHealth Literacy Framework, which identified 7 dimensions of eHealth literacy, the eHealth Literacy Questionnaire (eHLQ) was developed. The tool has demonstrated robust psychometric properties in the Danish setting, but validity testing should be an ongoing and accumulative process. OBJECTIVE: This study aims to evaluate validity evidence based on test content, response process, and internal structure of the eHLQ in the Australian community health setting. METHODS: A mixed methods approach was used with cognitive interviewing conducted to examine evidence on test content and response process, whereas a cross-sectional survey was undertaken for evidence on internal structure. Data were collected at 3 diverse community health sites in Victoria, Australia. Psychometric testing included both the classical test theory and item response theory approaches. Methods included Bayesian structural equation modeling for confirmatory factor analysis, internal consistency and test-retest for reliability, and the Bayesian multiple-indicators, multiple-causes model for testing of differential item functioning. RESULTS: Cognitive interviewing identified only 1 confusing term, which was clarified. All items were easy to read and understood as intended. A total of 525 questionnaires were included for psychometric analysis. All scales were homogenous with composite scale reliability ranging from 0.73 to 0.90. The intraclass correlation coefficient for test-retest reliability for the 7 scales ranged from 0.72 to 0.95. A 7-factor Bayesian structural equation modeling using small variance priors for cross-loadings and residual covariances was fitted to the data, and the model of interest produced a satisfactory fit (posterior productive P=.49, 95% CI for the difference between observed and replicated chi-square values -101.40 to 108.83, prior-posterior productive P=.92). All items loaded on the relevant factor, with loadings ranging from 0.36 to 0.94. No significant cross-loading was found. There was no evidence of differential item functioning for administration format, site area, and health setting. However, discriminant validity was not well established for scales 1, 3, 5, 6, and 7. Item response theory analysis found that all items provided precise information at different trait levels, except for 1 item. All items demonstrated different sensitivity to different trait levels and represented a range of difficulty levels. CONCLUSIONS: The evidence suggests that the eHLQ is a tool with robust psychometric properties and further investigation of discriminant validity is recommended. It is ready to be used to identify eHealth literacy strengths and challenges and assist the development of digital health interventions to ensure that people with limited digital access and skills are not left behind.

Validity arguments for patient-reported outcomes: justifying the intended interpretation and use of data.

BACKGROUND: Contrary to common usage in the health sciences, the term "valid" refers not to the properties of a measurement instrument but to the extent to which data-derived inferences are appropriate, meaningful, and useful for intended decision making. The aim of this study was to determine how validity testing theory (the Standards for Educational and Psychological Testing) and methodology (Kane's argument-based approach to validation) from education and psychology can be applied to validation practices for patient-reported outcomes that are measured by instruments that assess theoretical constructs in health. METHODS: The Health Literacy Questionnaire (HLQ) was used as an example of a theory-based self-report assessment for the purposes of this study. Kane's five inferences (scoring, generalisation, extrapolation, theory-based interpretation, and implications) for theoretical constructs were applied to the general interpretive argument for the HLQ. Existing validity evidence for the HLQ was identified and collated (as per the Standards recommendation) through a literature review and mapped to the five inferences. Evaluation of the evidence was not within the scope of this study. RESULTS: The general HLQ interpretive argument was built to demonstrate Kane's five inferences (and associated warrants and assumptions) for theoretical constructs, and which connect raw data to the intended interpretation and use of the data. The literature review identified 11 HLQ articles from which 57 sources of validity evidence were extracted and mapped to the general interpretive argument. CONCLUSIONS: Kane's five inferences and associated warrants and assumptions were demonstrated in relation to the HLQ. However, the process developed in this study is likely to be suitable for validation planning for other measurement instruments. Systematic and transparent validation planning and the generation (or, as in this study, collation) of relevant validity evidence supports developers and users of PRO instruments to determine the extent to which inferences about data are appropriate, meaningful and useful (i.e., valid) for intended decisions about the health and care of individuals, groups and populations.

Co-designing eHealth and Equity Solutions: Application of the Ophelia (Optimizing Health Literacy and Access) Process.

Background: The unequal access, challenges and outcomes related to using technology have created the digital divide, which leads to health inequalities. The aim of this study was to apply the Ophelia (Optimizing Health Literacy and Access) process, a widely used systematic approach to whole of community co-design, to the digital context to generate solutions to improve health and equity outcomes. Methods: This was a mixed method study. A cross-sectional survey was undertaken at 3 health organizations in Victoria, Australia using the eHealth Literacy Questionnaire (eHLQ) as a needs assessment tool. Cluster analysis was conducted to identify subgroups with varying eHealth literacy needs. These data, combined with semi-structured interviews with clients, were used to generate vignettes representing different eHealth literacy profiles. The vignettes were presented at co-design workshops with clients and health professionals to generate solutions for digital health services improvement. Expert validation and proof-of-concept testing was explored through mapping the process against Ophelia guiding principles. Results: The cluster analyses identified 8 to 9 clusters with different profiles of eHealth literacy needs, with 4 to 6 vignettes developed to represent the eHealth literacy strengths and weaknesses of clients at each of the 3 sites. A total of 32, 43, and 32 solutions across 10 strategies were co-created based on ideas grounded in local expertise and experiences. Apart from digital solutions, non-digital solutions were frequently recommended as a strategy to address eHealth literacy needs. Expert validation identified at least half of the ideas were very important and feasible, while most of the guiding principles of the Ophelia process were successfully applied. Conclusion: By harnessing collective creativity through co-design, the Ophelia process has been shown to assist the development of solutions with the potential to improve health and equity outcomes in the digital context. Implementation of the solutions is needed to provide further evidence of the impact of the process. The suggested inclusion of non-digital solutions revealed through the co-design process reminds health organizations and policymakers that solutions should be flexible enough to suit individual needs. As such, taking a co-design approach to digital health initiatives will assist in preventing the widening of health inequalities.

Applying the Electronic Health Literacy Lens: Systematic Review of Electronic Health Interventions Targeted at Socially Disadvantaged Groups.

BACKGROUND: Electronic health (eHealth) has the potential to improve health outcomes. However, eHealth systems need to match the eHealth literacy needs of users to be equitably adopted. Socially disadvantaged groups have lower access and skills to use technologies and are at risk of being digitally marginalized, leading to the potential widening of health disparities. OBJECTIVE: This systematic review aims to explore the role of eHealth literacy and user involvement in developing eHealth interventions targeted at socially disadvantaged groups. METHODS: A systematic search was conducted across 10 databases for eHealth interventions targeted at older adults, ethnic minority groups, low-income groups, low-literacy groups, and rural communities. The eHealth Literacy Framework was used to examine the eHealth literacy components of reviewed interventions. The results were analyzed using narrative synthesis. RESULTS: A total of 51 studies reporting on the results of 48 interventions were evaluated. Most studies were targeted at older adults and ethnic minorities, with only 2 studies focusing on low-literacy groups. eHealth literacy was not considered in the development of any of the studies, and no eHealth literacy assessment was conducted. User involvement in designing interventions was limited, and eHealth intervention developmental frameworks were rarely used. Strategies to assist users in engaging with technical systems were seldom included in the interventions, and accessibility features were limited. The results of the included studies also provided inconclusive evidence on the effectiveness of eHealth interventions. CONCLUSIONS: The findings highlight that eHealth literacy is generally overlooked in developing eHealth interventions targeted at socially disadvantaged groups, whereas evidence about the effectiveness of such interventions is limited. To ensure equal access and inclusiveness in the age of eHealth, eHealth literacy of disadvantaged groups needs to be addressed to help avoid a digital divide. This will assist the realization of recent technological advancements and, importantly, improve health equity.

Questionnaire validation practice within a theoretical framework: a systematic descriptive literature review of health literacy assessments.

OBJECTIVE: Validity refers to the extent to which evidence and theory support the adequacy and appropriateness of inferences based on score interpretations. The health sector is lacking a theoretically-driven framework for the development, testing and use of health assessments. This study used the Standards for Educational and Psychological Testing framework of five sources of validity evidence to assess the types of evidence reported for health literacy assessments, and to identify studies that referred to a theoretical validity testing framework. METHODS: A systematic descriptive literature review investigated methods and results in health literacy assessment development, application and validity testing studies. Electronic searches were conducted in EBSCOhost, Embase, Open Access Theses and Dissertations and ProQuest Dissertations. Data were coded to the Standards' five sources of validity evidence, and for reference to a validity testing framework. RESULTS: Coding on 46 studies resulted in 195 instances of validity evidence across the five sources. Only nine studies directly or indirectly referenced a validity testing framework. Evidence based on relations to other variables is most frequently reported. CONCLUSIONS: The health and health equity of individuals and populations are increasingly dependent on decisions based on data collected through health assessments. An evidence-based theoretical framework provides structure and coherence to existing evidence and stipulates where further evidence is required to evaluate the extent to which data are valid for an intended purpose. This review demonstrates the use of the Standards' theoretical validity testing framework to evaluate sources of evidence reported for health literacy assessments. Findings indicate that theoretical validity testing frameworks are rarely used to collate and evaluate evidence in validation practice for health literacy assessments. Use of the Standards' theoretical validity testing framework would improve evaluation of the evidence for inferences derived from health assessment data on which public health and health equity decisions are based.

Evaluation of the Health Education Impact Questionnaire (heiQ), a Self-Management Skill Assessment Tool, in Italian Chronic Patients.

BACKGROUND: The Health Education Impact Questionnaire (heiQ) aims to evaluate eight self-management skills in people with chronic conditions. Knowledge about the relations between these self-management skills and different quality of life (QoL) outcomes has received little attention. It is also important to provide further evidence on its properties in non-English healthcare contexts, as the questionnaire is being used in cross-cultural research. Furthermore, in the Italian healthcare context, the relationship between the medical staff and the patients remains asymmetrical, with the latter having the role of passive recipients of medical prescriptions and services. The current study provided further evidence about the psychometric properties of the heiQ among Italian people with chronic conditions, specifically by assessing the factor structure, reliability, convergent/divergent and criterion validity (ie, the specific contribution of each of the self-management skills to QoL outcomes). METHODS: Two hundred ninety-nine individuals with a chronic condition (mean age = 61.4 years, 50% females) completed the heiQ and the Medical Outcomes Study-Short Form (MOS SF-36). Confirmatory factor analyses, Composite Reliability Indices (CRI), bivariate correlations and linear regression analyses were computed. RESULTS: A model with 8 correlated factors showed good fit, in a similar way to previous studies. CRI values were acceptable to good for all the subscales. Associations between some of the heiQ subscales and some of the MOS SF-36 subscales supported criterion validity. In particular, it was confirmed by the moderate associations between the constructive attitudes and approaches subscale and the MOS SF-36 vitality and perceived mental health and by the moderate correlations between the health directed activities subscale and the MOS SF-36 Vitality. In linear regressions, higher emotional distress predicted higher physical and mental QoL, while higher mental QoL was also associated with stronger constructive attitudes and approaches. CONCLUSION: The heiQ has robust properties across translations and it can also be used routinely in Italian healthcare contexts. The evidence that all the other self-management skills did not predict either physical or mental QoL could suggest that the self-management model of chronic diseases is still not sufficiently developed in the Italian context, where patients are passive recipients of medical instructions.

Translation method is validity evidence for construct equivalence: analysis of secondary data routinely collected during translations of the Health Literacy Questionnaire (HLQ).

BACKGROUND: Cross-cultural research with patient-reported outcomes measures (PROMs) assumes that the PROM in the target language will measure the same construct in the same way as the PROM in the source language. Yet translation methods are rarely used to qualitatively maximise construct equivalence or to describe the intents of each item to support common understanding within translation teams. This study aimed to systematically investigate the utility of the Translation Integrity Procedure (TIP), in particular the use of item intent descriptions, to maximise construct equivalence during the translation process, and to demonstrate how documented data from the TIP contributes evidence to a validity argument for construct equivalence between translated and source language PROMs. METHODS: Analysis of secondary data was conducted on routinely collected data in TIP Management Grids of translations (n = 9) of the Health Literacy Questionnaire (HLQ) that took place between August 2014 and August 2015: Arabic, Czech, French (Canada), French (France), Hindi, Indonesian, Slovak, Somali and Spanish (Argentina). Two researchers initially independently deductively coded the data to nine common types of translation errors. Round two of coding included an identified 10th code. Coded data were compared for discrepancies, and checked when needed with a third researcher for final code allocation. RESULTS: Across the nine translations, 259 changes were made to provisional forward translations and were coded into 10 types of errors. Most frequently coded errors were Complex word or phrase (n = 99), Semantic (n = 54) and Grammar (n = 27). Errors coded least frequently were Cultural errors (n = 7) and Printed errors (n = 5). CONCLUSIONS: To advance PROM validation practice, this study investigated a documented translation method that includes the careful specification of descriptions of item intents. Assumptions that translated PROMs have construct equivalence between linguistic contexts can be incorrect due to errors in translation. Of particular concern was the use of high level complex words by translators, which, if undetected, could cause flawed interpretation of data from people with low literacy. Item intent descriptions can support translations to maximise construct equivalence, and documented translation data can contribute evidence to justify score interpretation and use of translated PROMS in new linguistic contexts.

Italian validation of the health education impact questionnaire (heiQ) in people with chronic conditions.

BACKGROUND: The health education impact Questionnaire (heiQ) measures eight self-management skills in people with chronic conditions. It seems to be important to provide cross-cultural evidence on its properties in non-English healthcare contexts. The present study assessed the psychometric properties of the heiQ in Italian adults with chronic conditions. METHODS: Two hundred ninety-nine individuals with a chronic condition (mean age = 61.4 years, 50.16% females) completed the heiQ and the Medical Outcomes Study-Short Form (SF-36). Confirmatory factor analyses, Composite Reliability Indices, and bivariate correlations were performed. RESULTS: Structural validity based on 8 correlated factors with good fit was in line with previous research. Concurrent validity was confirmed, as shown by moderate associations between the scores on the Constructive attitudes and approaches, Self-monitoring and insight, Health directed activities, Social integration and support, and Emotional distress subscales and the scores on SF-36 Physical functioning, General health perceptions, Vitality, Social functioning, Perceived mental health and Role limitations due to physical and emotional problems subscales. CONCLUSIONS: The Italian heiQ has strong properties and it can be used routinely also in the Italian healthcare services.

Questionnaire validation practice: a protocol for a systematic descriptive literature review of health literacy assessments.

INTRODUCTION: Contemporary validity testing theory holds that validity lies in the extent to which a proposed interpretation and use of test scores is justified, the evidence for which is dependent on both quantitative and qualitative research methods. Despite this, we hypothesise that development and validation studies for assessments in the field of health primarily report a limited range of statistical properties, and that a systematic theoretical framework for validity testing is rarely applied. Using health literacy assessments as an exemplar, this paper outlines a protocol for a systematic descriptive literature review about types of validity evidence being reported and if the evidence is reported within a theoretical framework. METHODS AND ANALYSIS: A systematic descriptive literature review of qualitative and quantitative research will be used to investigate the scope of validation practice in the rapidly growing field of health literacy assessment. This review method employs a frequency analysis to reveal potentially interpretable patterns of phenomena in a research area; in this study, patterns in types of validity evidence reported, as assessed against the criteria of the 2014 Standards for Educational and Psychological Testing, and in the number of studies using a theoretical validity testing framework. The search process will be consistent with the Preferred Reporting Items for Systematic Reviews and Meta-analyses statement. Outcomes of the review will describe patterns in reported validity evidence, methods used to generate the evidence and theoretical frameworks underpinning validation practice and claims. This review will inform a theoretical basis for future development and validity testing of health assessments in general. ETHICS AND DISSEMINATION: Ethics approval is not required for this systematic review because only published research will be examined. Dissemination of the review findings will be through publication in a peer-reviewed journal, at conference presentations and in the lead author's doctoral thesis.

Characterisation of health literacy strengths and weaknesses among people at metabolic and cardiovascular risk: Validity testing of the Health Literacy Questionnaire.

OBJECTIVES: Health literacy refers to the ability of individuals to gain access to, use, and understand health information and services in order to maintain a good health. The assessment of health literacy profiles in a population is potentially crucial to respond to health needs. The Health Literacy Questionnaire explores nine dimensions of health literacy and has been shown to display robust psychometric properties. The aim was to test the validity of the multidimensional Health Literacy Questionnaire and to describe the health literacy profiles in a French population at risk of cardiovascular disease. METHODS: Data were collected using self-administered questionnaires from 175 participants attending health education and support programmes in local associations of patients in Paris. Analysis included scale reliability, confirmatory factor analysis, and health literacy profiles via descriptive statistics. RESULTS: In confirmatory factor analysis, the nine-factor structure was close to the original Health Literacy Questionnaire. A nine-factor confirmatory factor analysis model was fitted to the 44 items with no cross-loadings or correlated residuals allowed. Given the restricted nature of the model, the fit was satisfactory: χ2 WLSMV(866 df) = 1383.81, p = 0.0000, comparative fit index = 0.925, Tucker-Lewis index = 0.918, root mean square error of approximation = 0.058, weighted root mean square residual = 1.175. Composite reliability ranged from 0.77 to 0.91. Among the 9 scales of the Health Literacy Questionnaire, the highest scores were found for scale 1 'Feeling understood and supported by healthcare professionals' and scale 9 'Understand health information enough to know what to do' and the lowest for scale 2 'Having sufficient information to manage my health' and scale 7 'Navigating the healthcare system'. CONCLUSION: The French version of the Health Literacy Questionnaire was shown to be psychometrically robust with good reliability. In the context of France, the 9 scales of Health Literacy Questionnaire allow a thorough assessment of health literacy strengths and weaknesses to respond to health literacy needs and improve the accessibility of health information and services.

Application of validity theory and methodology to patient-reported outcome measures (PROMs): building an argument for validity.

BACKGROUND: Data from subjective patient-reported outcome measures (PROMs) are now being used in the health sector to make or support decisions about individuals, groups and populations. Contemporary validity theorists define validity not as a statistical property of the test but as the extent to which empirical evidence supports the interpretation of test scores for an intended use. However, validity testing theory and methodology are rarely evident in the PROM validation literature. Application of this theory and methodology would provide structure for comprehensive validation planning to support improved PROM development and sound arguments for the validity of PROM score interpretation and use in each new context. OBJECTIVE: This paper proposes the application of contemporary validity theory and methodology to PROM validity testing. ILLUSTRATIVE EXAMPLE: The validity testing principles will be applied to a hypothetical case study with a focus on the interpretation and use of scores from a translated PROM that measures health literacy (the Health Literacy Questionnaire or HLQ). DISCUSSION: Although robust psychometric properties of a PROM are a pre-condition to its use, a PROM's validity lies in the sound argument that a network of empirical evidence supports the intended interpretation and use of PROM scores for decision making in a particular context. The health sector is yet to apply contemporary theory and methodology to PROM development and validation. The theoretical and methodological processes in this paper are offered as an advancement of the theory and practice of PROM validity testing in the health sector.

Percentile ranks and benchmark estimates of change for the Health Education Impact Questionnaire: Normative data from an Australian sample.

OBJECTIVE: Participant self-report data play an essential role in the evaluation of health education activities, programmes and policies. When questionnaire items do not have a clear mapping to a performance-based continuum, percentile norms are useful for communicating individual test results to users. Similarly, when assessing programme impact, the comparison of effect sizes for group differences or baseline to follow-up change with effect sizes observed in relevant normative data provides more directly useful information compared with statistical tests of mean differences and the evaluation of effect sizes for substantive significance using universal rule-of-thumb such as those for Cohen's 'd'. This article aims to assist managers, programme staff and clinicians of healthcare organisations who use the Health Education Impact Questionnaire interpret their results using percentile norms for individual baseline and follow-up scores together with group effect sizes for change across the duration of typical chronic disease self-management and support programme. METHODS: Percentile norms for individual Health Education Impact Questionnaire scale scores and effect sizes for group change were calculated using freely available software for each of the eight Health Education Impact Questionnaire scales. Data used were archived responses of 2157 participants of chronic disease self-management programmes conducted by a wide range of organisations in Australia between July 2007 and March 2013. RESULTS: Tables of percentile norms and three possible effect size benchmarks for baseline to follow-up change are provided together with two worked examples to assist interpretation. CONCLUSION: While the norms and benchmarks presented will be particularly relevant for Australian organisations and others using the English-language version of the Health Education Impact Questionnaire, they will also be useful for translated versions as a guide to the sensitivity of the scales and the extent of the changes that might be anticipated from attendance at a typical chronic disease self-management or health education programme.

The Health Literacy Questionnaire (HLQ) at the patient-clinician interface: a qualitative study of what patients and clinicians mean by their HLQ scores.

BACKGROUND: The Health Literacy Questionnaire (HLQ) has nine scales that each measure an aspect of the multidimensional construct of health literacy. All scales have good psychometric properties. However, it is the interpretations of data within contexts that must be proven valid, not just the psychometric properties of a measurement instrument. The purpose of this study was to establish the extent of concordance and discordance between individual patient and clinician interpretations of HLQ data in the context of complex case management. METHODS: Sixteen patients with complex needs completed the HLQ and were interviewed to discuss the reasons for their answers. Also, the clinicians of each of these patients completed the HLQ about their patient, and were interviewed to discuss the reasons for their answers. Thematic analysis of HLQ scores and interview data determined the extent of concordance between patient and clinician HLQ responses, and the reasons for discordance. RESULTS: Highest concordance (80%) between patient and clinician item-response pairs was seen in Scale 1 and highest discordance (56%) was seen in Scale 6. Four themes were identified to explain discordance: 1) Technical or literal meaning of specific words; 2) Patients' changing or evolving circumstances; 3) Different expectations and criteria for assigning HLQ scores; and 4) Different perspectives about a patient's reliance on healthcare providers. CONCLUSION: This study shows that the HLQ can act as an adjunct to clinical practice to help clinicians understand a patient's health literacy challenges and strengths early in a clinical encounter. Importantly, clinicians can use the HLQ to detect differences between their own perspectives about a patient's health literacy and the patient's perspective, and to initiate discussion to explore this. Provision of training to better detect these differences may assist clinicians to provide improved care. The outcomes of this study contribute to the growing body of international validation evidence about the use of the HLQ in different contexts. More specifically, this study has shown that the HLQ has measurement veracity at the patient and clinician level and may support clinicians to understand patients' health literacy and enable a deeper engagement with healthcare services.

Systematic development and implementation of interventions to OPtimise Health Literacy and Access (Ophelia).

BACKGROUND: The need for healthcare strengthening to enhance equity is critical, requiring systematic approaches that focus on those experiencing lesser access and outcomes. This project developed and tested the Ophelia (OPtimising HEalth LIteracy and Access) approach for co-design of interventions to improve health literacy and equity of access. Eight principles guided this development: Outcomes focused; Equity driven, Needs diagnosis, Co-design, Driven by local wisdom, Sustainable, Responsive and Systematically applied. We report the application of the Ophelia process where proof-of-concept was defined as successful application of the principles. METHODS: Nine sites were briefed on the aims of the project around health literacy, co-design and quality improvement. The sites were rural/metropolitan, small/large hospitals, community health centres or municipalities. Each site identified their own priorities for improvement; collected health literacy data using the Health Literacy Questionnaire (HLQ) within the identified priority groups; engaged staff in co-design workshops to generate ideas for improvement; developed program-logic models; and implemented their projects using Plan-Do-Study-Act (PDSA) cycles. Evaluation included assessment of impacts on organisations, practitioners and service users, and whether the principles were applied. RESULTS: Sites undertook co-design workshops involving discussion of service user needs informed by HLQ (n = 813) and interview data. Sites generated between 21 and 78 intervention ideas and then planned their selected interventions through program-logic models. Sites successfully implemented interventions and refined them progressively with PDSA cycles. Interventions generally involved one of four pathways: development of clinician skills and resources for health literacy, engagement of community volunteers to disseminate health promotion messages, direct impact on consumers' health literacy, and redesign of existing services. Evidence of application of the principles was found in all sites. CONCLUSIONS: The Ophelia approach guided identification of health literacy issues at each participating site and the development and implementation of locally appropriate solutions. The eight principles provided a framework that allowed flexible application of the Ophelia approach and generation of a diverse set of interventions. Changes were observed at organisational, staff, and community member levels. The Ophelia approach can be used to generate health service improvements that enhance health outcomes and address inequity of access to healthcare.

Structural properties and psychometric improvements of the Health Literacy Questionnaire in a Slovak population.

OBJECTIVES: Health literacy is an important determinant of health and health equity and therefore requires robust measurement. The aim was to examine the psychometric properties of the Slovak version of the Health Literacy Questionnaire (HLQ) including revised wording of response categories. METHODS: A cross-sectional survey of the general Slovak adult population (N = 360, mean age 39) was conducted with the HLQ following its translation and cultural adaptation. Psychometric tests (confirmatory factor analysis, Cronbach's alpha, composite reliability) and association (linear regression, ANOVA) with sociodemographic variables were undertaken. The performance of alternative version of response options were explored with the Mann-Whittney U test and item response theory. RESULTS: A highly restrictive nine-factor confirmatory factor analysis showed acceptable fit [χ 2WLSMV = 1684 (df = 866), p < 0.0001; CFI = 0.943, TLI = 0.938, RMSEA = 0.051, WRMR = 1.297] and reliability was acceptable (range 0.73-0.84). The revised response categories had a better distribution with lower average scores in three domains, compared with the original, and improved item information curves. CONCLUSIONS: The nine HLQ scales are robust, providing a fine-grained assessment of health literacy. The revised response options improve psychometric properties and are recommended for future studies.

Validation of the dutch version of the health education impact questionnaire (HEIQ) and comparison of the Dutch translation with the English, German and French HEIQ.

BACKGROUND: The Health Education Impact Questionnaire (heiQ) evaluates the effectiveness of health education and self-management programs provided to people dealing with a wide range of conditions. Aim of this study was to translate, culturally adapt and validate the Dutch translation of the heiQ and to compare the results with the English, German and French translations. METHODS: A systematic translation process was undertaken. Psychometric properties were studied among patients with arthritis, atopic dermatitis, food allergy and asthma (n = 286). Factorial validity using confirmatory factor analysis, item difficulty (D), item remainder correlation and composite reliability were conducted. Stability was tested using the intra-class correlation coefficient (ICC). RESULTS: Items were well understood and only minor language adjustments were required. Confirmatory fit indices were >0.95 and item difficulty was D ≥ 0.65 for all items in scales showing acceptable fit indices, except for the reversed Emotional distress scale. Composite reliability ranged between 0.67 and 0.85. Test-retest reliability (n = 93) ICC varied between 0.61 and 0.84. Comparisons with other translations showed comparable fit indices. A lower ICC on Self-monitoring and insight scale was observed. CONCLUSIONS: The Dutch translation of the heiQ was found to be well understood and user friendly by patients with Rheumatoid Arthritis, Atopic Dermatitis, Food allergy and asthma and to have robust psychometric properties for evaluating the impact of health education and self-management programs. Given the wide applications of the heiQ and the comparability of the Dutch results with the English, German and French version, the heiQ is a practical and useful questionnaire to evaluate the impact of self-management support programs in different countries and populations with different diseases.

German translation, cultural adaptation, and validation of the Health Literacy Questionnaire (HLQ).

The Health Literacy Questionnaire (HLQ), developed in Australia in 2012 using a 'validity-driven' approach, has been rapidly adopted and is being applied in many countries and languages. It is a multidimensional measure comprising nine distinct domains that may be used for surveys, needs assessment, evaluation and outcomes assessment as well as for informing service improvement and the development of interventions. The aim of this paper is to describe the German translation of the HLQ and to present the results of the validation of the culturally adapted version. The HLQ comprises 44 items, which were translated and culturally adapted to the German context. This study uses data collected from a sample of 1,058 persons with chronic conditions. Statistical analyses include descriptive and confirmatory factor analyses. In one-factor congeneric models, all scales demonstrated good fit after few model adjustments. In a single, highly restrictive nine-factor model (no cross-loadings, no correlated errors) replication of the original English-language version was achieved with fit indices and psychometric properties similar to the original HLQ. Reliability for all scales was excellent, with a Cronbach's Alpha of at least 0.77. High to very high correlations between some HLQ factors were observed, suggesting that higher order factors may be present. Our rigorous development and validation protocol, as well as strict adaptation processes, have generated a remarkable reproduction of the HLQ in German. The results of this validation provide evidence that the HLQ is robust and can be recommended for use in German-speaking populations. TRIAL REGISTRATION: German Clinical Trial Registration (DRKS): DRKS00000584. Registered 23 March 2011.

Measuring health literacy in community agencies: a Bayesian study of the factor structure and measurement invariance of the health literacy questionnaire (HLQ).

BACKGROUND: The development of the Health Literacy Questionnaire (HLQ), reported in 2013, attracted widespread international interest. While the original study samples were drawn from clinical and home-based aged-care settings, the HLQ was designed for the full range of healthcare contexts including community-based health promotion and support services. We report a follow-up study of the psychometric properties of the HLQ with respondents from a diverse range of community-based organisations with the principal goal of contributing to the development of a soundly validated evidence base for its use in community health settings. METHODS: Data were provided by 813 clients of 8 community agencies in Victoria, Australia who were administered the HLQ during the needs assessment stage of the Ophelia project, a health literacy-based intervention. Most analyses were conducted using Bayesian structural equation modelling that enables rigorous analysis of data but with some relaxation of the restrictive requirements for zero cross-loadings and residual correlations of 'classical' confirmatory factor analysis. Scale homogeneity was investigated with one-factor models that allowed for the presence of small item residual correlations while discriminant validity was studied using the inter-factor correlations and factor loadings from a full 9-factor model with similar allowance for small residual correlations and cross-loadings. Measurement invariance was investigated scale-by-scale using a model that required strict invariance of item factor loadings, thresholds, residual variances and co-variances. RESULTS: All HLQ scales were found to be homogenous with composite reliability ranging from 0.80 to 0.89. The factor structure of the HLQ was replicated and 6 of the 9 scales were found to exhibit clear-cut discriminant validity. With a small number of exceptions involving non-invariance of factor loadings, strict measurement invariance was established across the participating organisations and the gender, language background, age and educational level of respondents. CONCLUSIONS: The HLQ is highly reliable, even with only 4 to 6 items per scale. It provides unbiased mean estimates of group differences across key demographic indicators. While measuring relatively narrow constructs, the 9 dimensions are clearly separate and therefore provide fine-grained data on the multidimensional area of health literacy. These analyses provide researchers, program managers and policymakers with a range of robust evidence by which they can make judgements about the appropriate use of the HLQ for their community-based setting.

Cultural adaptation and validation of the Health Literacy Questionnaire (HLQ): robust nine-dimension Danish language confirmatory factor model.

Health literacy is an important construct in population health and healthcare requiring rigorous measurement. The Health Literacy Questionnaire (HLQ), with nine scales, measures a broad perception of health literacy. This study aimed to adapt the HLQ to the Danish setting, and to examine the factor structure, homogeneity, reliability and discriminant validity. The HLQ was adapted using forward-backward translation, consensus conference and cognitive interviews (n = 15). Psychometric properties were examined based on data collected by face-to-face interview (n = 481). Tests included difficulty level, composite scale reliability and confirmatory factor analysis (CFA). Cognitive testing revealed that only minor re-wording was required. The easiest scale to respond to positively was 'Social support for health', and the hardest were 'Navigating the healthcare system' and 'Appraisal of health information'. CFA of the individual scales showed acceptably high loadings (range 0.49-0.93). CFA fit statistics after including correlated residuals were good for seven scales, acceptable for one. Composite reliability and Cronbach's α were >0.8 for all but one scale. A nine-factor CFA model was fitted to items with no cross-loadings or correlated residuals allowed. Given this restricted model, the fit was satisfactory. The HLQ appears robust for its intended application of assessing health literacy in a range of settings. Further work is required to demonstrate sensitivity to measure changes.