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

Abstract

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.

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

“…The HLQ was informed by the World Health Organization definition of health literacy: the cognitive and social skills which determine the motivation and ability of individuals to gain access to, understand and use information in ways which promote and maintain good health [54]. While validity testing of the HLQ has been conducted in English-speaking settings [55–59], evidence for the use of translated versions of the HLQ in non-English-speaking settings is still being collected [60–62]. …”

“…Given that our case of a translated PROM is hypothetical, we do not provide a validity argument from (hypothetical) evaluated evidence. While a wide range of evidence has been generated for the original English HLQ, only some evidence has been generated for the use of translated HLQs in some specific settings [60–62, 77, 78]; therefore, the accumulation of much more evidence is warranted. The publications and examples that are cited in Table 1 provide guidance for the types of studies that could be conducted by users of translated PROMs and also indicate where evidence for translated HLQs is still required.…”

“…A developer or other person deeply familiar with the PROM’s content and purpose oversees the concordance between the intents of original items and target language items. For example, two papers that describe the translation of the HLQ to other languages (Slovak [62] and Danish [60]) discuss the method of translation including the use of HLQ item intents, and they list the participants who took part in the detailed analysis of the translated items to collectively decide on the final itemsSystematic recording of steps in the translation and in the analysis of the recorded data, including changes made through the processIn-depth cognitive interviews with target audience in the target culture about the items on the translated PROM, and content analysis to compare narrative data from interviews with the source language PROM item intents and construct definitions 2. Response processes [11] — cognitive processes, and interpretation of test items by respondents and users, as measured against the intended interpretation or construct definition 2.1 Respondents to both the translated PROM and source language PROM engage in the same or similar cognitive (response) processes when responding to items, and these processes align with the source language construct criteria, thus indicating that similar respondents across cultures are formulating responses to the same items in the same wayEvidence that linguistic equivalence and cultural appropriateness has been achieved in the PROM translationEvidence that the cognitive processes of respondents match construct criteria (i.e.…”

Barriers to Breast Cancer Screening among Diverse Cultural Groups in Melbourne, Australia

“…A four-point response scale is used to assess domains 1 to 5 (strongly disagree to strongly agree), and a five-point scale is used to assess domains 6 to 9 (cannot do or always difficult to always easy). The HLQ has a strong and reproducible theoretical structure that has been found to be robust in several studies [33,34,35,36]. The HLQ was translated using a formal forward and (blind) back translation procedure, with the forward translators guided by a detailed item intent document.…”

Relationship Between Patient-Reported Outcome Measures and the Severity of Chronic Obstructive Pulmonary Disease in the Context of an Innovative Digitally Supported 24-Hour Service: Longitudinal Study (Preprint)

“…Ability to understand health information), were applied in 29,473 people within the Danish National Health Survey [15]. It has been validity tested in the Danish language [16], as well as other European languages and found to have a robust psychometric properties [17,18].…”