Translation, cultural adaptation and psychometric properties of the Ghanaian language (Akan; Asante Twi) version of the Health Literacy Questionnaire

Abstract

Background Patients’ competencies and resources to manage their own health, which is termed health literacy, is a necessity for better health outcomes. Thus, it is relevant to have a comprehensive health literacy measurement tool suitable for populations of interest. The Health Literacy Questionnaire (HLQ) is a tool useful for health literacy assessment covering nine dimensions/scales of health literacy. The HLQ has been translated and validated in diverse contexts but has so far not been assessed in any country in sub-Saharan Africa. We sought to translate this tool into the most common language used in Ghana and assess its validity. Methods We carried out a cross-sectional study using the HLQ concurrently with an assessment of a malaria programme for caregivers with children under 5 years. The HLQ was translated using a systematic translation procedure. We analysed the psychometric properties of the HLQ based on data collected by face-to-face interview of 1234 caregivers. The analysis covered tests on difficulty level of scales, composite reliability, Cronbach’s alpha and confirmatory factor analysis (CFA). Results Cognitive testing showed that some words were ambiguous, which led to minor rewording of the questionnaire. A nine-factor CFA model was fitted to the 44 question items with no cross-loadings or correlated residuals allowed. Given the very restricted nature of the model, the fit was quite satisfactory: χ2 DWLS (866 df) = 17,177.58, p < 0.000, CFI = 0.971, TLI = 0.969, RMSEA = 0.126 and SRMR = 0.107. Composite reliability and Cronbach’s alpha were > 0.65 for all scales except Cronbach’s alpha for scale 9, ‘Understanding health information well enough to know what to do’ (0.57). The mean differences between most demographic groups among health literacy scales were statistically significant. Conclusion The Akan-Twi version of HLQ proved relevant in our description of the health literacy levels among the caregivers in our study. This validated tool will be useful to conduct health literacy needs assessments to guide policies addressing such needs. Further work is needed to validate this tool for use in Ghana and similar contexts.

Cultural Adaptation and Validity Testing of the Portuguese Version of the Health Literacy Questionnaire (HLQ)

“…The HLQ has been shown to have robust psychometric properties in its original version [ 21 , 22 ], as well as across European cultures [ 23 , 24 , 25 , 26 , 27 , 28 , 29 , 30 , 31 ] and in some Asian and African cultures [ 32 , 33 , 34 ], supporting the initial nine-factor model and thus confirming its construct validity for use in a variety of settings. To allow assessment in communities and across specific populations with the aim of adaptation of services and structures to the health needs of people struggling with disease management or prevention, the HLQ has been translated and undergone validity testing in different countries and underlies the work done in the scope of the WHO National Health Literacy Demonstration Projects, in which Portugal is involved [ 10 ].…”

“…They considered that “the range of conditions studied here, sample sizes exceeding N ≥ 300 are most likely to ensure adequate convergence of the robust WLS estimator, accurate recovery of factor loadings and covariances, and satisfactory approximation of standard errors and the (chi-square) statistic. Thus, we considered a sample > 300 ensure a robust analysis with WLSMV that provides accurate estimates of all the information from the factor analysis” [ 33 ]. Eligible participants were clinic attendees aged 18 or older with a diagnosis of diabetes.…”

“…Item difficulty was determined by descriptive statistics consistent with previous HLQ studies [ 24 , 26 , 33 ]. For the first five domains, the difficulty level was calculated as the number of strongly disagree/disagree responses divided by the number of agree/strongly agree responses.…”

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

“…The development and publication of validity evidence has not kept pace with the application of the HLQ in practice. However, since the literature review for this study was conducted, more articles presenting evidence for the HLQ have been published [ 1 , 2 , 11 , 13 , 21 , 66 , 73 , 89 , 96 , 107 , 108 ].…”

Use of the English Health Literacy Questionnaire (HLQ) with Health Science University Students in Nepal: A Validity Testing Study

“…The nine domains of the HLQ are designed to measure the experiences people have when they engage in understanding, accessing and using health information and health services. In its development context, the HLQ was found to have strong construct validity, reliability and acceptability to clients and clinicians [ 30 , 35 ] and confirmatory factor analysis (CFA) has found that the items and scales in HLQ translations tend to behave in comparable ways to the English-language HLQ [ 36 , 37 , 38 , 39 ], even among disparate groups in low-resource settings [ 40 , 41 , 42 ]. HLQ data are used in pre-post evaluations and to develop profiles of health literacy strengths and needs to describe the health literacy of individuals and whole populations [ 12 , 43 ].…”