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Validating the European Health Literacy Survey Questionnaire in people with type 2 diabetes. Latent trait analyses applying multidimensional Rasch modelling and confirmatory factor analysis.
Karlstad University, Faculty of Health, Science and Technology (starting 2013), Department of Health Sciences (from 2013).ORCID iD: 0000-0001-8911-2102
Oslo and Akershus University College of Applied Sciences.
Karlstad University, Faculty of Health, Science and Technology (starting 2013), Department of Health Sciences (from 2013).ORCID iD: 0000-0001-7082-6834
Karlstad University, Faculty of Health, Science and Technology (starting 2013), Department of Health Sciences (from 2013).
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2017 (English)In: Journal of Advanced Nursing, ISSN 0309-2402, E-ISSN 1365-2648, Vol. 73, no 11, p. 2730-2744Article in journal (Refereed) Published
Abstract [en]

AIM: To validate the European Health Literacy Survey Questionnaire (HLS-EU-Q47) in people with type 2 diabetes mellitus.

BACKGROUND: The HLS-EU-Q47 latent variable is outlined in a framework with four cognitive domains integrated in three health domains, implying 12 theoretically defined subscales. Valid and reliable health literacy measurers are crucial to effectively adapt health communication and education to individuals and groups of patients.

DESIGN: Cross-sectional study applying confirmatory latent trait analyses.

METHODS: Using a paper-and-pencil self-administered approach, 388 adults responded in March 2015. The data were analysed using the Rasch methodology and confirmatory factor analysis.

RESULTS: Response violation and trait violation (multidimensionality) of local independence were identified. Fitting the 'multidimensional random coefficients multinomial logit' model, 1-, 3- and 12-dimensional Rasch models were applied and compared. Poor model fit and differential item functioning were present in some items and several subscales suffered from poor targeting and low reliability. Despite multidimensionality in the data, we did not observe any unordered response categories.

CONCLUSION: Interpreting the domains as distinct but related latent dimensions, the data fit a 12-dimensional Rasch model and a 12-factor confirmatory factor model best. Therefore, the analyses did not support the estimation of one overall 'health literacy score'. To support the plausibility of claims based on the HLS-EU score(s), we suggest: removing the health care aspect to reduce the magnitude of multidimensionality; rejecting redundant items to confine response dependency; adding 'harder' items and applying a six-point rating scale to improve subscale targeting and reliability; and revising items to improve model fit. This article is protected by copyright. All rights reserved.

Place, publisher, year, edition, pages
Oxford: Blackwell Publishing, 2017. Vol. 73, no 11, p. 2730-2744
Keywords [en]
HLS-EU-Q47, confirmatory factor analysis, health literacy, multidimensional Rasch modelling, nursing research, type 2 diabetes mellitus
National Category
Nursing
Research subject
Nursing Science
Identifiers
URN: urn:nbn:se:kau:diva-55162DOI: 10.1111/jan.13342PubMedID: 28543754OAI: oai:DiVA.org:kau-55162DiVA, id: diva2:1111626
Available from: 2017-06-19 Created: 2017-06-19 Last updated: 2018-06-12Bibliographically approved
In thesis
1. Measuring health literacy: Evaluating psychometric properties of the HLS-EU-Q47 and the FCCHL, suggesting instrument refinements and exploring health literacy in people with type 2 diabetes and in the general Norwegian population
Open this publication in new window or tab >>Measuring health literacy: Evaluating psychometric properties of the HLS-EU-Q47 and the FCCHL, suggesting instrument refinements and exploring health literacy in people with type 2 diabetes and in the general Norwegian population
2018 (English)Doctoral thesis, comprehensive summary (Other academic)
Alternative title[no]
Måling av health literacy : Evaluering av psykometriske egenskaper av HLS-EU-Q47 og FCCHL, forslag til instrumentforbedringer og kartlegging av health literacy blant personer med diabetes type 2 og generell norsk befolkning
Abstract [en]

Aim: The overall aim was to measure health literacy (HL) in people with type 2 diabetes (T2DM) and in the general Norwegian population.

Methods: Sampling 388 people with T2DM (papers I, II and IV) and 900 individuals (III) in the general Norwegian population a cross-sectional design was applied. Rasch modelling and confirmatory factor analysis were used to evaluate the psychometric properties of the 47 items HLS-EU-Q47 questionnaire (I and III) and the 14 items FCCHL scale (II), and to develop and evaluate a 12 item short version, HLS-N-Q12 (III and IV), based on HLS-EU-Q47. Descriptive and inferential statistics were used to describe HL and to investigate associations between HL and various independent variables.

Main results: The HLS-EU-Q47 displayed psychometric shortcomings in both populations (I and III). A 12-dimensional model described the data best. Several items showed misfit to the Rasch model and statistical dependence. Aiming at meeting the requirements of objective measurement, the HLS-N-Q12 was suggested (III and IV). Evaluating the FCCHL in people with T2DM, the data fitted a three-dimensional model best (II). Several items showed misfit to the Rasch model and unordered response categories. However, a three-dimensional 12-item version of the FCCHL had acceptable psychometric properties. Education, good general health and empowerment were positively associated with HL in people with T2DM, explaining about 17% of the total variance in HL (IV).

Conclusions: In both populations, the HLS-N-Q12 displayed solid psychometric properties and might therefore be used as a measure of HL for both clinical and research purposes. Nurses and other health professionals must be aware that HL influence individuals’ proficiency in managing their health. Hence, nurses and other health professionals should map HL in individuals and adapt health information accordingly.

Abstract [no]

Hensikt: Avhandlingens overordnede hensikt var å måle health literacy (HL) blant personer med diabetes type 2 (T2DM) og generell norsk befolkning.

Metode: Kvantitativ tverrsnittsstudie hvor 388 personer med T2DM (I, II og IV) og 900 personer fra norsk befolkning (III) var inkludert. Rasch modellering og konfirmatorisk faktoranalyse ble anvendt for å evaluere de psykometriske egenskapene til instrumentene HLS-EU-Q47 (I og III) og FCCHL (II), som består av henholdsvis 47 og 14 spørsmål, og for å utvikle og evaluere en kortversjon av HLS-EU-Q47, HLS-N-Q12, bestående av 12 spørsmål (III og IV). Deskriptiv og inferensiell statistikk ble anvendt for å beskrive HL i utvalgene og for å studere sammenhenger mellom HL og ulike uavhengige variabler.

Hovedresultater: HLS-EU-Q47 viste psykometriske svakheter i begge utvalgene (I og III). HLS-EU-Q47 data viste best tilpasning til en 12-dimensjonal modell. Flere spørsmål viste dårlig tilpasning til Rasch modellen, samt statistisk avhengighet. Med hensikt i å oppnå kravene for objektive målinger, ble HLS-N-Q12 foreslått (III og IV). I evalueringen av FCCHL blant personer med T2DM viste data best tilpasning til en tredimensjonal modell (II). Spørsmål med dårlig tilpasning til Rasch modellen og uordnede svarkategorier ble avdekket. Imidlertid viste en tredimensjonal versjon av FCCHL bestående av 12 spørsmål akseptable psykometriske egenskaper. Utdanning, god generell helse og empowerment, var positivt assosiert med HL blant personer med T2DM, og forklarte rundt 17% av den totale variansen av HL (IV).

Konklusjoner: HLS-N-Q12 viste solide psykometriske egenskaper i begge populasjonene og kan derfor anvendes for å måle HL både i praksis og innen forskning.  Sykepleiere må være oppmerksomme på at HL påvirker den enkeltes muligheter for å håndtere egen helse. Sykepleiere bør dermed kartlegge HL hos den enkelte og tilpasse helseinformasjon deretter.

Abstract [en]

In today’s health care, we are accountable for our own health and responsible for making cautious health-related decisions based on available information. Health literacy is a vital competence in accomplishing this. Knowledge about people’s health literacy is therefore central to nurses aiming at adapting health information to target groups. The overall aim of this thesis was to measure health literacy in people with type 2 diabetes and in the general Norwegian population.

This thesis demonstrates the usefulness of Rasch modelling as an addition to confirmatory factor analysis in evaluating psychometric properties of health-related scales, such as the HLS-EU-Q47 and the FCCHL. The results indicate that the short form of HLS-EU-Q47, the HLS-N-Q12, meet the assumptions and the requirements of fundamental measurements and could be used to measure health literacy in both people with type 2 diabetes and in the general Norwegian population.

Judging whether health information from various sources are valid and reliable was found to be the most difficult health-literacy task in both populations. Explaining variance in health literacy in people with type 2 diabetes, health literacy stood out as being positively associated with education, good general health and empowerment.

Place, publisher, year, edition, pages
Karlstad: Karlstads universitet, 2018. p. 96
Series
Karlstad University Studies, ISSN 1403-8099 ; 2018:15
Keywords
confirmatory factor analysis, FCCHL, health literacy, health-promotion nursing, HLS-EU-Q47, HLS-N-Q12, measurement, Norwegian population, psychometric evaluation, Rasch modelling, type 2 diabetes, validation, FCCHL, health literacy, helsefremmende sykepleie, HLS-EU-Q47, HLS-N-Q12, konfirmatorisk faktor analyse, måling, norsk befolkning, personer med diabetes type 2, psykometrisk evaluering, Rasch modellering, validering
National Category
Health Sciences
Research subject
Nursing Science
Identifiers
urn:nbn:se:kau:diva-66928 (URN)978-91-7063-846-6 (ISBN)978-91-7063-941-8 (ISBN)
Public defence
2018-05-25, Lagerlöfsalen 1A305, Karlstad, 10:00 (Swedish)
Opponent
Supervisors
Available from: 2018-05-04 Created: 2018-04-06 Last updated: 2018-05-04Bibliographically approved

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