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Establishing the HLS-Q12 short version of the European Health Literacy Survey Questionnaire: Latent trait analyses using Rasch modelling and confirmatory factor modelling
Karlstad University, Faculty of Health, Science and Technology (starting 2013), Department of Health Sciences (from 2013). Inland Norway University of Applied Sciences.ORCID iD: 0000-0001-8911-2102
Karlstad University, Faculty of Health, Science and Technology (starting 2013), Department of Health Sciences (from 2013). Inland Norway University of Applied Sciences.ORCID iD: 0000-0001-7082-6834
Inland Norway University of Applied Sciences.
Oslo Metropolitan Universitet.
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2018 (English)In: BMC Health Services Research, ISSN 1472-6963, E-ISSN 1472-6963, Vol. 18, no 506Article in journal (Other academic) Epub ahead of print
Abstract [en]

The European Health Literacy Survey Questionnaire (HLS-EU-Q47) is widely used in assessing health literacy (HL). There has been some controversy whether the comprehensive HLS-EU-Q47 data, reflecting a conceptual model of four cognitive domains across three health domains (i.e. 12 subscales), fit unidimensional Rasch models. Still, the HLS-EU-Q47 raw score is commonly interpreted as a sufficient statistic. Combining Rasch modelling and confirmatory factor analysis, we reduced the 47 item scale to a parsimonious 12 item scale that meets the assumptions and requirements of objective measurement while offering a clinically feasible HL screening tool. This paper aims at (1) evaluating the psychometric properties of the HLS-EU-Q47 and associated short versions in a large Norwegian sample, and (2) establishing a short version (HLS-Q12) with sufficient psychometric properties.MethodsUsing computer-assisted telephone interviews during November 2014, data were collected from 900 randomly sampled individuals aged 16 and over. The data were analysed using the partial credit parameterization of the unidimensional polytomous Rasch model (PRM) and the 'between-item' multidimensional PRM, and by using one-factorial and multi-factorial confirmatory factor analysis (CFA) with categorical variables.ResultsUsing likelihood-ratio tests to compare data-model fit for nested models, we found that the observed HLS-EU-Q47 data were more likely under a 12-dimensional Rasch model than under a three- or a one-dimensional Rasch model. Several of the 12 theoretically defined subscales suffered from low reliability owing to few items. Excluding poorly discriminating items, items displaying differential item functioning and redundant items violating the assumption of local independency, a parsimonious 12-item HLS-Q12 scale is suggested. The HLS-Q12 displayed acceptable fit to the unidimensional Rasch model and achieved acceptable goodness-of-fit indexes using CFA.ConclusionsUnlike the HLS-EU-Q47 data, the parsimonious 12-item version (HLS-Q12) meets the assumptions and the requirements of objective measurement while offering clinically feasible screening without applying advanced psychometric methods on site. To avoid invalid measures of HL using the HLS-EU-Q47, we suggest using the HLS-Q12. Valid measures are particularly important in studies aiming to explain the variance in the latent trait HL, and explore the relation between HL and health outcomes with the purpose of informing policy makers.

Place, publisher, year, edition, pages
2018. Vol. 18, no 506
Keywords [en]
Confirmatory factor analysis of categorical data; Health literacy; HLS-EU-Q47; HLS-Q12; Rasch modelling; Short version; Validation
National Category
Health Sciences
Research subject
Nursing Science
Identifiers
URN: urn:nbn:se:kau:diva-66962DOI: 10.1186/s12913-018-3275-7OAI: oai:DiVA.org:kau-66962DiVA, id: diva2:1196624
Note

I avhandlingen publicerad med manuskripttiteln: Proposing the HLS-N-Q12 based on a review of the European Health Literacy Survey Questionnaire and associated short versions : Latent trait analyses using Rasch modelling and confirmatory factor modelling

Available from: 2018-04-10 Created: 2018-04-10 Last updated: 2018-06-28Bibliographically 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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Finbråten, Hanne SøbergWilde-Larsson, BodilNordström, Gun

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