Roy Batterham

The grounded psychometric development and initial validation of the Health Literacy Questionnaire (HLQ)

BackgroundHealth literacy has become an increasingly important concept in public health. We sought to develop a comprehensive measure of health literacy capable of diagnosing health literacy needs across individuals and organisations by utilizing perspectives from the general population, patients, practitioners and policymakers.MethodsUsing a validity-driven approach we undertook grounded consultations (workshops and interviews) to identify broad conceptually distinct domains. Questionnaire items were developed directly from the consultation data following a strict process aiming to capture the full range of experiences of people currently engaged in healthcare through to people in the general population. Psychometric analyses included confirmatory factor analysis (CFA) and item response theory. Cognitive interviews were used to ensure questions were understood as intended. Items were initially tested in a calibration sample from community health, home care and hospital settings (N=634) and then in a replication sample (N=405) comprising recent emergency department attendees.ResultsInitially 91 items were generated across 6 scales with agree/disagree response options and 5 scales with difficulty in undertaking tasks response options. Cognitive testing revealed that most items were well understood and only some minor re-wording was required. Psychometric testing of the calibration sample identified 34 poorly performing or conceptually redundant items and they were removed resulting in 10 scales. These were then tested in a replication sample and refined to yield 9 final scales comprising 44 items. A 9-factor CFA model was fitted to these items with no cross-loadings or correlated residuals allowed. Given the very restricted nature of the model, the fit was quite satisfactory: χ2WLSMV(866 d.f.) = 2927, p<0.000, CFI = 0.936, TLI = 0.930, RMSEA = 0.076, and WRMR = 1.698. Final scales included: Feeling understood and supported by healthcare providers; Having sufficient information to manage my health; Actively managing my health; Social support for health; Appraisal of health information; Ability to actively engage with healthcare providers; Navigating the healthcare system; Ability to find good health information; and Understand health information well enough to know what to do.ConclusionsThe HLQ covers 9 conceptually distinct areas of health literacy to assess the needs and challenges of a wide range of people and organisations. Given the validity-driven approach, the HLQ is likely to be useful in surveys, intervention evaluation, and studies of the needs and capabilities of individuals.

The health literacy management scale (HeLMS): a measure of an individual's capacity to seek, understand and use health information within the healthcare setting.

OBJECTIVE Health literacy refers to an individuals ability to seek, understand, and use health information. This paper describes the development and psychometric testing of the health literacy management scale (HeLMS). METHODS Content areas were identified from a conceptual framework derived from interviews and concept mapping. Items were generated from statements from concept mapping participants. Construction (N=333) and replication (N=350) samples were participants in chronic disease self-management programs and emergency department attendees. Factor analysis was used to refine constructs and define psychometric properties. RESULTS Consultations generated 8 scales each with 4-5 items: Understanding health information, Accessing GP healthcare services, Communication with health professionals, Being proactive and Using health information, Patient attitudes towards their health, Social support, and Socioeconomic considerations. Confirmatory factor analyses indicated good fit of the data with the model (RMSEA=0.07, SRMR=0.05, CFI=0.97) and all domains had high internal consistency (Cronbach alpha>0.82). CONCLUSION The HeLMS has acceptable psychometric properties and assesses a range of health literacy constructs important to patients when seeking, understanding and using health information within the healthcare system. PRACTICE IMPLICATIONS The HeLMS presents a new approach to assessing health literacy in healthcare settings.

The OPtimising HEalth LIterAcy (Ophelia) process: study protocol for using health literacy profiling and community engagement to create and implement health reform.

BackgroundHealth literacy is a multi-dimensional concept comprising a range of cognitive, affective, social, and personal skills and attributes. This paper describes the research and development protocol for a large communities-based collaborative project in Victoria, Australia that aims to identify and respond to health literacy issues for people with chronic conditions. The project, called Ophelia (OPtimising HEalth LIterAcy) Victoria, is a partnership between two universities, eight service organisations and the Victorian Government. Based on the identified issues, it will develop and pilot health literacy interventions across eight disparate health services to inform the creation of a health literacy response framework to improve health outcomes and reduce health inequalities.Methods/DesignThe protocol draws on many inputs including the experience of the partners in previous co-creation and roll-out of large-scale health-promotion initiatives. Three key conceptual models/discourses inform the protocol: intervention mapping; quality improvement collaboratives, and realist synthesis. The protocol is outcomes-oriented and focuses on two key questions: ‘What are the health literacy strengths and weaknesses of clients of participating sites?’, and ‘How do sites interpret and respond to these in order to achieve positive health and equity outcomes for their clients?’. The process has six steps in three main phases. The first phase is a needs assessment that uses the Health Literacy Questionnaire (HLQ), a multi-dimensional measure of health literacy, to identify common health literacy needs among clients. The second phase involves front-line staff and management within each service organisation in co-creating intervention plans to strategically respond to the identified local needs. The third phase will trial the interventions within each site to determine if the site can improve identified limitations to service access and/or health outcomes.DiscussionThere have been few attempts to assist agencies to identify, and respond, in a planned way, to the varied health literacy needs of their clients. This project will assess the potential for targeted, locally-developed health literacy interventions to improve access, equity and outcomes.

The evaluation of chronic disease self-management support across settings: the international experience of the health education impact questionnaire quality monitoring system.

Chronic disease self-management is a growing field yet few systematic measures of its impact exist. The Health Education Impact Questionnaire (heiQ)-rigorously developed in partnership with key stakeholders-is a panel of eight highly relevant questionnaires that has been tested and applied in many settings. Wide uptake across diseases has occurred because it resonates with patient concerns, helps researchers and practitioners develop quality services, and assists policy-makers to appreciate the value of self-management support interventions. The heiQ continues to be adapted for new uses and applications creating a web of knowledge of the value and impact of health education programs.

Health Literacy: What Is It and Why Is It Important to Measure?

This report summarizes the proceedings of the first Outcome Measures in Rheumatology Clinical Trials (OMERACT) Health Literacy Special Interest Group workshop at the OMERACT 10 conference. Health literacy refers to an individual’s capacity to seek, understand, and use health information. Discussion centered on the relevance of health literacy to the rheumatology field; whether measures of health literacy were important in the context of clinical trials and routine care; and, if so, whether disease-specific measures were required. A nominal group process involving 27 workshop participants, comprising a patient group (n = 12) and a healthcare professional and researcher group (n = 15), confirmed that health literacy encompasses a broad range of concepts and skills that existing scales do not measure. It identified the importance and relevance of patient abilities and characteristics, but also health professional factors and broader contextual factors. Sixteen themes were identified: access to information; cognitive capacity; disease; expression/communication; finances; health professionals; health system; information; literacy/numeracy; management skills; medication; patient approach; dealing with problems; psychological characteristics; social supports; and time. Each of these was divided further into subthemes of one or more of the following: knowledge, attitude, attribute, relationship, skill, action, or context. There were virtually no musculoskeletal-specific statements, suggesting that a generic health literacy tool in rheumatology is justified. The detailed concepts across themes provided new and systematic insight into what needs to be done to improve health literacy and consequently reduce health inequalities. These data will be used to derive a more comprehensive measure of health literacy.

Can we achieve accountability for long-term outcomes?☆☆☆

OBJECTIVE To explore options for the development of a set of indicators to assess the long-term outcomes achieved by all people with a given disabling condition in a given population. DATA SOURCES The review draws on empirical studies of predictive indicators, theoretical literature on long-term recovery processes, and literature from administrative science on the use of indicators in accountability systems. STUDY SELECTION Studies were selected that explicitly sought to relate short-term and long-term outcomes or that explored the mediating factors in the relationship between impairment, disability, and handicap. DATA EXTRACTION The focus of the review is on (1) empirical evidence of the relationship between short- and long-term outcomes, particularly in causal claims, and (2) theoretical analyses of the factors that mediate this relationship. DATA SYNTHESIS Evidence is presented that certain outcome states can be considered thresholds that make the outcome usable and, hence, sustainable or that create the opportunity for further improvement. Such thresholds could meet the construct validity criteria necessary for measures that are to be used as indicators in an accountability system. The interaction between psychological and physical factors in setting thresholds means that both objective and subjective indicators are required in an indicator system. CONCLUSIONS It may well be possible to develop a parsimonious set of population-based outcome indicators for people with disabilities. The key safeguards required are construct validity and the involvement of people with disabilities in both the development and use of the indicators.

Integration of primary health care services: perceptions of Australian general practitioners, non-general practitioner health service providers and consumers at the general practice-primary care interface

Abstract Introduction. In conjunction with GPs reporting on their own practice experiences, the experiences of non-GP health professionals and consumer representatives working at the primary care–general practice interface provide valuable considerations for exploring concepts for the development of a GP Integration Index relevant to Australian General Practice. Objectives. To identify concepts that GPs, non-GP health service providers and consumer representatives perceive to be important in facilitating a well integrated approach to delivering primary care, and how these are perceived to be occurring in practice. Method. Group discussions about GP integration were elicited using concept mapping with four groups of GPs and seven groups of health professionals and consumer representatives, purposively selected for diversity in demographic location and practice setting from three Australian States. From Victoria, 19 GPs from two different types of practice settings, 12 Consumer Representatives from 10 separate organisations, 17 Hospital Administrators from 16 major public and private hospitals, 18 specialist doctors representing 12 specialist organisations and 13 Community Service Providers. From Queensland, 13 rural GPs and 22 Nurses representing 10 separate nursing groups were selected. From Western Australia, 19 GPs representing a mix of solo practice, group practice and hospital settings, and 40 Allied Health providers representing various private practitioners and hospital and community centre based allied health practitioners. Concept mapping results from the groups were pooled and analysed using a descriptive meta-matrix to identify overarching themes. Results. Eight overarching themes were identified from consolidated concept maps: GP role; quality outcomes; practice management/accessibility; communication and networks; health care system politics; education and knowledge; personal attributes and attitudes; and lifestyle. Within these major themes, clusters of concepts rated as at least ‘important for patient care’ included various non-clinical aspects of primary care delivery. There was emphasis on a patient—centred and holistic care approach. Strongly advocated by all groups was the need for teamwork between GPs and other health care professionals involved in primary care of the patient. Conclusion. The use of concept mapping was successful in ensuring that the breadth of the topic was explored in its entirety among these groups, contributing to the identification of the dimensions of the concept of GP-integration. Findings from these groups will be pooled and subjected to structural equation modelling processes, to develop a general practice integration index relevant to the Australian setting.

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

ObjectivesHealth 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.MethodsA 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.ResultsA highly restrictive nine-factor confirmatory factor analysis showed acceptable fit [χ2WLSMV = 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.ConclusionsThe 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.

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

BackgroundThe 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.MethodsNine 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.ResultsSites 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.ConclusionsThe 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.

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

BackgroundThe 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.MethodsSixteen 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.ResultsHighest 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.ConclusionThis 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.