title: 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.
authors.affiliation: Department of Public Health, Section of Health Promotion and Health Services Research, Aarhus University, Bartholins Alle 2, 8000 Aarhus C, Denmark ; Steno Diabetes Center, Health Promotion Research, Gentofte, Denmark.
authors.forename: Helle Terkildsen
authors.identifier: 0000-0003-0525-7254
authors.initials: HT
authors.lastname: Maindal
authors.affiliation: Department of Public Health, University of Copenhagen, Copenhagen, Denmark.
authors.forename: Lars
authors.identifier: 0000-0002-0909-4088
authors.initials: L
authors.lastname: Kayser
authors.affiliation: Department of Public Health, University of Copenhagen, Copenhagen, Denmark ; Research and Knowledge Centre, Danish Veteran Centre, Ringsted, Denmark.
authors.forename: Ole
authors.identifier: 0000-0002-1681-4338
authors.initials: O
authors.lastname: Norgaard
authors.affiliation: Department of Public Health, Section of Health Promotion and Health Services Research, Aarhus University, Bartholins Alle 2, 8000 Aarhus C, Denmark.
authors.forename: Anne
authors.initials: A
authors.lastname: Bo
authors.affiliation: Health Systems Improvement Unit, Deakin University Centre for Population Health Research, School of Health and Social Development, Geelong, VIC Australia.
authors.forename: Gerald R
authors.identifier: 0000-0001-6306-7593
authors.initials: GR
authors.lastname: Elsworth
authors.affiliation: Health Systems Improvement Unit, Deakin University Centre for Population Health Research, School of Health and Social Development, Geelong, VIC Australia.
authors.forename: Richard H
authors.identifier: 0000-0002-9081-2699
authors.initials: RH
authors.lastname: Osborne
keywords: HLQ; Health literacy; Measurement; Psychometrics; Questionnaire; Validation