title: Measuring health literacy in community agencies: a Bayesian study of the factor structure and measurement invariance of the health literacy questionnaire (HLQ).
abstract: BACKGROUND
  The development of the Health Literacy Questionnaire (HLQ), reported in 2013, attracted widespread international interest. While the original study samples were drawn from clinical and home-based aged-care settings, the HLQ was designed for the full range of healthcare contexts including community-based health promotion and support services. We report a follow-up study of the psychometric properties of the HLQ with respondents from a diverse range of community-based organisations with the principal goal of contributing to the development of a soundly validated evidence base for its use in community health settings.
  
  
  METHODS
  Data were provided by 813 clients of 8 community agencies in Victoria, Australia who were administered the HLQ during the needs assessment stage of the Ophelia project, a health literacy-based intervention. Most analyses were conducted using Bayesian structural equation modelling that enables rigorous analysis of data but with some relaxation of the restrictive requirements for zero cross-loadings and residual correlations of 'classical' confirmatory factor analysis. Scale homogeneity was investigated with one-factor models that allowed for the presence of small item residual correlations while discriminant validity was studied using the inter-factor correlations and factor loadings from a full 9-factor model with similar allowance for small residual correlations and cross-loadings. Measurement invariance was investigated scale-by-scale using a model that required strict invariance of item factor loadings, thresholds, residual variances and co-variances.
  
  
  RESULTS
  All HLQ scales were found to be homogenous with composite reliability ranging from 0.80 to 0.89. The factor structure of the HLQ was replicated and 6 of the 9 scales were found to exhibit clear-cut discriminant validity. With a small number of exceptions involving non-invariance of factor loadings, strict measurement invariance was established across the participating organisations and the gender, language background, age and educational level of respondents.
  
  
  CONCLUSIONS
  The HLQ is highly reliable, even with only 4 to 6 items per scale. It provides unbiased mean estimates of group differences across key demographic indicators. While measuring relatively narrow constructs, the 9 dimensions are clearly separate and therefore provide fine-grained data on the multidimensional area of health literacy. These analyses provide researchers, program managers and policymakers with a range of robust evidence by which they can make judgements about the appropriate use of the HLQ for their community-based setting.
authors.affiliation: Health Systems Improvement Unit, School of Health and Social Development, Deakin University, Geelong, Australia. gerald.elsworth@deakin.edu.au.
authors.forename: Gerald R
authors.initials: GR
authors.lastname: Elsworth
authors.affiliation: Health Systems Improvement Unit, School of Health and Social Development, Deakin University, Geelong, Australia.
authors.forename: Alison
authors.initials: A
authors.lastname: Beauchamp
authors.affiliation: Health Systems Improvement Unit, School of Health and Social Development, Deakin University, Geelong, Australia.
authors.forename: Richard H
authors.initials: RH
authors.lastname: Osborne
keywords: BSEM; Bayesian structural equation modelling; HLQ; Health Literacy Questionnaire; Health literacy; Measurement invariance