Application of validity theory and methodology to patient-reported outcome measures (PROMs): building an argument for validity

Research areas and trends in family-centered care in the 21st century: a bibliometric review

Introduction

Family-centered care (FCC) is a model of care provision that sees a patient's loved ones as essential partners to the health care team and positively influences the psychological safety of patients and loved ones.

Objectives

This review aims to present an overview of impactful publications, authors, institutions, journals, countries, fields of application and trends of FCC in the 21st century as well as suggestions on further research.

Methods

The Web of Science Database was searched for publications on FCC between January 2000 and Dezember 2023. After screening for duplicates, VOS Viewer and CiteSpace were used to analyze and visualize the data.

Results

Scientific interest in FCC has grown and resulted in the scientific output of 4,836 publications originating from 103 different countries. Based on the frequent author keywords, FCC was of greatest interest in neonatology and pediatrics, nursing, critical and intensive care, end-of-life and palliative care, and patient-related outcomes. The recent research hotspots are "patient engagement," "qualitative study," and "health literacy."

Conclusion

FCC has gained recognition and spread from the pediatric to the adult palliative, intensive, end-of-life and geriatric care settings. This is a very reassuring development since adults, especially when older, want and need the assistance of their social support systems. Recent research directions include the involvement of patients in the development of FCC strategies, health literacy interventions and the uptake of telemedicine solutions.

The Juvenile Arthritis Quality of Life Questionnaire in patients with juvenile idiopathic arthritis: Turkish version, validity, and reliability study

INTRODUCTION

This study aimed to assess the cultural adaptation, validity, and reliability of the Turkish version of the Juvenile Arthritis Quality of Life Questionnaire (JAQQ) in patients with juvenile idiopathic arthritis (JIA).

METHODS

A total of 100 JIA patients (64% female), aged 9 to 18 years, participated in the study conducted at a tertiary care university hospital. The JAQQ was culturally adapted through a rigorous translation process and administered alongside established measures, including the Childhood Health Assessment Questionnaire (CHAQ), Juvenile Arthritis Biopsychosocial Questionnaire (JABQ), and Children's Depression Inventory (CDI). Validity and reliability were evaluated using Spearman's correlation coefficients, Cronbach's alpha, intraclass correlation coefficient (ICC), standard error of the mean (SEM), and minimal detectable change (MDC).

RESULTS

The Turkish version of JAQQ exhibited high convergent validity, correlating significantly with CHAQ, JABQ, and CDI. No floor or ceiling effects were observed in the total JAQQ score, indicating a balanced assessment. Internal consistency was excellent (Cronbach's α = 0.948), and test-retest reliability was satisfactory (ICC = 0.913). SEM and MDC95 values were 0.357 and 0.99, respectively.

CONCLUSIONS

The Turkish adaptation of JAQQ emerges as a valid and reliable instrument for comprehensively assessing the health-related quality of life in children and adolescents diagnosed with JIA. The questionnaire's robust psychometric properties, coupled with distinctive features like individualized assessment, highlight its potential as a valuable tool for both clinical assessment and scientific research in the field of pediatric rheumatology. Key Points • The Juvenile Arthritis Quality of Life Questionnaire (JAQQ) is an important scale that evaluates the quality of life of children with Juvenile Idiopathic Arthritis (JIA). • JAQQ is known and used in the field of pediatric rheumatology in Turkey, but its Turkish adaptation has not been made before. • Our study includes 100 JIA patients aged between 9 and 18 years and shows that the Turkish version of JAQQ is valid and reliable in measuring the quality of life of these children. • This research contributes to the accurate assessment of the quality of life in Turkish children diagnosed with JIA, providing valuable insights for both clinical and scientific studies.

Profiles of health literacy and digital health literacy in clusters of hospitalised patients: a single-centre, cross-sectional study

OBJECTIVE

To investigate health literacy (HL) and digital health literacy (eHL) among patients hospitalised in surgical and medical wards using a cluster analysis approach.

DESIGN

Cross-sectional study using Ward's hierarchical clustering method to measure cluster adequacy by evaluating distances between cluster centroids (a measure of cohesion). Different distances produced different cluster solutions.

SETTING AND PARTICIPANTS

The study was conducted at a Norwegian university hospital. A total of 260 hospitalised patients were enrolled between 24 May and 6 June 2021.

DATA COLLECTION

All data were collected by self-reported questionnaires. Data on HL and eHL were collected by the Health Literacy Questionnaire (HLQ) and the eHealth Literacy Questionnaire (eHLQ). We also collected data on background characteristics, health status and patient diagnosis.

RESULTS

We found six HLQ clusters to be the best solution of the sample, identifying substantial diversity in HL strengths and challenges. Two clusters, representing 21% of the total sample, reported the lowest HLQ scores in eight of nine HLQ domains. Compared with the other clusters, these two contained the highest number of women, as well as the patients with the highest mean age, a low level of education and the lowest proportion of being employed. One of these clusters also represented patients with the lowest health status score. We identified six eHL clusters, two of which represented 31% of the total sample with the lowest eHLQ scores in five of seven eHLQ domains, with background characteristics comparable to patients in the low-scoring HLQ clusters.

CONCLUSIONS

This study provides new, nuanced knowledge about HL and eHL profiles in different clusters of patients hospitalised in surgical and medical wards. With such data, healthcare professionals can take into account vulnerable patients' HL needs and tailor information and communication accordingly.

Practical guide to implementing patient-reported outcome measures in gender-affirming care: evaluating acceptability, appropriateness and feasibility

OBJECTIVE

Assess acceptability, appropriateness and feasibility of the Practical Guide to Implementing patient-reported outcome measures (PROMs) in Gender-Affirming Care (PG-PROM-GAC) from a sample of patients and healthcare professionals.

DESIGN

Cross-sectional study conducted August-October 2023.

SETTING

Participants were recruited from a National Health Service (NHS) gender clinic.

PARTICIPANTS

Patient participants seeking care and healthcare professionals working at an NHS gender clinic were eligible for participation. The PG-PROM-GAC was sent to participants via email for review.

OUTCOME MEASURES

Three validated tools to measure acceptability, appropriateness and feasibility were administered: the acceptability of intervention measure (AIM), intervention appropriateness measure (IAM) and feasibility of intervention measure (FIM). The percentage of participants indicating agreement or disagreement with items on the AIM, IAM and FIM was calculated.

RESULTS

A total of 132 transgender and gender diverse (TGD) patients (mean age, SD: 33, 14) and 13 gender-affirming healthcare professionals (mean age, SD: 43, 11) completed the AIM, IAM and FIM, representing a range of gender identities. The cumulative percentage of patients indicating agree or strongly agree on the AIM, IAM and FIM for the patient-relevant strategies in the PG-PROM-GAC was over 50% for each item. The cumulative percentage of patients indicating disagree or strongly disagree on the AIM, IAM and FIM for the PG-PROM-GAC was less than 20% for each item. The cumulative percentage of healthcare professionals indicating agree or strongly agree on the AIM, IAM and FIM for the healthcare professional-relevant strategies in the PG-PROM-GAC was over 38% for each item. The cumulative percentage of healthcare professionals indicating disagree or strongly disagree on the AIM, IAM and FIM for the PG-PROM-GAC was less than 15% for each item.

CONCLUSIONS

Gender-affirming healthcare professionals and TGD patients find the PG-PROM-GAC acceptable, appropriate and feasible. The PG-PROM-GAC is ready-to-use for clinicians, policy-makers and researchers committed to service improvement for gender-affirming care.

The Parent Health Literacy Questionnaire (HLQ-Parent). Adaptation and validity testing with parents of children with epilepsy

AIMS

The aim of this study was to adapt the Health Literacy Questionnaire (HLQ) in English and Norwegian for use with parents.

METHODS

The research group evaluated all HLQ items and, where relevant, modified them to refocus the attribution of care to that of a child by a parent. Five cognitive interviews with parents were undertaken to gain a detailed depiction of the meanings and processes they used to respond to the HLQ items. Assessment of the psychometric properties of the revised HLQ was undertaken using data from a cross-sectional survey of 254 parents of children with epilepsy. Analysis included internal consistency (Cronbach's alpha) and confirmatory factor analysis (CFA).

RESULTS

Some 22 out of 44 items and the names of three domains were modified (e.g. attribution changed from 'me' to 'my child'). Cognitive interviews indicated that parents interpreted the HLQ-Parent items in the way intended. All but three factor loadings were high to acceptable. All nine HLQ scales showed satisfactory to good internal consistency (Cronbach's alpha 0.70 to 0.87). When fitting one-factor CFA models, correlated residuals were required for four scales to generate an acceptable fit. One scale, '8. Ability to find good health information', required inclusion of two correlated residuals to generate an acceptable CFA model fit, indicating that further work on this scale is warranted.

CONCLUSIONS

The results from both the adaptation process and the CFA analysis supported the relevance, understanding and theoretical structure of the instrument in a parental context.

A validation study of the 30-day questionnaire in the national Norwegian Tonsil Surgery Register: can we trust the data reported by the patients?

PURPOSE

The aim of this study was to validate the Patient Reported Outcome Measure (PROM) in the Norwegian Tonsil Surgery Register (NTSR) and to examine whether any improvements to the questionnaire could be useful.

METHODS

This is a prospective, descriptive study. NTSR collects data from patients who undergo tonsil surgery and the intention of the register is to improve the quality of treatment and to contribute to research. The patients answers questions about admission due to postoperative haemorrhage, infection and pain 30 days after surgery. 305 patients were contacted on phone 1-2 weeks after answering the questionnaires electronically (ePROM) and asked the same questions. 180 of 305 patients we contacted had some kind of complications after surgery. They were asked additional questions to search for possible points for improvement of the questionnaire.

RESULTS

When comparing the results on the ePROM with the answers on phone, we found that 12 out of 14 variables achieve almost perfect agreement (AC1 ≥ 0.81). Two variables are categorized to be substantial agreement (AC1 = 0.61-0.80). The additional questions showed us that the questionnaire can be improved with more detailed information regarding the severity of the postoperative haemorrhage and the need of better treatment against postoperative pain.

CONCLUSION

This study shows that the information from the 30-day ePROM has high reliability. The questions were understood as they were intended, and the answers reflect what the patients had of complications. Some changes can be done to improve the questionnaire and to open up for more research around the tonsillectomy procedure.

Patient and healthcare professional perspectives on implementing patient-reported outcome measures in gender-affirming care: a qualitative study

OBJECTIVES

Patient and healthcare professional perspectives are needed to develop a gender-affirming care patient-reported outcome measure (PROM) implementation plan. We aimed to identify top considerations relevant to gender-affirming care PROM implementation from patient and healthcare professional perspectives.

DESIGN, SETTINGS AND PARTICIPANTS

This qualitative study conducted in the UK between January and April 2023 includes focus groups with a patient sample diverse in age and gender identity, and a healthcare professional sample diverse in age and role. Established methods in implementation science and the Consolidated Framework for Implementation Research were used to create interview guides, and analyse data. Focus groups were audio recorded, transcribed verbatim and analysed by two independent researchers. Patient and healthcare professional focus groups were conducted separately.

PRIMARY OUTCOME MEASURES

Patient and healthcare professional perspectives on PROM implementation were explored through focus groups and until data saturation.

RESULTS

A total of 7 virtual focus groups were conducted with 24 participants (14 patients, mean (SD) age, 43 (14.5); 10 healthcare professionals, mean (SD) age, 46 (11.3)). From patient perspectives, key barriers to PROM implementation were mistrust with PROMs, lack of accessibility, burden, and lack of communication on why PROMs are important and how they will help care. From healthcare professional perspectives, key barriers to PROM implementation were lack of accessibility, burden with PROM administration and scoring, costs of implementation (financial and time), and lack of communication on what PROMs are and how they benefit service provision.

CONCLUSION

Gender-affirming care PROM implementation must address: patient mistrust with PROMs, accessibility, communication on what PROMs are and how they can be used, reducing burden, and hybridised implementation. These factors may also be applicable to other clinical areas interested in implementing PROMs.

Approaches to the development of new screening tools that assess distress in Indigenous peoples: A systematic mixed studies review

This mixed studies review assessed the extent of the literature related to approaches used to develop new tools that screen for distress in Indigenous adults globally. It answered the research question: What qualitative and quantitative approaches are used to develop new screening tools that assess distress in Indigenous peoples globally? CINAHL, Embase, Emcare, Medline, PsychInfo and Scopus databases were systematically searched to identify relevant articles published between January 2000 and February 2023. Articles describing the development of a new screening tool for Indigenous peoples, globally, published in English since 2000 and constituted a full publication of primary research, met the inclusion criteria. Studies underwent quality appraisal using the Mixed-Methods Appraisal Tool. A sequential exploratory design guided data analysis. Synthesis occurred using a two-phase sequential method. Nineteen articles constituted the data set. Articles described the use of qualitative, quantitative, or mixed methods in approximately equal numbers. Overall, qualitative methods were used in early stages of tool development, with mixed and quantitative methods used to pilot and validate them. However, most studies did not follow the theoretical guidelines for tool development, and while validation studies took place in over half of the data set, none adequately assessed construct validity. Sixty percent of the articles were located using citation searches, which suggests database searches were ineffective. Valid tools that screen for distress in Indigenous populations support equitable access to health care. This review found that most screening tools were developed in Australia. However, additional evidence of their validity is needed in addition to a valid diagnostic tool that supports the determination of criterion validity. These needs present important future research opportunities.

Linguistic adaptation and psychometric properties of the health literacy questionnaire in serbian language among people with chronic diseases

OBJECTIVE

To translate the Health Literacy Questionnaire (HLQ) to Serbian language and examine its psychometric characteristics.

METHODS

This cross-sectional study was conducted among 295 people with chronic diseases from the Foča region (Republic of Srpska, Bosnia and Herzegovina). The HLQ was translated according to the translation integrity procedure. Construct validity was tested using confirmatory factor analysis (CFA) using the maximum likelihood estimator and reliability was estimated using the α and ω coefficients.

RESULTS

Minor linguistic differences in 17 items were observed between the original and the initial forward translation and were corrected. The parameters of one-factor CFA on domains 3 and 8 fitted well. The parameters of the CFA for domains 1, 2, 4, 5, 6, 7 and 9 were acceptable after modification using residuals' correlation. The α and ω coefficients for all domains were good to excellent (>0.80).

CONCLUSION

Each domain of the HLQ in Serbian has acceptable construct validity and overall good reliability. This study adds to the growing evidence that the HLQ is a useful tool to provide in-depth multidimensional information on health literacy to improve researchers and policymakers understanding of the health literacy strengths, needs and preferences across cultures and languages.

Evaluation of symptoms in respiratory syncytial virus infection in adults: psychometric evaluation of the Respiratory Infection Intensity and Impact Questionnaire™ symptom scores

BACKGROUND

The Respiratory Infection Intensity and Impact Questionnaire (RiiQ™) is a patient-reported outcome measure designed to assess symptoms and impacts of respiratory syncytial virus (RSV) infection. This study evaluated the construct validity, reliability, and responsiveness of the RiiQ™ Respiratory and Systemic Symptoms Scale scores.

METHODS

Prospective data were analyzed from a total of 1795 participants, including from non-hospitalized patients with acute respiratory infection (ARI) and no coinfections enrolled in a Phase 2b RSV vaccine study (RSV-positive: n = 60; RSV-negative: n = 1615), and two observational studies of patients hospitalized with RSV (n = 20; n = 100). Descriptive statistics, confirmatory factor analysis (CFA), test-retest intraclass correlation coefficients (ICCs), construct validity correlations (between a clinician-assessed clinical questionnaire and the RiiQ™ symptoms scale), known-groups validity, and responsiveness (correlations of change scores) were evaluated.

RESULTS

Mean patient age ranged from 66.5 to 71.5 years and the majority of patients were female. Initial assessments in the vaccine trial (ARI Day 1) were suggestive of less severe illness than in the observational studies with hospitalized patients. CFA loadings (> 0.40) supported summary scores. ICCs exceeding the recommended threshold of 0.70 supported test-retest reliability for Respiratory and Systemic Symptoms, except in the small observational study. At the scale level, correlations were moderate to strong (|r| ≥ 0.3) and positive between the Respiratory Symptoms Scale and the related clinical questionnaire scores, reflecting measurement of similar symptoms in support of convergent validity. Correlations with change in Patient Global Impression of Severity > 0.30 supported responsiveness.

CONCLUSIONS

Psychometric tests applied to the RiiQ™ Symptoms scales provide evidence of its reliability, construct validity, discriminating ability, and responsiveness for use in clinical studies to assess the onset and severity of RSV symptoms.

Translation, cultural adaptation and validity assessment of the Dutch version of the eHealth Literacy Questionnaire: a mixed-method approach

BACKGROUND

The digitalization of healthcare requires users to have sufficient competence in using digital health technologies. In the Netherlands, as well as in other countries, there is a need for a comprehensive, person-centered assessment of eHealth literacy to understand and address eHealth literacy related needs, to improve equitable uptake and use of digital health technologies.

OBJECTIVE

We aimed to translate and culturally adapt the original eHealth Literacy Questionnaire (eHLQ) to Dutch and to collect initial validity evidence.

METHODS

The eHLQ was translated using a systematic approach with forward translation, an item intent matrix, back translation, and consensus meetings with the developer. A validity-driven and multi-study approach was used to collect validity evidence on 1) test content, 2) response processes and 3) internal structure. Cognitive interviews (n = 14) were held to assess test content and response processes (Study 1). A pre-final eHLQ version was completed by 1650 people participating in an eHealth study (Study 2). A seven-factor Confirmatory Factor Analysis (CFA) model was fitted to the data to assess the internal structure of the eHLQ. Invariance testing was performed across gender, age, education and current diagnosis.

RESULTS

Cognitive interviews showed some problems in wording, phrasing and resonance with individual's world views. CFA demonstrated an equivalent internal structure to the hypothesized (original) eHLQ with acceptable fit indices. All items loaded substantially on their corresponding latent factors (range 0.51-0.81). The model was partially metric invariant across all subgroups. Comparison of scores between groups showed that people who were younger, higher educated and who had a current diagnosis generally scored higher across domains, however effect sizes were small. Data from both studies were triangulated, resulting in minor refinements to eight items and recommendations on use, score interpretation and reporting.

CONCLUSION

The Dutch version of the eHLQ showed strong properties for assessing eHealth literacy in the Dutch context. While ongoing collection of validity evidence is recommended, the evidence presented indicate that the eHLQ can be used by researchers, eHealth developers and policy makers to identify eHealth literacy needs and inform the development of eHealth interventions to ensure that people with limited digital access and skills are not left behind.

Vitamin D and chronotype: is there any relationship in individuals with obesity?

PURPOSE

Chronotype is the attitude to perform most of the daily activities in the morning ("morning chronotype", MC) or in the evening ("evening chronotype", EC). The latter, as well as vitamin D deficiency, has been associated with an increased risk of obesity-related complications, likely through the promotion of insulin resistance. Therefore, we aimed to investigate whether there is any relationship between vitamin D (25-OH-D) and chronotype in individuals with obesity.

METHODS

In this cross-sectional study, we enrolled 59 individuals (43.1 ± 13 years; 17M/42F) with obesity. Anthropometric parameters, lifestyle habits, personal medical history, chronotype, insulin resistance, and 25-OH-D were assessed.

RESULTS

Individuals with EC presented significantly higher BMI than MC (p < 0.001), greater waist (p = 0.012), and hip circumferences (p = 0.001). Individuals with EC showed significantly lower insulin sensitivity (p = 0.017) and 25-OH-D than MC. In addition, the prevalence of vitamin D deficiency and impaired fasting glucose was significantly higher in EC than in MC. 25-OH-D directly correlated with chronotype score (r = 0.351; p = 0.019) whereas inversely with BMI (r = - 0.363; p = 0.016). The regression analysis showed that BMI was most tightly associated with 25-OH-D concentrations (β = - 0.323, p = 0.032), followed by chronotype score (β = 0.340, p = 0.042). Using chronotype score as the dependent variable, BMI significantly predicted a lower chronotype score (β = - 0.586, p < 0.001).

CONCLUSION

The present study showed that 25-OH-D, as well as chronotype, correlate independently with obesity.

The impact of COVID-19 on sleep for autistic children: A systematic review

BACKGROUND

Up to 80% of children with autism experience behavioural sleep problems, predominantly relating to bedtime resistance, sleep anxiety, sleep dysregulation, and shorter duration, which are associated with increased autistic symptom expression and emotional and behavioural difficulties. Researchers predicted the COVID-19 pandemic would worsen sleep and behavioural difficulties for autistic children, due to their need for routine and certainty. This systematic review is the first to focus on delineating the role of sleep disturbance in exacerbating autistic symptoms and internalising and externalising behaviours during the pandemic.

METHOD

In this PROSPERO registered systematic review, we aggregated and synthesised findings from empirical studies from 2020 onwards that included children with autism and examined sleep outcomes, using narrative and framework synthesis due to the variety of methods and designs employed. We identified additional relevant themes through inductive thematic analysis.

RESULTS

Seventy-one studies met the search criteria, and we selected seventeen for review following screening and quality assessment. These studies reported mixed findings; with strongest support for worsening of sleep problems typically experienced by autistic children, including difficulties with sleep regulation and shorter sleep duration. Further, sleep problems were associated with increased expression of autistic characteristics.

CONCLUSIONS

Preliminary findings of worsening sleep and increased autistic characteristics for autistic children throughout the COVID-19 pandemic highlight the need for ongoing, accessible and flexible service provision during exposure to environmental stressors. We propose that behavioural sleep interventions are well suited to telehealth adaptation and play an important role in supporting families when in-person treatment for sleep problems is not possible.

Translation and adaptation of the stroke-specific quality of life scale into Swahili

Background

Stroke care requires a patient-centred, evidence-based and culturally appropriate approach for better patient clinical outcomes. Quality of life necessitates precise measuring using health-related quality measures that are self-reported and language appropriate. However, most of the self-reported measures were devised in Europe and therefore not considered contextually appropriate in other settings, more so in Africa.

Objectives

Our study aimed to produce a Swahili version by translating and adapting the stroke-specific quality of life (SSQOL) scale among people with stroke in Kenya.

Method

We used a questionnaire translation and cross-cultural adaptation. The pre-validation sample of 36 adult participants was drawn from 40 registered people with stroke, from the Stroke Association of Kenya (SAoK). Quantitative data were collected using both English and Swahili versions of the SSQOL scale. The mean, standard deviation (s.d.) and overall scores were calculated and are presented in tables.

Results

The back translation revealed a few inconsistencies. Minor semantic and equivalence alterations were done in the vision, mood, self-care, upper extremity function and mobility domains by the expert review committee. Respondents indicated that all questions were well-understood and captured. The stroke onset mean age was 53.69 years and the standard deviation was 14.05.

Conclusion

The translated version of the Swahili SSQOL questionnaire is comprehensible and well-adapted to the Swahili-speaking population.

Clinical implication

The SSQOL has the potential to be a useful outcome measure for use in Swahili-speaking patients with stroke.

Patient-reported outcome measures in cardiovascular disease

In today's medical ecosystem, it is vital to measure the outcomes that are most important to the patients. As such, patient-reported outcome measures (PROMS) can be an essential metric to deliver high-quality cardiovascular care, particularly in the subset of patients who remain disappointed with their outcomes. PROMS should be a reproducible and reflective report of what is fundamental to a patient over time and across treatments with proper standards in the analysis, interpretation, and reporting of the collected data. These reports can also be sensitive to changes, whether improvements or deteriorations in the quality of care and medical attitude, but a lack of standardization makes it difficult to draw robust conclusions and compare findings across treatments. As a research tool, PROMS can have a significant prognostic prominence, offering a powerful instrument of comparison between different treatment modalities. With the information technology (IT) abilities of today, we can leverage mobile tools and powerful computer systems to perform sophisticated data analysis using patient-derived data and randomization. This may eliminate guesswork and generate impactful metrics to better inform the decision-making process. PROMS analysed by proper standardized algorithms can avoid physician bias and be integrated into the hospital teamwork. Therefore, there is a strong need for integration of PROMS into the evaluation of cardiovascular interventions and procedures, and establishment of international standards in the analyses of patient-reported outcomes and quality of life data to address this need and develop therapeutic recommendations.

Assessment of Quality of Life in Rectal Cancer with Organ-Preservation Treatment: Are We There yet?

Rectal cancer is a common cancer and shows an increased incidence with older age. Although the gold standard treatment is surgical excision, minimally invasive approaches are increasingly used and organ preservation is becoming a reasonable approach. The conservative treatment approach includes local excision, external beam radiotherapy and brachytherapy. However, these all carry a risk of side-effects. It is crucial to provide patients with information to quantify the improvement or detriment in quality of life with their cancer treatment. This can only be done with patient-reported outcome measures (PROMs) as tools within current and future trials. Colorectal cancer has numerous publications with specific PROMs. However, PROMs reporting in rectal cancer is more sparse; PROMs are generally extrapolated from colorectal cancer. Rectal PROMs trials hold small population samples and PROMs as an end point is scarce. We present a review of recent literature based on the PROMs reporting of quality of life for rectal cancer patients and introduce the CITRuS trial as an innovative feasibility study related to electronic PROMs data collection.

The Relationship between Health Literacy and COVID-19 Vaccination Prevalence during a Rapidly Evolving Pandemic and Infodemic

The gap between how health information is communicated and what people understand and can use to make informed health decisions is called health literacy. This gap was exacerbated by the rapidly changing and excessive volume of information, misinformation, and disinformation during the COVID-19 pandemic. People with lower health literacy may not have understood the importance of COVID-19 vaccination for themselves or for their communities. Our aim was to understand health literacy levels within Fulton County, Georgia, and their relationship to vaccine prevalence. Fulton county residents ages 18 and over (n = 425) completed an on-line Health Literacy Questionnaire. Individual, organizational, functional, interactive, and critical health literacy scales were created. Vaccination prevalence data were collected from the Georgia Vaccine Distribution Dashboard. All data were divided into one of three county areas. There were statistically significant variations in vaccine prevalence χ2(3) = 29.325, p < 0.001 among the three county areas. All levels of health literacy predicted overall county vaccination prevalence F (4,420) = 85.941, p < 0.001, There were significant differences in health literacy levels among two of the three county area pairs; the lowest resourced county area had the lowest vaccination prevalence and health literacy rates. This is the first example of relating direct health literacy measures across a major metropolitan US county with vaccine prevalence data.

International Urogynecology Consultation: Patient Reported Outcome Measures (PROs) use in the evaluation of patients with pelvic organ prolapse

INTRODUCTION AND HYPOTHESIS

Patient-reported outcome measure instruments include patient-reported outcomes (PROs) and patient-reported goals (PRGs), which allow practitioners to measure symptoms and determine outcomes of treatment that matter to patients.

METHODS

This is a structured review completed by the International Urogynecology Consultation (IUC), sponsored by the International Urogynecological Association (IUGA). The aim of this working group was to evaluate and synthesize the existing evidence for PROs and PRGs in the initial clinical work-up/evaluation and research arena for patients with pelvic organ prolapse (POP).

RESULTS

The initial search generated 3589 non-duplicated studies. After abstract review by 4 authors, 211 full texts were assessed for eligibility by 2 writing group members, and 199 studies were reviewed in detail. Any disagreements on abstract or full-text articles were resolved by a third reviewer or during video meetings as a group. The list of POP PROs and information on PRGs was developed from these articles. Tables were generated to describe the validation of each PRO and to provide currently available, validated translations.

CONCLUSIONS

All patients presenting for POP should be evaluated for vaginal, bladder, bowel and sexual symptoms including their goals for symptom treatment. This screening can be facilitated by a validated PRO; however, most PROs provide more information than needed to provide clinical care and were designed for research purposes.

Digital Health Literacy as a Predictor of Awareness, Engagement, and Use of a National Web-Based Personal Health Record: Population-Based Survey Study

Background

Web-based personal health records (PHRs) have the potential to improve the quality, accuracy, and timeliness of health care. However, the international uptake of web-based PHRs has been slow. Populations experiencing disadvantages are less likely to use web-based PHRs, potentially widening health inequities within and among countries.

Objective

With limited understanding of the predictors of community uptake and use of web-based PHR, the aim of this study was to identify the predictors of awareness, engagement, and use of the Australian national web-based PHR, My Health Record (MyHR).

Methods

A population-based survey of adult participants residing in regional Victoria, Australia, was conducted in 2018 using telephone interviews. Logistic regression, adjusted for age, was used to assess the relationship among digital health literacy, health literacy, and demographic characteristics, and the 3 dependent variables of MyHR: awareness, engagement, and use. Digital health literacy and health literacy were measured using multidimensional tools, using all 7 scales of the eHealth Literacy Questionnaire and 4 out of the 9 scales of the Health Literacy Questionnaire.

Results

A total of 998 responses were analyzed. Many elements of digital health literacy were strongly associated with MyHR awareness, engagement, and use. A 1-unit increase in each of the 7 eHealth Literacy Questionnaire scales was associated with a 2- to 4-fold increase in the odds of using MyHR: using technology to process health information (odds ratio [OR] 4.14, 95% CI 2.34-7.31), understanding of health concepts and language (OR 2.25, 95% CI 1.08-4.69), ability to actively engage with digital services (OR 4.44, 95% CI 2.55-7.75), feel safe and in control (OR 2.36, 95% CI 1.43-3.88), motivated to engage with digital services (OR 4.24, 95% CI 2.36-7.61), access to digital services that work (OR 2.49, 95% CI 1.32-4.69), and digital services that suit individual needs (OR 3.48, 95% CI 1.97-6.15). The Health Literacy Questionnaire scales of health care support, actively managing health, and social support were also associated with a 1- to 2-fold increase in the odds of using MyHR. Using the internet to search for health information was another strong predictor; however, older people and those with less education were less likely to use MyHR.

Conclusions

This study revealed strong and consistent patterns of association between digital health literacy and the use of a web-based PHR. The results indicate potential actions for promoting PHR uptake, including improving digital technology and skill experiences that may improve digital health literacy and willingness to engage in web-based PHR. Uptake may also be improved through more responsive digital services, strengthened health care, and better social support. A holistic approach, including targeted solutions, is needed to ensure that web-based PHR can realize its full potential to help reduce health inequities.

Health literacy measurement: embracing diversity in a strengths-based approach to promote health and equity, and avoid epistemic injustice

Definitions of health literacy have evolved from notions of health-related literacy to a multidimensional concept that incorporates the importance of social and cultural knowledge, practices and contexts. This evolution is evident in the development of instruments that seek to measure health literacy in different ways. Health literacy measurement is important for global health because diverse stakeholders, including the WHO, use these data to inform health practice and policy, and to understand sources of inequity. In this Practice paper, we explore the potential for negative consequences, bias and epistemic injustice to occur when health literacy instruments are used across settings without due regard for the lived experiences of people in various contexts from whom data are collected. A health literacy measurement approach that is emic-sensitive, strengths based and solution oriented is needed to minimise biased data interpretation and use and to avoid epistemic injustice.

Cultural and linguistic adaption and testing of the Health Literacy Questionnaire (HLQ) among healthy people in Korea

Backgrounds

This study administered the Health Literacy Questionnaire (HLQ) among Korean adults to examine its factor structure, reliability, and validity.

Methods

The HLQ items were translated and culturally adapted to the Korean context. The convenience sampling method was used, and data were collected. The difficulty level, confirmatory factor analysis (CFA) using diagonal weighted least squares (DWLS) estimator in R, discriminant validity, and composite reliability were performed.

Results

The easiest scale to obtain a high score was “Scale 4. Social support for health” and the hardest was “Scale 7. Navigating the healthcare system.” Nine one-factor models fitted well. The nine-factor structural equation model fitted the data well. All HLQ scales were homogenous, with composite reliability.

Conclusions

The Korean version of the HLQ has a strong construct and high composite reliability when applied to Korean adults.

Cultural Adaptation and Validity Testing of the Portuguese Version of the Health Literacy Questionnaire (HLQ)

Background: Health literacy is considered a determinant of self-management behaviors and health outcomes among people with diabetes. The assessment of health literacy is central to understanding the health needs of a population. This study aimed to adapt the Health Literacy Questionnaire (HLQ) to the Portuguese context and to examine the psychometric properties of a population of people with diabetes. Methods: Data were collected using a self-administrated questionnaire from 453 people with diabetes in a specialized diabetes care unit. Analysis included item difficulty level, composite scale reliability, and confirmatory factor analysis (CFA). Results: The HLQ showed that the items were easily understood by participants. Composite reliability ranged from 0.74 to 0.83. A nine-factor CFA model was fitted to the 44 items. Given the very restricted model, the fit was quite satisfactory [χ²_wlsmv = 2147.3 (df = 866), p = 0.001; CFI = 0.931, TLI = 0.925, RMSEA = 0.057 (90% C.I. 0.054–0.060), and WRMR = 1.528]. Conclusion: The Portuguese version of the HLQ has shown satisfactory psychometric properties across its nine separate scales in people with diabetes. Given the strong observed properties of the HLQ across cultures, languages, and diseases, the HLQ is likely to be a useful tool in a range of Portuguese settings.

Parents of children with epilepsy: Characteristics associated with high and low levels of health literacy

Parents of children with epilepsy play a key role in the management of their child's condition. Their level of health literacy (HL), which refers to their ability to seek, understand, assess, remember, and utilize health information, is essential for handling the child optimally. The aim of this study was to investigate characteristics associated with high and low levels of different dimensions of HL in parents. HL was assessed with the multidimensional Health Literacy Questionnaire (parents' version) and the electronic Health Literacy Scale, using data from a cohort of 254 parents of children <12 years. Bivariate correlation and multiple hierarchal linear regression (STATA version 16 SE) were used to investigate variables associated with HL. Self-efficacy (St. β = 0.14-0.34) was the only variable that predicted higher scores on every HL scale. Being older than 35 years (St. β = 0.18-0.21), level of education (St. β = 0.16-0.27), and the child having a coordinator of services (St. β = 0.16-0.28) were associated with higher scores, while sick leave due to the child's epilepsy (St. β = -0.13 to -0.16), child comorbidities (St. β = -0.15 to -0.19), and higher levels of mental distress (St. β = -0.13 to -0.19) were associated with lower scores in several of the different HL dimensions. A total of 44.8% of the parents scored over the cutoff (≥1.85) predicting a mental disorder on the Hopkins symptom checklist. This is the first study to investigate multidimensional parental HL in a childhood epilepsy context. Our results highlight the need to investigate multiple variables, especially mental distress, to determine characteristics that may predict low parental HL. Further qualitative studies are needed to explore the underlying reasons for the parents' HL scores and to develop inventions tailored to meet different HL needs.

Measuring Health Status in Long-Term Residential Care: Adapting the Veterans RAND 12 Item Health Survey (VR-12©)

Objectives: Measuring the perceived mental and physical health status of older adults living in long-term residential care (LTRC) is central to patient-centered care. This study examined the qualitative content validity of the Veterans RAND 12 Item Health Survey (VR-12) for LTRC and, based on the findings, the authors developed an adapted version of the generic patient-reported outcome measure for this population.Methods: Content validity was evaluated in two steps: (1) initial resident feedback (n = 9) and research team consensus discussions and (2) cognitive interviews with residents (n = 18) and a research team consensus discussion. The cognitive interviews examined comprehension, acceptability, and relevance of the VR-12 items.Results: Two VR-12 items had limited acceptability in the LTRC setting, the reference to "work" in items was irrelevant to residents, and the lack of a frame of reference ("During the past week … ") impacted comprehension of several items.Conclusions: Study findings informed the development of an adapted version of the VR-12 for older adults living in Canadian LTRC homes and provided content validity evidence regarding its relevance and appropriateness for this population.Clinical implications: Measuring the health status of older adults living in LTRC can help to monitor changes in health status over time and support person-centered care.

Use of the English Health Literacy Questionnaire (HLQ) with Health Science University Students in Nepal: A Validity Testing Study

Research evidence shows that health literacy development is a key factor influencing non-communicable diseases care and patient outcomes. Healthcare professionals with strong health literacy skills are essential for providing quality care. We aimed to report the validation testing of the Health Literacy Questionnaire (HLQ) among health professional students in Nepal. A cross-sectional study was conducted with 419 health sciences students using the HLQ in Nepal. Validation testing and reporting were conducted using five sources outlined by ‘the 2014 Standards for Educational and Psychological Testing’. The average difficulty was lowest (17.4%) for Scale 4. Social support for health, and highest (51.9%) for Scale 6. Ability to actively engage with healthcare providers. One factor Confirmatory Factor Analysis (CFA) model showed a good fit for Scale 2, Scale 7 and Scale 9 and a reasonable fit for Scale 3 and Scale 4. The restricted nine-factor CFA model showed a satisfactory level of fit. The use of HLQ is seen to be meaningful in Nepal and warrants translation into native Nepali and other dominant local languages with careful consideration of cultural appropriateness using cognitive interviews.

How to Improve Interpretability of Patient-Reported Outcome Measures for Clinical Use: A Perspective on Measuring Abilities and Feelings

Two general classes of concepts measured by patient-reported outcome measures (PROMs) are abilities and feelings. Over the past several decades, there has been a significant progress in measuring both. Nevertheless, current multi-item scales are subject to criticism related to scale length, score dimensionality, interpretability, cultural bias, and insufficient detail in measuring specific domains. To address some of these issues, the author offers an alternative perspective on how questions about abilities and feelings could be formulated. Abilities can be defined in terms of a relationship between the level of performance and the associated perception of difficulty, and represented graphically by an ability curve. For feelings, it may be useful to measure frequency and intensity jointly to determine the proportion of time in each level of intensity. The resultant frequency × intensity matrix can be presented as a bar graph. Empirical data to support the feasibility and validity of these approaches to PROM design are provided, potential advantages and limitations are discussed, and some future research avenues are suggested.

Validity Testing and Cultural Adaptation of the eHealth Literacy Questionnaire (eHLQ) Among People With Chronic Diseases in Taiwan: Mixed Methods Study

Background

Advancements in digital technologies seek to promote health and access to services. However, people lacking abilities and confidence to use technology are likely to be left behind, leading to health disparities. In providing digital health services, health care providers need to be aware of users’ diverse electronic health (eHealth) literacy to address their particular needs and ensure equitable uptake and use of digital services. To understand such needs, an instrument that captures users’ knowledge, skills, trust, motivation, and experiences in relation to technology is required. The eHealth Literacy Questionnaire (eHLQ) is a multidimensional tool with 7 scales covering diverse dimensions of eHealth literacy. The tool was simultaneously developed in English and Danish using a grounded and validity-driven approach and has been shown to have strong psychometric properties.

Objective

This study aims to translate and culturally adapt the eHLQ for application among Mandarin-speaking people with chronic diseases in Taiwan and then undertake a rigorous set of validity-testing procedures.

Methods

The cross-cultural adaptation of the eHLQ included translation and evaluation of the translations. The measurement properties were assessed using classical test theory and item response theory (IRT) approaches. Content validity, known-group validity, and internal consistency were explored, as well as item characteristic curves (ICCs), item discrimination, and item location/difficulty.

Results

The adapted version was reviewed, and a recommended forward translation was confirmed through consensus. The tool exhibited good content validity. A total of 420 people with 1 or more chronic diseases participated in a validity-testing survey. The eHLQ showed good internal consistency (Cronbach α=.75-.95). For known-group validity, all 7 eHLQ scales showed strong associations with education. Unidimensionality and local independence assumptions were met except for scale 2. IRT analysis showed that all items demonstrated good discrimination (range 0.27-12.15) and a good range of difficulty (range 0.59-1.67) except for 2 items in scale 7.

Conclusions

Using a rigorous process, the eHLQ was translated from English into a culturally appropriate tool for use in the Mandarin language. Validity testing provided evidence of satisfactory-to-strong psychometric properties of the eHLQ. The 7 scales are likely to be useful research tools for evaluating digital health interventions and for informing the development of health technology products and interventions that equitably suit diverse users’ needs.

Mediterranean Diet: What Are the Consequences for Menopause?

Menopause is a natural event occurring in a woman's life that is often accompanied by symptoms that might affect the quality of life. Diet has been shown to influence menopausal-related symptoms. Therefore, the present study aimed to investigate whether the adherence to the Mediterranean Diet (MD) might influence menopausal symptoms in women with obesity. This cross-sectional study involved postmenopausal women with obesity. Anthropometric and clinical parameters, and lifestyle habits were evaluated. All participants underwent interview questionnaires to assess: the adherence to the MD (PREDI PREvencion con DIetaMEDiterranea, PREDIMED), sleep quality (Pittsburgh Sleep Quality Index, PSQI), and severity of menopausal symptoms (Menopausal Rating Scale, MRS). One hundred postmenopausal women were enrolled (age 57.1 ± 7.3 years, BMI 35.0 ± 5.5 kg/m²). The mean PREDIMED score was 7.82 ± 1.66 showing moderate adherence to MD. Women in the marked MRS class had a significantly lower PREDIMED score than the none-to-moderate MRS class (p=0.036). The intake of legumes was associated with a lower MRS class (r= -0.201, p=0.045). In addition, the intake of extra-virgin olive oil inversely correlated with psychological symptoms (r= -0.230 p=0.021). Finally, 79% of participants were poor sleepers (mean PSQI score was 8.68 ± 3.6) and women in the severe MRS class had a worse sleep quality compared to other MRS classes. Post-menopausal women with marked menopausal symptoms had low adherence to MD. Legume consumption was associated with lower menopausal symptoms severity while extra virgin olive oil consumption was associated with lower psychological symptoms.

Translating and validating the Health Literacy Questionnaire into Urdu: a robust nine-dimension confirmatory factor model

Pakistani migrants are one of the fastest-growing communities in Australia, and the majority speak Urdu at home. There is a lack of information regarding the health literacy of this population. This study aimed to translate the Health Literacy Questionnaire (HLQ) into Urdu and to explore its psychometric properties. A structured standardized procedure was followed to translate and validate HLQ into Urdu. Data were collected from 202 Pakistani migrants residing in Australia. The HLQ-Urdu was well understood by the respondents. The structural properties of HLQ-Urdu were close to the original HLQ. Data for all HLQ scales met pre-specified criteria for fit in the one-factor CFA model. The composite reliability was high, ranging from 0.84 to 0.91. A strict nine-factor CFA model was also fitted to the data with no cross-loadings or correlated residuals allowed, which showed excellent model fit statistics [χ2WLSMV = 1266.022 (df = 866, p = 0.000), comparative fit index  = 0.995, Tucker-Lewis index = 0.994, root mean square error of approximation = 0.050 and standardized root mean square residual = 0.069]. The Urdu version of HLQ showed robust psychometric properties. This HLQ-Urdu tool is now ready to be used to assess health literacy in Pakistani migrants in Australia. Availability of health literacy tools in migrant languages may help healthcare providers better understand the health literacy needs of migrant communities.

Validity arguments for patient-reported outcomes: justifying the intended interpretation and use of data

BACKGROUND

Contrary to common usage in the health sciences, the term "valid" refers not to the properties of a measurement instrument but to the extent to which data-derived inferences are appropriate, meaningful, and useful for intended decision making. The aim of this study was to determine how validity testing theory (the Standards for Educational and Psychological Testing) and methodology (Kane's argument-based approach to validation) from education and psychology can be applied to validation practices for patient-reported outcomes that are measured by instruments that assess theoretical constructs in health.

METHODS

The Health Literacy Questionnaire (HLQ) was used as an example of a theory-based self-report assessment for the purposes of this study. Kane's five inferences (scoring, generalisation, extrapolation, theory-based interpretation, and implications) for theoretical constructs were applied to the general interpretive argument for the HLQ. Existing validity evidence for the HLQ was identified and collated (as per the Standards recommendation) through a literature review and mapped to the five inferences. Evaluation of the evidence was not within the scope of this study.

RESULTS

The general HLQ interpretive argument was built to demonstrate Kane's five inferences (and associated warrants and assumptions) for theoretical constructs, and which connect raw data to the intended interpretation and use of the data. The literature review identified 11 HLQ articles from which 57 sources of validity evidence were extracted and mapped to the general interpretive argument.

CONCLUSIONS

Kane's five inferences and associated warrants and assumptions were demonstrated in relation to the HLQ. However, the process developed in this study is likely to be suitable for validation planning for other measurement instruments. Systematic and transparent validation planning and the generation (or, as in this study, collation) of relevant validity evidence supports developers and users of PRO instruments to determine the extent to which inferences about data are appropriate, meaningful and useful (i.e., valid) for intended decisions about the health and care of individuals, groups and populations.

Content validation of a self-report daily diary in patients with sickle cell disease

BACKGROUND

Sickle Cell Disease (SCD) is a genetic progressive vascular disease that impacts patients overall health and quality of life. Sickle-cell pain crises (SCPCs) are a hallmark clinical presentation of SCD and have been associated with increased morbidity and mortality. The Sickle Cell Pain Diary- Self Report (SCPD-S) was developed as a daily patient-reported outcome (PRO) measure primarily intended to capture the frequency and severity of SCD-related pain during and outside of a SCPC. The SCPD-S also examines the impact of the pain associated with an SCPC on other health-related quality of life concepts. The objective of this study was to investigate the content validity of the SCPD-S.

METHODS

The content validation testing included 18 in-depth hybrid concept elicitation and cognitive debriefing interviews conducted with SCD patients in the US aged 12 years and older. Interviewers used a semi-structured interview guide and a think-aloud approach for the cognitive debriefing portion. All interviews were recorded, transcribed, coded and analyzed.

RESULTS

Eighteen interviews across two rounds were conducted. Round 1 hybrid interviews (n = 12) resulted in the expansion of the SCPD-S from 13 to 19 items. Items on the impact of an SCPC on social and recreational activities, sleep, and emotional well-being were added. Five items were significantly revised, as were three response choice sets. Round 2 hybrid interviews (n = 6) confirmed the comprehensiveness of the revised diary, understandability of the wording, and appropriateness of the recall period and response sets. Saturation analyses specific to concept elicitation revealed that no additional interviews were needed.

CONCLUSIONS

This study provided evidence to support the content validity of the SCPD-S, a self-report daily diary. Data gathered during patient interviews indicated that the SCPD-S is a fit for purpose measure of SCD and SCPC-related pain frequency and severity and the impact of this pain on other health-related quality of life concepts including fatigue and emotional health. The numerous changes to the SCPD-S as a result of the study findings highlight the importance of the content validation process when developing a PRO measure.

Long-Term Patient Satisfaction and Quality of Life After Breast-Conserving Therapy: A Prospective Study Using the BREAST-Q

Background

Poor patient-reported satisfaction after breast-conserving therapy (BCT) has been associated with impaired health-related quality of life (HRQOL) and subsequent depression in retrospective analysis. This prospective cohort study aimed to assess the HRQOL of patients who have undergone BCT using the BREAST-Q, and to identify clinical risk factors for lower patient satisfaction.

Methods

Patients with primary breast cancer undergoing BCT were asked to complete the BREAST-Q preoperatively (T1) for baseline evaluation, then 3 to 4 weeks postoperatively (T2), and finally 1 year after surgery (T3). Clinicopathologic data were extracted from the patients’ charts. Repeated measures analysis of variance (ANOVA) was used to determine significant differences in mean satisfaction and well-being levels among the test intervals. Multiple linear regression was used to evaluate risk factors for lower satisfaction.

Results

The study enrolled 250 patients. The lowest baseline BREAST-Q score was reported for “satisfaction with breast” (mean, 61 ± 19), but this increased postoperatively (mean, 66 ± 18) and was maintained at the 1 year follow-up evaluation (mean, 67 ± 21). “Physical well-being” decreased from T1 (mean, 82 ± 17) to T2 (mean, 28 ± 13) and did not recover much by T3 (mean, 33 ± 13), being the lowest BREAST-Q score postoperatively and in the 1-year follow-up evaluation. In multiple regression, baseline psychosocial well-being, body mass index (BMI), and type of incision were risk factors for lower “satisfaction with breasts.”

Conclusion

Both the aesthetic/surgery-related and psychological aspects are equally important with regard to “satisfaction with breasts” after BCT. The data could serve as the benchmark for future studies.

Enabling patient-reported outcome measures in clinical trials, exemplified by cardiovascular trials

OBJECTIVES

There has been limited success in achieving integration of patient-reported outcomes (PROs) in clinical trials. We describe how stakeholders envision a solution to this challenge.

METHODS

Stakeholders from academia, industry, non-profits, insurers, clinicians, and the Food and Drug Administration convened at a Think Tank meeting funded by the Duke Clinical Research Institute to discuss the challenges of incorporating PROs into clinical trials and how to address those challenges. Using examples from cardiovascular trials, this article describes a potential path forward with a focus on applications in the United States.

RESULTS

Think Tank members identified one key challenge: a common understanding of the level of evidence that is necessary to support patient-reported outcome measures (PROMs) in trials. Think Tank participants discussed the possibility of creating general evidentiary standards depending upon contextual factors, but such guidelines could not be feasibly developed because many contextual factors are at play. The attendees posited that a more informative approach to PROM evidentiary standards would be to develop validity arguments akin to courtroom briefs, which would emphasize a compelling rationale (interpretation/use argument) to support a PROM within a specific context. Participants envisioned a future in which validity arguments would be publicly available via a repository, which would be indexed by contextual factors, clinical populations, and types of claims.

CONCLUSIONS

A publicly available repository would help stakeholders better understand what a community believes constitutes compelling support for a specific PROM in a trial. Our proposed strategy is expected to facilitate the incorporation of PROMs into cardiovascular clinical trials and trials in general.

Migrant Communities at the Center in Co-design of Health Literacy-Based Innovative Solutions for Non-communicable Diseases Prevention and Risk Reduction: Application of the OPtimising HEalth LIteracy and Access (Ophelia) Process

The drivers of high prevalence of non-communicable diseases (NCD) among migrants are well-documented. Health literacy is regarded as a potential tool to reduce health inequalities and improve migrant's access to and quality of health care. Yet, little is known about the health literacy needs among these groups and how to address them. This paper outlines the protocol for a migrant community-based co-design project that seeks to optimize health literacy, health promotion, and social cohesion in support of prevention of NCDs among migrants in Lisbon using the OPtismizing HEalth LIteracy and Access (Ophelia) process. This participatory implementation research project starts with a mixed-methods needs assessment covering health literacy strengths, weaknesses and needs of migrants, and local data about determinants of health behaviors, service engagement, and organizational responsiveness. Diverse migrant groups will be engaged and surveyed using the Health Literacy Questionnaire and questions on sociodemographic and economic characteristics, health status, use of health services, and perceived impact of the COVID-19 pandemic. Semi-structured interviews with migrants will also be conducted. Based on data collected, vignettes will be developed representing typical persons with diverse health literacy profiles. Migrants and stakeholders will participate in ideas generation workshops for depth co-creation discussions in simulated real-world situations based on the vignettes, to design health literacy-based multisectoral interventions. Selected interventions will be piloted through quality improvement cycles to ensure ongoing local refinements and ownership development. Through a genuine engagement, the project will evaluate the uptake, effectiveness and sustainability of the interventions. This protocol takes a grounded approach to produce evidence on real health literacy needs from the perspective of key stakeholders, especially migrants, and embodies strong potential for effective knowledge translation into innovative, locally relevant, culturally and context congruent solutions for prevention of NCDs among migrants. Given the diverse communities engaged, this protocol will likely be adaptable to other migrant groups in a wide range of contexts, particularly in European countries. The scale-up of interventions to similar contexts and populations will provide much needed evidence on how health literacy interventions can be developed and applied to reduce health inequality and improve health in diverse communities.

Patient-reported outcome measures (PROMs): A review of generic and condition-specific measures and a discussion of trends and issues

BACKGROUND

Patient-reported outcome measures (PROMs) are questionnaires that collect health outcomes directly from the people who experience them. This review critically synthesizes information on generic and selected condition-specific PROMs to describe trends and contemporary issues regarding their development, validation and application.

METHODS

We reviewed academic and grey literature on validated PROMs by searching databases, prominent websites, Google Scholar and Google Search. The identification of condition-specific PROMs was limited to common conditions and those with a high burden of disease (eg cancers, cardiovascular disorders). Trends and contemporary issues in the development, validation and application of PROMs were critically evaluated.

RESULTS

The search yielded 315 generic and condition-specific PROMs. The largest numbers of measures were identified for generic PROMs, musculoskeletal conditions and cancers. The earliest published PROMs were in mental health-related conditions. The number of PROMs grew substantially between 1980s and 2000s but slowed more recently. The number of publications discussing PROMs continues to increase. Issues identified include the use of computer-adaptive testing and increasing concerns about the appropriateness of using PROMs developed and validated for specific purposes (eg research) for other reasons (eg clinical decision making).

CONCLUSIONS

The term PROM is a relatively new designation for a range of measures that have existed since at least the 1960s. Although literature on PROMs continues to expand, challenges remain in selecting reliable and valid tools that are fit-for-purpose from the many existing instruments.

PATIENT OR PUBLIC CONTRIBUTION

Consumers were not directly involved in this review; however, its outcome will be used in programmes that engage and partner with consumers.

Health literacy as predictors of fluid management in people receiving hemodialysis in China: A structural equation modeling analysis

OBJECTIVES

To explore the impact of health literacy (HL) on perceived benefits of fluid restriction (PBFR), self-reported fluid restriction (SRFR) and relative-interdialytic weight gain (R-IDWG) in people receiving hemodialysis (HD).

METHODS

We conducted a cross-sectional study in two nephrology departments from two hospitals in Guangzhou, China (n = 226). The HL questionnaire, PBFR Subscale of Health Belief Model Constructs and Fluid Adherence Subscale of the HD Patients Therapy Adherence Scale were used. R-IDWG was calculated by the mean IDWG (from 3 consecutive HD), divided by the dry weight.

RESULTS

In structural equation modeling, three domains of the HL questionnaire, namely Actively Managing My Health, Social Support and Actively Engaging with Healthcare Providers (HCPs), were directly and positively associated with PBFR. Higher Actively Managing My Health predicted higher SRFR both directly and indirectly. Sufficient Social Support and adequate Actively Engaging with HCPs predicted higher SRFR indirectly. All three HL domains predicted R-IDWG indirectly.

CONCLUSION

Improving patients' HL could increase their understanding of PBFR and be more apt to follow fluid restrictions and reduce R-IDWG.

PRACTICE IMPLICATIONS

A better understanding of the relationships among HL, PBFR, SRFR and R-IDWG will allow for tailored interventions to decrease R-IDWG in people receiving HD.

Translation, cross-cultural adaptation, reliability, and validity of Turkish version of the university of California Los Angeles (UCLA) shoulder scale into Turkish

PURPOSE

To translate and culturally adapt the University of California Los Angeles (UCLA) shoulder scale into Turkish (T-UCLA) and determine its psychometric properties.

MATERIAL AND METHODS

The UCLA scale was translated into Turkish using Beaton guidelines. Ninety-one patients (46 male; mean age: 46.0 ± 13.7 years) with shoulder disorders completed T-UCLA and American Shoulder and Elbow Score (ASES), Simple Shoulder Test (SST) and 36-Item Short Form (SF-36). Test-retest reliability was tested in 50 patients at a mean of 5.2 ± 2.2 days after initial assessment. Validity was evaluated in 91 patients, and correlations between ASES, SST and SF-36 were analyzed. Responsiveness was assessed in 33 patients who underwent arthroscopic rotator cuff repair with a mean follow-up of 12.8 ± 0.5 months.

RESULTS

Test-retest reliability of overall T-UCLA, pain and function subscales were 0.96, 0.94 and 0.86, respectively. The correlation coefficients between T-UCLA and SST and ASES were r = 0.752 and r = 0.783, respectively (p < 0.001). The highest correlations between T-UCLA and SF-36 were observed in physical functioning (r = 0.64) and bodily pain subscales (r = 0.66). No ceiling or floor effect observed. Overall and subscales of T-UCLA were highly responsive (ES = 3.22-4.31).

CONCLUSION

T-UCLA has sufficient reliability and validity similar to original and translated versions. T-UCLA is responsive in patients who underwent rotator cuff repair.Implications for rehabilitationIn this study, Turkish version of the UCLA was found to be a reliable and valid outcome measure in patients with various shoulder pathologies.Turkish version of the UCLA is a very responsive tool in patients with who underwent arthroscopic repair of rotator cuff tears.

Implications of response shift for micro-, meso-, and macro-level healthcare decision-making using results of patient-reported outcome measures

PURPOSE

Results of patient-reported outcome measures (PROMs) are increasingly used to inform healthcare decision-making. Research has shown that response shift can impact PROM results. As part of an international collaboration, our goal is to provide a framework regarding the implications of response shift at the level of patient care (micro), healthcare institute (meso), and healthcare policy (macro).

METHODS

Empirical evidence of response shift that can influence patients' self-reported health and preferences provided the foundation for development of the framework. Measurement validity theory, hermeneutic philosophy, and micro-, meso-, and macro-level healthcare decision-making informed our theoretical analysis.

RESULTS

At the micro-level, patients' self-reported health needs to be interpreted via dialogue with the clinician to avoid misinterpretation of PROM data due to response shift. It is also important to consider the potential impact of response shift on study results, when these are used to support decisions. At the meso-level, individual-level data should be examined for response shift before aggregating PROM data for decision-making related to quality improvement, performance monitoring, and accreditation. At the macro-level, critical reflection on the conceptualization of health is required to know whether response shift needs to be controlled for when PROM data are used to inform healthcare coverage.

CONCLUSION

Given empirical evidence of response shift, there is a critical need for guidelines and knowledge translation to avoid potential misinterpretations of PROM results and consequential biases in decision-making. Our framework with guiding questions provides a structure for developing strategies to address potential impacts of response shift at micro-, meso-, and macro-levels.

Constructing arguments for the interpretation and use of patient-reported outcome measures in research: an application of modern validity theory

The past 100 years have witnessed an evolution of the meaning of validity and validation within the fields of education and psychology. Validity was once viewed as a property of tests and scales, but is now viewed as the extent to which theory and evidence support proposed interpretations and uses of test scores. Uncertainty about what types of validity evidence were needed motivated the current "argument-based" approach, as reflected in the 2014 Standards for Educational and Psychological Testing. According to this approach, investigators should delineate the assumptions required in order for a proposed interpretation or use to be plausible and then seek evidence that supports or refutes those assumptions. Though validation practices within the field of patient-reported outcome measurement have implicitly included many elements of the argument-based approach, the approach has yet to be explicitly adopted. To facilitate adoption, this article proposes an initial set of assumptions that might be included in most arguments for research-related interpretations and uses of scores from patient-reported outcome measures. The article also includes brief descriptions of the types of evidence that would be best suited for evaluating each assumption. It is hoped that these generic assumptions will stimulate further discussion and debate among quality of life researchers regarding how best to adopt modern validity theory to patient-reported outcome measures.

Towards a comprehensive, person-centred assessment of health literacy: translation, cultural adaptation and psychometric test of the Dutch Health Literacy Questionnaire

Background

Many health literacy instruments focus on reading skills, numeracy and/or information processing aspects only. In the Netherlands, as in other countries, the need for a comprehensive, person-centred measure of health literacy was observed and consequently the decision was made to translate the Health Literacy Questionnaire (HLQ) into Dutch. The HLQ has nine health literacy domains covering people’s experiences and skills. This research sought to translate, culturally adapt and psychometrically test the HLQ.

Methods

The translation and adaptation was done using a systematic approach with forward translation guided by item intents, blind back translation, and a consensus meeting with the developer. The Dutch version of the HLQ was applied in a sample of non-hospitalized, chronically ill patients. Descriptive statistics were generated to describe mean, standard deviation and floor and ceiling effects for all items. A Confirmatory Factor Analysis (CFA) model was fitted to the data. Scores on the nine domains of the HLQ were compared across demographic and illness characteristics as a form of known-groups validity. Psychometric analyses included Cronbach’s alpha, item-rest and item-remainder correlations.

Results

Using CFA, the Dutch HLQ psychometric structure was found to strongly align with the hypothesised (original) nine independent domains of the English version. The nine scales were found to be highly reliable (all scales had alpha between 0.83 and 0.94). Six of the nine HLQ-scales had items that show ceiling-effects. There were no ceiling effects present at the scale level. Scores on the scales of the HLQ differed according to demographic and illness characteristics: people who were older, lower educated and living alone and patients with multiple chronic diseases generally scored lower.

Conclusions

The Dutch version of the HLQ is a robust and reliable instrument that measures nine different domains of health literacy. The questionnaire was tested in a sample of chronically ill patients, and should be further tested in the general population as well as in different disease groups. The HLQ is a major addition to currently available instruments in the Netherlands, since it measures health literacy from a multi-dimensional perspective and builds on patients’ experiences and skills.

Translation, cultural adaptation and psychometric properties of the Ghanaian language (Akan; Asante Twi) version of the Health Literacy Questionnaire

Background

Patients’ competencies and resources to manage their own health, which is termed health literacy, is a necessity for better health outcomes. Thus, it is relevant to have a comprehensive health literacy measurement tool suitable for populations of interest. The Health Literacy Questionnaire (HLQ) is a tool useful for health literacy assessment covering nine dimensions/scales of health literacy. The HLQ has been translated and validated in diverse contexts but has so far not been assessed in any country in sub-Saharan Africa. We sought to translate this tool into the most common language used in Ghana and assess its validity.

Methods

We carried out a cross-sectional study using the HLQ concurrently with an assessment of a malaria programme for caregivers with children under 5 years. The HLQ was translated using a systematic translation procedure. We analysed the psychometric properties of the HLQ based on data collected by face-to-face interview of 1234 caregivers. The analysis covered tests on difficulty level of scales, composite reliability, Cronbach’s alpha and confirmatory factor analysis (CFA).

Results

Cognitive testing showed that some words were ambiguous, which led to minor rewording of the questionnaire. A nine-factor CFA model was fitted to the 44 question items with no cross-loadings or correlated residuals allowed. Given the very restricted nature of the model, the fit was quite satisfactory: χ2 DWLS (866 df) = 17,177.58, p < 0.000, CFI = 0.971, TLI = 0.969, RMSEA = 0.126 and SRMR = 0.107. Composite reliability and Cronbach’s alpha were > 0.65 for all scales except Cronbach’s alpha for scale 9, ‘Understanding health information well enough to know what to do’ (0.57). The mean differences between most demographic groups among health literacy scales were statistically significant.

Conclusion

The Akan-Twi version of HLQ proved relevant in our description of the health literacy levels among the caregivers in our study. This validated tool will be useful to conduct health literacy needs assessments to guide policies addressing such needs. Further work is needed to validate this tool for use in Ghana and similar contexts.

Development and validity testing of the Adolescent Health Literacy Questionnaire (AHLQ): Protocol for a mixed methods study within the Irish school setting

INTRODUCTION

Health literacy research has focused predominantly on the adult population, and much less is understood about this concept from an adolescent perspective. The tools currently available to measure adolescent health literacy have been adapted from adult versions. This limits their applicability to young people because of the developmental characteristics that impact on adolescents' behaviour, including impulse control and judgement skills. This protocol describes the intended development and validity testing of a questionnaire to measure health literacy in adolescents.

METHODS AND ANALYSIS

This protocol describes this mixed methods study that has three phases: the first phase will involve grounded research with adolescents using qualitative group interviews, co-design and concept mapping workshops to understand what health and healthy behaviours mean to adolescents and to explore their health literacy needs and the potential domains for the questionnaire. The draft health literacy domains identified will be presented to the youth advisory panel, and the questionnaire will be altered based on their feedback. Cognitive pretesting of the questionnaire items will also be conducted. Phase 2 will involve piloting the questionnaire to a two-stage random sample of young people in five urban and rural schools in Ireland. Test-retest reliability will be conducted using Pearson correlation coefficient. Confirmatory factor analysis will also be conducted to analyse the psychometric properties of the questionnaire. Phase 3 will involve the questionnaire being rolled out to a nationally representative sample of adolescents (n=6052) in Ireland to assess their levels of health literacy.

ETHICS AND DISSEMINATION

Ethical approval to conduct this study has been granted from the University College Dublin Human Research Ethics Committee - Sciences (LS-20-08). Informed assent from adolescents and informed consent from parents/guardians will be sought. The findings of this research will be disseminated at national and international conferences, as well as through publication in peer-reviewed journals.

Head-to-Head Comparison of the Psychometric Properties of 3 Carer-Related Preference-Based Instruments

OBJECTIVES

To compare the psychometric properties of the Adult Social Care Outcomes Toolkit for carers (ASCOT-Carer), the Carer Experience Scale (CES), and the Care-related Quality of Life (CarerQol) to inform the choice of instrument in future studies.

METHODS

Data were derived from a 2018 online survey of informal carers in Australia. Reliability was assessed via internal consistency (Cronbach alpha, α) and test-retest reliability (intraclass correlation coefficient, ICC) for respondents who self-reported no change in their quality of life as a carer over 2 weeks. Convergent validity was evaluated via predetermined hypotheses about associations (Spearman's rank correlation) with existing, validated measures. Discriminative validity was assessed based on the ability of the carer-related scores to distinguish between different informal care situations (Mann-Whitney U, Kruskal-Wallis one-way analysis of variance).

RESULTS

Data from 500 carers were analyzed. The ASCOT-Carer demonstrated a higher degree of internal consistency, possibly due to a unidimensional structure, and test-retest reliability than the CarerQol and CES (α = 0.87, 0.65, 0.59; ICC, 0.87, 0.67, 0.81, respectively). All 3 instruments exhibited convergent validity and detected statistically significant associations between carer-related scores and different informal care situations, except for the CarerQol-7D and sole carer status.

CONCLUSIONS

The ASCOT-Carer, CarerQol, and CES performed reasonably well psychometrically; the ASCOT-Carer exhibited the best psychometric properties overall in this sample of Australian informal carers. Findings should be used in conjunction with consideration of research goals, carer population, targeted carer-related constructs, and prevailing perspectives on the economic evaluation to inform choice of instrument in future studies.

The Health Literacy Questionnaire: Initial Validity Testing in a Norwegian Sample

BACKGROUND

The Health Literacy Questionnaire (HLQ) is a multidimensional generic questionnaire developed to capture a wide range of health literacy needs. There is a need for validation evidence for the Norwegian version of the HLQ (N-HLQ).

OBJECTIVE

The present study tested an initial version of the Norwegian HLQ by exploring its utility and construct validity among a group of nursing students.

METHODS

A pre-test survey was performed in participants (N = 18) who were asked to consider every item in the N-HLQ (44 items across nine scales). The N-HLQ was then administered to 368 respondents. Scale consistency was identified and extracted in a series of factor analyses (principal component analysis [PCA] with oblimin rotation) demanding a nine-dimension solution performed on randomly drawn 50% of the samples obtained by bootstrapping. Correlations between the nine factors obtained in the 13-factor PCA and the scale scores computed by the scale scoring syntaxes provided by the authors of the original HLQ were estimated.

KEY RESULTS

The pre-test survey did not result in the need to rephrase items. The internal consistency of the nine HLQ scales was high, ranging from 0.81 to 0.72. The best fit for reproduction of the scales from the original HLQ was found for these dimensions: "1. feeling understood and supported by health care providers," "2. having sufficient information to manage my health," and "3. actively managing my health." For the dimensions "7. navigating in the healthcare system" and "8. ability to find good health information," a rather high degree of overlap was found, as indicated by relatively low differences between mean highest correlations and mean next-highest correlations.

CONCLUSIONS

Despite some possible overlap between dimensions 7 and 8, the N-HLQ appeared relatively robust. Thus, this study's results contribute to the evidence validation base for the N-HLQ in Norwegian populations. [HLRP: Health Literacy Research and Practice. 2020;4(4):e190-e199.] PLAIN LANGUAGE SUMMARY: This study tested the Norwegian version of the Health Literacy Questionnaire. The questionnaire (44 items across nine scales) was completed by 368 nursing students. Despite some overlap between scale 7 ("navigating in the health care system") and scale 8 ("ability to find good health information"), the questionnaire appears to serve as a good measurement for health literacy in the Norwegian population.

Exploring health literacy in patients with chronic kidney disease: a qualitative study

Background

Patients with chronic kidney disease make day-to-day decisions about how to self-manage their disease. Chronic kidney disease (CKD) includes a risk for progression towards end-stage renal disease and the development of comorbidities, such as cardiovascular disease, which represents the leading cause of death among these patients. To reduce these risks, CKD patients are recommended to follow a healthy lifestyle with physical activity, food and fluid restrictions, and adherence to complex medication regimes throughout all phases of the disease. To manage the complexity of this health situation, health literacy (HL) is considered essential. The current prevailing understanding is that HL is a multidimensional concept and comprises a range of cognitive, affective, social, and personal skills that determine the motivation and ability to gain access to, understand, and use health information. Recently, we investigated multiple aspects of HL in CKD patients in a quantitative cross-sectional study utilizing the Health Literacy Questionnaire (HLQ) and observed that finding good health information and appraising health information were the most challenging aspects of HL. This study aimed to explore CKD patients’ lived experiences of different dimensions of HL presented in the HLQ.

Methods

This qualitative study utilized in-depth semistructured interviews. Twelve patients with different levels of HL were included. The interviews were analyzed using thematic analysis as described by Braun and Clarke.

Results

We identified three main themes that were significant for CKD patients’ HL: 1. Variation in people’s attitudes and behavior as health information seekers, 2. The problem of fragmented healthcare in the context of multimorbidity makes the healthcare system challenging to navigate, and 3. The value of a good relationship with healthcare providers.

Conclusion

CKD patients take different approaches to health information. Limiting or avoiding health information may be a strategy used by some individuals to cope with the disease and does not necessarily mean that health information is inaccessible or difficult to understand. Comorbidity and a fragmented healthcare system can make the healthcare system challenging to navigate. A good and trusting relationship with healthcare providers seems to promote several aspects of HL and should be promoted to optimize CKD patients’ HL.

Health literacy strengths and limitations among rural fishing communities in Egypt using the Health Literacy Questionnaire (HLQ)

Introduction

Health literacy is an important determinant of health. The aim of this study was to use a multi-dimensional measurement tool to describe the health literacy of people living in a fishing community in northern Egypt.

Methods and analysis

Data were collected from 436 people (fisherman and their families), using the Health Literacy Questionnaire (HLQ), which includes 9 scales. Effect sizes (ES) for standardized mean differences estimated the magnitude of difference between demographic groups.

Results

The mean age of participants was 42 years, 50% were male, 42% were working in the fishing sector, 17.9% had access to the Internet and 36.8% were illiterate. Male participants showed higher capabilities in scales 3. Actively managing my health and 4. Social support for health (ES = 0.21 and 0.27, respectively). In comparison to other occupations, fishing occupation had a negative impact on scale 7. Navigating the healthcare system (ES -0.23). Also, higher educational level was associated with higher HLQ indicators. Across all scales, scale 2. Having sufficient information to manage my health showed the lowest mean (SD) score; 2.23 (0.76) indicating that most people reported they didn’t have enough information.

Conclusions

This study has revealed that fishermen and their families have a wide range of health literacy difficulties which are likely to have profound negative effects on health behavior and health outcomes.

Questionnaire validation practice within a theoretical framework: a systematic descriptive literature review of health literacy assessments

OBJECTIVE

Validity refers to the extent to which evidence and theory support the adequacy and appropriateness of inferences based on score interpretations. The health sector is lacking a theoretically-driven framework for the development, testing and use of health assessments. This study used the Standards for Educational and Psychological Testing framework of five sources of validity evidence to assess the types of evidence reported for health literacy assessments, and to identify studies that referred to a theoretical validity testing framework.

METHODS

A systematic descriptive literature review investigated methods and results in health literacy assessment development, application and validity testing studies. Electronic searches were conducted in EBSCOhost, Embase, Open Access Theses and Dissertations and ProQuest Dissertations. Data were coded to the Standards' five sources of validity evidence, and for reference to a validity testing framework.

RESULTS

Coding on 46 studies resulted in 195 instances of validity evidence across the five sources. Only nine studies directly or indirectly referenced a validity testing framework. Evidence based on relations to other variables is most frequently reported.

CONCLUSIONS

The health and health equity of individuals and populations are increasingly dependent on decisions based on data collected through health assessments. An evidence-based theoretical framework provides structure and coherence to existing evidence and stipulates where further evidence is required to evaluate the extent to which data are valid for an intended purpose. This review demonstrates the use of the Standards' theoretical validity testing framework to evaluate sources of evidence reported for health literacy assessments. Findings indicate that theoretical validity testing frameworks are rarely used to collate and evaluate evidence in validation practice for health literacy assessments. Use of the Standards' theoretical validity testing framework would improve evaluation of the evidence for inferences derived from health assessment data on which public health and health equity decisions are based.