Measurement invariance across chronic conditions: a systematic review and an empirical investigation of the Health Education Impact Questionnaire (heiQ™)

Assessing health empowerment - Brazilian cross-cultural adaptation and validity testing of the health education impact questionnaire (heiQ) among people with chronic low back pain

BACKGROUND

There is no patient reported outcome measure available in Brazilian Portuguese to comprehensively assess outcomes following administration of patient education programs for people with chronic conditions.

OBJECTIVE

To describe the cross-cultural adaptation and measurement properties of the Brazilian Portuguese version of the Health Education Impact Questionnaire (heiQ), a multidimensional questionnaire designed for the evaluation of patient education programs, which was tested in people with chronic low back pain (LBP).

METHODS

One hundred thirty-seven individuals with non-specific chronic LBP (age: 38.7 ± 13.2) were enrolled in the study. The translation was performed according to international standards. Intraclass correlation coefficient (ICC) was used to assess test-retest reliability, Cronbach's α to assess internal consistency, Pearson rank correlation to compare the heiQ scales with comparator scales, and confirmatory factor analysis (CFA) for structural validity.

RESULTS

The test-retest analysis yielded ICC values ranging from 0.75 to 0.91. Cronbach's alphas for the seven scales ranged from 0.70 to 0.89. Significant correlations between affective and general health constructs and the heiQ scales (72%) were observed. For the majority of the scales, the CFA fit statistics showed to be good to excellent.

CONCLUSION

Overall, the Brazilian Portuguese version of the heiQ showed acceptable reliability, internal consistency, construct validity, and structural validity in individuals with chronic LBP. The heiQ scales may serve as direct outcomes to assess education and self-management programs for the Brazilian Portuguese speaker population.

Fertility quality of life tool: update on research and practice considerations

The 36-item Fertility Quality of Life (FertiQoL) tool is increasingly used in research and practice. It measures quality of life in four personal domains (emotional, social, relational, mind/body) and two treatment domains (tolerability, environment). A literature review of published empirical research using FertiQoL was undertaken to provide an overview of this research base. Five databases were searched using 'FertiQoL' and its variant. In total, 41 published articles from 35 independent samples in 23 countries involving 16,315 participants, mainly in clinical settings, were reviewed. FertiQoL was used for three main purposes: (i) to assess quality of life and FertiQoL measurement properties (especially Core FertiQoL) using cross-sectional designs; (ii) to identify correlates, predictors, and consequences of fertility quality of life (some of which included international comparisons); (iii) to assess the effect of psychological interventions on fertility quality of life. The range of median FertiQoL Core, Treatment and subscale (scaled) scores in 31 samples was between 60 and 75. Poorer fertility quality of life was consistently associated with being a woman, longer duration of infertility, poorer psychological functioning and lower patient-centred care. Some FertiQoL subscale scores improved after psychological interventions. Future research should address measurement issues and examine reported associations with fertility quality of life.

Does the Partners in Health scale allow meaningful comparisons of chronic condition self-management between men and women? Testing measurement invariance

AIMS

To determine if the Partners in Health scale, pertinent to assessing patient chronic condition self-management, operates equivalently for men and women.

BACKGROUND

There are distinct gender-based differences in self-management behaviours and health perceptions. This may introduce non-invariance in self-report measures. Testing of measurement invariance is a recommended practice in nursing science to ensure robust metrics.

DESIGN

A representative cross-sectional population survey in South Australian.

METHOD

In 2014, 940 people responded to the South Australian Health Omnibus Survey, a battery of health-related questions. MI and estimation of heterogeneity was tested using Bayesian confirmatory factor analysis.

RESULTS

Findings showed self-management constructs were interpreted equivalently between men and women. Observed population heterogeneity associated lower education levels with poorer illness and treatment knowledge, smokers with poorer treatment partnerships and mental health problems with lower coping capacity.

CONCLUSION

Approximate measurement invariance was achieved between men and women for Partners in Health scale.

IMPACT

There is a lack of well-validated generic instruments, including investigation into gender variability, for measuring chronic condition self-management behaviours. Lower education levels were found to connect with poorer knowledge of health condition and treatment. Mental health problems attenuated ability to cope with the effect of the condition. Findings can facilitate the development of better tailored interventions for self-management of patients' chronic condition/s.

Challenges in Measuring Healthcare Transition Readiness: Taking Stock and Looking Forward

THEORETICAL PRINCIPLES

The construct of transition readiness has become commonplace in healthcare transition (HCT) research, yet conceptualization of this construct is rarely considered. Given the centrality of construct conceptualization in measure development and validity theory, analysis of measurement implications of conceptualizations of transition readiness is essential.

PHENOMENON ADDRESSED

The purpose of this paper is to provide a review and critical analysis of transition readiness measurement through the lens of construct conceptualization and its implications for validation and healthcare transition research.

RESEARCH LINKAGES

Drawing on contemporary validity theory, theoretical discussions of construct conceptualization from management studies, and transition readiness measurement research, this paper will explore how transition readiness has been conceptualized and operationalized in HCT research and articulate problems, challenges and gaps relevant to transition readiness. There remains a lack of consensus on what transition readiness is or should be and careful attention to the implications of elements of conceptual definitions are essential to move the field of transition readiness measurement forward. Recommendations for future work in the field in relation to conceptual clarity, the implications of multidimensionality, change over time, and consequences of measurement are suggested.

Effects of a COPD self-management support intervention: a randomized controlled trial

BACKGROUND

This study examines the effects of the COPD-specific health promoting self-management intervention "Better living with COPD" on different self-management-related domains, self-efficacy, and sense of coherence (SOC).

METHODS

In a randomized controlled design, 182 people with COPD were allocated to either an intervention group (offered Better living with COPD in addition to usual care) or a control group (usual care). Self-management-related domains were measured by the Health Education Impact Questionnaire (heiQ) before and after intervention. Self-efficacy was measured by the General Self-Efficacy Scale (GSE) and SOC was measured by the 13-item Sense of Coherence Scale (SOC-13). Effects were assessed by ANCOVA, using intention-to-treat (ITT) analysis and per-protocol analysis (PPA).

RESULTS

The PPA and the ITT analysis showed significant positive changes on Constructive attitudes and approaches (heiQ) (ITT: P=0.0069; PPA: P=0.0021) and Skill and technique acquisition (heiQ) (ITT: P=0.0405; PPA: P=0.0356). Self-monitoring and insight (heiQ) showed significant positive change in the PPA (P=0.0494). No significant changes were found on the other self-management domains (heiQ), self-efficacy (GSE), or SOC (SOC-13).

CONCLUSION

Better living with COPD had a significant positive short-term effect on some self-management-related domains, and could be an intervention contributing to the support of self-management in people with COPD. However, further work is needed to establish the clinical relevance of the findings and to evaluate the long-term effects.

Illness representations, pain and physical function in patients with rheumatic disorders: between- and within-person associations

OBJECTIVES

Rehabilitation for patients with rheumatic diseases improves both illness representations (IR) and clinical outcomes such as pain and physical functioning (PF). However, it is unclear whether IR may affect and, in turn, are affected by pain and PF. In this study, we examined both between-person associations and within-person associations between IR and pain/PF over time on three measurement occasions. Furthermore, cross-lagged relationships were examined.

DESIGN AND MAIN OUTCOME MEASURES

This secondary analysis is based on data from N = 186 patients with rheumatic diseases. Data on pain, PF and IR were assessed using self-report questionnaires at the beginning, the end and three months after a 3-week inpatient rehabilitation.

METHODS

To separate between- and within-person level, data were analysed using random-intercept cross-lagged panel models.

RESULTS

On both the between-person level (r = |0.21| - |0.44|) and the within-person level (r = |0.15| - |0.46|), pain and PF were related to cognitive and emotional IR. In addition, we found within-person bidirectional cross-lagged effects between emotional IR and PF.

CONCLUSION

IR show complex relationships with pain and PF. Improving PF might improve subsequent illness-related emotional distress and vice versa.

Assessment of depression before and after inpatient rehabilitation in COPD patients: Psychometric properties of the German version of the Patient Health Questionnaire (PHQ-9/PHQ-2)

BACKGROUND

Depression is a frequent comorbidity of COPD and leads to worse clinical COPD-outcomes. PHQ-9 and PHQ-2 are two widely used brief instruments to assess depression. However, psychometric properties in COPD patients are unknown. This study examines factorial validity, measurement invariance and composite reliability (CR) of PHQ-9/PHQ-2, respectively, and concordance between both tools.

METHODS

This is a secondary analysis of N = 561 COPD patients who filled out the PHQ-9 at the begin (T0), the end (T1) and 3/6/9/12 (T2/T3/T4/T5) months after pulmonary inpatient rehabilitation. Structural equation modeling was used to examine factorial validity and measurement invariance between gender, GOLD disease severity groups and over time. Concordance was assessed using Cohen's Kappa, Yules Y, positive and negative agreement.

RESULTS

A one-factor model (with one freed residual covariance) showed best model fit. At least partial scalar invariance could be established. Concordance between both instruments was substantial. 31.7% (26.2%) COPD patients showed clinically relevant depression according to PHQ-9 (PHQ-2) at T0. At T0-T2, PHQ-9 classified more patients as depressed than did PHQ-2. According to both measures, depression rates declined after rehabilitation. Reliability was high for both PHQ-9 (CR = 0.94) and PHQ-2 (CR = 0.89).

LIMITATIONS

No gold-standard (clinical interview) to assess depression was used. Therefore, diagnostic accuracy for PHQ-9/PHQ-2 remains unclear.

CONCLUSIONS

PHQ-9 and PHQ-2 fulfill important psychometric criteria (factorial validity, invariance, reliability) for measuring depression in COPD. The results support their use in clinical practice to assess severity of depression. Diagnostic accuracy to identify major/minor depression of both instruments should be examined in future studies.

Determining the efficacy of the chronic disease self-management programme and readability of 'living a healthy life with chronic conditions' in a New Zealand setting

BACKGROUND

Self-management programmes are an increasingly popular way of treating chronic diseases.

AIMS

This study aims to determine the efficacy of the Stanford Chronic Disease Self-Management Programme (CDSMP) in a New Zealand context by assessing course outcomes and readability of the accompanying reference guide Living a Healthy Life with Chronic Conditions, 4th Edition.

METHODS

This is a cross-sectional pre-post study conducted in Auckland between August 2009 and September 2015, using CDSMP participants' baseline and follow-up Health Education Intervention Questionnaire (heiQ^TM ) data. Readability of the guide was assessed using the Gunning Fog Index, Coleman Liau, Flesch Reading Ease, Flesch Kincaid Grade Level and Simplified Measure of Gobbledygook scores.

RESULTS

Significant evidence of improvement (P ≤ 0.001) was observed in seven of the eight domains measured by the heiQ^TM (Deakin University, Centre for Population Health Research, Melbourne, Vic., Australia). The greatest improvements were seen in skill and technique acquisition (mean change score 0.25, P ≤ 0.001) and self-monitoring and insight (0.18, P ≤ 0.001). There was little evidence of improvement in health service navigation (0.04, P = 0.17). Readability analyses indicate that a person needs to be reading at a minimum of U.S. 8th grade level in order to understand the text, and possibly up to 11th grade.

CONCLUSIONS

The CDSMP is effective for improving patient self-efficacy in the New Zealand setting. However, adaptation of the programme to support better health service navigation is warranted. The readability of the reference guide is not suitable for this setting and requires further improvement.

Making robust decisions about the impact of health education programs: Psychometric evaluation of the Health Education Impact Questionnaire (heiQ) in diverse patient groups in Norway

OBJECTIVE

To undertake a rigorous psychometric evaluation of the widely used eight-scale heiQ version 2.0 (evaluating immediate effects of self-management interventions) in diverse patient groups in Norway.

METHODS

Cross-sectional survey data were collected from 1019 Norwegians. Data were extracted from studies among people with musculoskeletal disorders (n=516), psoriasis (n=254), heart disease (n=97), and Type 2 diabetes (n=152). To investigate the factorial validity of the Norwegian heiQ, confirmatory factor analyses (CFA) were carried out using Mplus.

RESULTS

One-factor model fit, without modifications, was acceptable for the Emotional distress scale. Only one correlated residual was required to be fitted in each of the other scales to achieve satisfactory model fit. The postulated highly restricted full eight-factor model (no cross-loadings, no correlated residuals) showed good fit to the data. Internal consistency was acceptable for most scales (0.72-0.90) but low for Self-monitoring and insight.

CONCLUSION

This study of the Norwegian heiQ replicates the factor structure of the original Australian heiQ, using robust and highly restricted CFA procedures, demonstrating a clean independent clusters model structure.

PRACTICE IMPLICATIONS

Researchers, program implementers and policymakers could use the Norwegian heiQ with confidence to generate reliable information on program outcomes and support quality improvement activities.

Improved self-management skills predict improvements in quality of life and depression in patients with chronic disorders

OBJECTIVE

Self-management programs aim to improve patients' skills to manage their chronic condition in everyday life. Improvement in self-management is assumed to bring about improvements in more distal outcomes, such as quality of life. This study aimed to test the hypothesis that changes in self-reported self-management skills observed after participation in self-management programs predict changes in both quality of life and depressive symptoms three months later.

METHODS

Using latent change modeling, the relationship between changes in latent variables over three time points (start and end of rehabilitation, after three months) was analysed. The sample comprised 580 patients with different chronic conditions treated in inpatient rehabilitation clinics. The influence of additional predictor variables (age, sex, perceived social support) and type of disorder as a moderator variable was also tested.

RESULTS

Changes in self-reported self-management skills after rehabilitation predicted changes in both quality of life and depressive symptoms at the end of rehabilitation and the 3 months follow-up. These relationships remained significant after the inclusion of other predictor variables and were similar across disorders.

CONCLUSION

The findings provide support for the hypothesis that improvements in proximal outcomes of self-management programs may foster improvements in distal outcomes. Further studies should investigate treatment mechanisms.

Individual prevention courses for occupational skin diseases: changes in and relationships between proximal and distal outcomes

BACKGROUND

To treat people with occupational contact dermatitis, the German Accident Prevention and Insurance Association in the Health and Welfare Services offers 2-day individual prevention (IP) seminars.

OBJECTIVES

We investigated whether there are short-term and medium-term changes in proximal (e.g. behaviour) and distal (e.g. symptoms) outcomes after an IP seminar, whether changes in proximal outcomes are associated with changes in distal outcomes, and whether subgroups can be identified that benefit in particular.

PATIENTS/MATERIALS/METHODS

In a prospective study, 502 participants of 85 IP courses completed the health education impact questionnaire (heiQ™) and skin symptom questionnaire (Skindex-29) at the start of the course, immediately thereafter, and after 6 months. Change was assessed according to standardized effect size. Regression techniques were used to analyse associations between proximal and distal outcomes.

RESULTS

After 6 months, participants showed improved self-management skills and preventive behaviour, and less fear of job loss, disease-related symptoms, and emotional distress. Significant associations between proximal and distal outcomes were found. Participants who felt more limited by their skin disease showed greater effects.

CONCLUSIONS

The results are consistent with the assumption that IP courses provide a range of benefits for people with occupational contact dermatitis. Changes in distal outcomes may be influenced by changes in proximal outcomes.

Measurement invariance of English and French Health Education Impact Questionnaire (heiQ) empowerment scales validated for cancer

PURPOSE

If measurement invariance (MI) is demonstrated for a scale completed by respondents from two different language groups, it means that the scale measures the same construct in the same way in both groups. We assessed MI of the French- and English-language versions of the five Health Education Impact Questionnaire (heiQ) empowerment scales validated for the cancer setting.

METHODS

Data came from two cross-sectional studies of Canadian cancer survivors (704 English, 520 French). Single-group confirmatory factor analysis (CFA) was used to test whether the hypothesized factor structure of the French-language heiQ empowerment scales fit the data. Multi-group CFAs were conducted to assess different levels of MI conditions (configural, metric, scalar, strict, as well as MI of factor variances, covariances, and latent means) of the French- and English-language heiQ empowerment scales.

RESULTS

The correlated five-factor model showed good fit in both language groups (goodness-of-fit indices: CFI ≥ .97; RMSEA ≤ .07). Goodness-of-fit indices and tests of differences in fit between models supported MI of the five-factor model across the two language groups (∆CFI ≤ -.010 combined with ∆RMSEA ≤ .015).

CONCLUSIONS

The French- and English-language heiQ empowerment scales measure the same five dimensions of empowerment in the same way across both language groups. Thus, any observed similarities or differences between French- and English-speaking respondents completing these scales are valid and reflect similarities or differences in empowerment across language groups, not measurement artifact. Consequently, heiQ empowerment data from English- and French-speaking respondents can be directly pooled or contrasted in data analyses.