This paper reports on the translation, adaptation and psychometric properties of the HLQ version of Asante-Twi (Local Ghanaian language) with a sample of 1234 caregivers with children under five years. This target group was selected because we needed the HLQ to assess the impact of a community malaria programme for children under five years on the health literacy levels of caregivers. The article highlights the importance of having reliable tools for assessing health literacy in African settings, which are very different from European and Western countries, and even Asian countries. This version of the HLQ for Ghana appears to have acceptable, if not quite perfect, psychometric properties, with dimension 9 (which is very 'functional') having a less well fit, and several other dimensions with borderline fits (<0.80), and more items with factor loading <0.60 than in the other translations. The interpretation of the findings from this study is discussed in the context of previous HLQ validation studies in other languages and in the context of the current study.
The results of the nine-factor CFA show that the model has an acceptable fit. However, in the one-factor analysis, the scale 9 ‘Understanding health information well enough to know what to do´ seemed to have high point estimates for RMSEA >0.1 and low estimates for CFI and TLI ≤0.95, which means the model fits less well. Debussche et al.(15) reported a similar finding in the validation study of the French version of HLQ, where all scales had a good fit except scale 9. Furthermore, we observed that some question items of scale 9 loaded negatively on the scale although close to zero, a finding that stands out from other studies. This means the items negatively influence the scale or do not contribute to the construct, ‘understanding of health information well enough to know what to do’. The items included the questions how easy or difficult do you find it to: 1) accurately follow the instructions from healthcare providers? and 2) understand what health providers are asking you to do? Both questions reveal how people respond to instructions from health providers and should load well on understanding health information; this was, however, not the case in this context. This could be attributed to the translation and how the translated questions may have altered the intended meaning. As noted from the consensus meeting, many deliberations and discussions were assigned to these two questions, because the backward translations sounded stronger, exaggerating the intended meaning of the original version. However, the forward translations were approved as the panel agreed that they fitted the meaning of the original English version. Nonetheless, it is likely that the accepted forward translations might have had stronger meanings than the original version, and thus the exaggerations resulting from the translations might have shifted the focus from understanding to applying the information.
The less fitting model for scale 9 and the overall model could also be attributed to the context and cultural relevance of the construct. As this questionnaire measures health literacy as a multi-dimensional concept, with the dimensions constructed in a different context from Ghana, some of the items may not be factual(28) in Ghana and therefore will not support the model fit of the construct in Ghana. Thus, less fitting model does not always depict a bad model or bad dataset but the theory behind the concept, context differences and translation where necessary, could greatly influence how well the model fit. This is one reason why this study recommends further work on this questionnaire in Ghana, especially to re-examine scale 9 in the Ghanaian or similar contexts to improve on this measurement tool for such contexts (8, 12-14).
The difficulty levels of the scales appear to be higher than other validation studies except the Chinese(17), which was quite similar. However, the high difficulty levels in the Chinese study could be due to the sample consisting of older adults (60 years and above)(17). This is supported by a similar finding by Bo et al, reporting that older adults are more likely to lack sufficient health literacy skills(3). A high range of difficulty levels was primarily found in the second part of the questionnaire (scales 6 to 9), which is in line with findings from other validation studies on the HLQ (8, 12-14, 17). However, the range of difficulty level for scales 6-9 from our findings is also higher (0.21 – 0.68) compared with the original English version (0.08 – 0.42)(8), but in line with the French version of the HLQ (0.32 – 0.69)(15). The higher difficulty levels found for HLQ part 2 indicates a larger health literacy gap and suggests that most caregivers in this study need some form of support to empower them in their engagements with the health system for better health care and health outcomes.
Within HLQ Part 1, scale 1 ‘Feeling understood and supported by healthcare providers’ shows high difficulty levels for all of the four items ranging from 0.50 - 0.54. Comparatively, the difficulty levels for the items in this scale were higher than that recorded in the other validation studies(8, 12-15, 17) with the lowest levels ranging from 0.10-0.19 for the Australian version (original version)(8). Considering the differences in development among the referenced countries, this result is expected from a relatively low resource setting such as Ghana.
The lack of health personnel in the Ghanaian health system may partly explain why as many as 60% of respondents report not having health provider support. Ghana has low provider to population ratios for both doctors (1 to 8481) and nurses(1 to 627) (29), thus, patients are likely not to get enough time with their healthcare providers. Furthermore, the low provider-patient ratios lead to pressure on the health workers that may negatively impact on their reliability and responsiveness(30). This makes it difficult to have at least one healthcare provider to consistently support patients making health decisions. Thus, health provider support might not be a strong feature of the health system, and it is not surprising to see low scores in this study. In a better-resourced health system with good coverage and access, the scale ‘Feeling supported by healthcare providers’ would to a larger extent reveal individual competences in benefitting from the support from the health system compared with low resource settings, where access to such support is more limited. Thus, although the scale shows the ability of an individual to engage with health providers, it is likely also to reflect how the health system is responsive to the needs of the individuals depending on the setting. Any intervention to address low levels of health literacy in this dimension might differ between low and high resource settings, with focus on individual competences in the well-resourced system, as opposed to a focus on health system gaps and organisational responsiveness to health literacy in poorly resourced systems.
Almost 90% of the respondents in our study spoke a local language at home and only 10% spoke English at home. The difference in mean scores between these two groups in Table 4 showed that the English speakers scored higher in especially the last four scales, including navigating the health system. In this paragraph, we discuss language as a barrier (9, 10, 31) to navigating health systems especially when the official language is different from the local language(s). As English serves as the official language in Ghana, most written health information is in English, including labels on medications. This works well for English speakers at the detriment of most of the population. It is not surprising that for items 9.3 and 9.4 (read and understand written health information; read and understand medication labels) most respondents (68% and 64%, respectively; Table 2) had low scores, and thus found the task to be difficult. Such low scores were not evident in the other validation studies (12, 14, 15, 17), probably because their official language was predominantly the most spoken language in the country. Contrary to these low scores, the majority (>70%) of respondents found it easy to understand and follow health information given orally (items 9.2 and 9.5).
These observations on language bring up discussions on the relevance of constructs developed in written cultures in oral cultures. The advantage of the HLQ is the possible oral administration which makes it useful even in Ghana which is predominantly an oral culture although it was developed in Australia, a written-cultural context. However, certain constructs may not fit as well in the Ghanaian setting as it did in Australia, other European settings and in China. In oral cultures, information, even when written, is often communicated orally to increase the understanding of the people of interest. Thus, for some constructs in the HLQ, despite the relevance of the constructs the items under the construct may not be applicable to the Ghanaian setting. For example, health workers would normally fill medical forms for patients after asking them the relevant details needed to fill the form and in addition, written health information and medication leaflets, are translated and communicated orally to patients. Therefore, although the construct of understanding health information is relevant, some items are quite abstract to the context. As demonstrated in the development of an item bank of health literacy questions in South Africa, tools for such settings should include both cognitive and factually based items to reflect the local context and increase the relevance and accuracy of the tool(28). This emphasizes the importance of assessing construct validity in the translation process, not only to ensure that the constructs reflect their intents but most important to assess how constructs and items could be restated or transposed to suit the context without deviating from the concept of interest(32)
Discussions on language barriers to access and use of healthcare systems have led to changes in policies in western countries concerning adding interpreters or providing language courses for the target population who do not speak the official language(9, 10) , e.g. immigrants and the Inuit population may not be good at speaking the official language of the country(10, 31). Sometimes the ability of an individual to read and write does not necessarily mean that the person can comprehend the meaning of the words(33). Although English is known by almost all groups across Ghana, it is not the day to day spoken language by most people and may thus hinder access to and effective use of the health system. Although healthcare providers speak the local languages, some messages might be lost in translation(10) and it becomes more problematic when the inscriptions on medications, medical forms and the information to navigate the health system are also in the official language. The challenge might be to provide written health information in all languages and dialects because of non-documentation of some of the dialects. Nevertheless, there is good reason to raise such discussions in countries facing similar language issues to find policies and approaches to curb this problem. The above also emphasises the importance of translating the questionnaire even in settings with English as the official language. Even if the questionnaire could be maintained in English, cultural and contextual adaptation might be necessary, e.g. perception of a health care provider and nuances of emphasis on certain meanings.
Strengths and limitations
Although the HLQ is one of the recommended tools by WHO(11) in low and middle income countries, this is the first validation study on the HLQ in Africa and thus serves as a first-hand information on how this tool works in an African context. We translated the HLQ to the most commonly spoken Ghanaian language and validated it using a relatively large sample. The validated Twi version of the HLQ can now be considered for assessment of health literacy in Ghana and other neighbouring countries such as Benin and Côte D'Ivoire, which have sub-populations speaking Twi. This could also be useful in countries with a higher number of residents of Ghanaian origin to describe their health literacy profiles.
However, the interpretations of findings are limited to a special group of the Ghanaian population being caregivers with children under five years, because the HLQ was needed to assess the impact of a malaria programme for children under five on the health literacy levels of their caregivers. Caregivers, especially mothers, influence the health status of their families and are thus key people to target to improve health literacy. Our interest in this special group, however, limits the generalisability of the findings. Hence, we recommend testing the questionnaire in other population groups to improve its usefulness in the general population. Another limitation is the potential response bias, as a questionnaire on malaria preceded the HLQ. The sequence might have steered responses to reflect health literacy in managing malaria in children under five rather than managing general health as intended. It might be easier for a caregiver to agree to a statement like “I feel I have enough information to manage my health”, if the person has malaria in mind. This is because the high prevalence of malaria has led to much familiarity with health information on the disease (34). However, we expect that a caregiver, who is for example confident in having sufficient information and in navigating the health system when reflecting on malaria, is in general likely to be more confident and be able to navigate the health system. Therefore, we believe that this potential bias is minor and would not likely alter the findings. Furthermore, malaria is the most common health condition accounting for 40% of all outpatient cases at health facilities (35). Using it as a proxy for health literacy is thus appropriate.
In the data collection, although we received response from all contacted respondents, we skipped some households in the absence of the inhabitants. However, there is less likelihood for any bias because, data collection covered a period from morning to evening which met the presence of many, thus, not many households were skipped.
The use of a non-native English speaker is a non-standard translation method in reference to the translation integrity procedure adapted in this study. We acknowledge that this might have reduced the quality of the backward translation but not the entire translation process. Our process may have resulted in a backward translation with non-standardized lexical choices and a lingua franca translation influenced by the expressions of the native language of the translator. However, the consensus discussion with one of the authors of the questionnaire, who is a native English speaker brought out the shortcomings of the forward translations which were discussed and amended accordingly.
This study calls for further investigations on the validity testing of the HLQ in Ghana or a context with similar cultural characteristics to improve the construct and cultural relevance of the HLQ in such settings for to develop suitable health literacy responsive interventions.