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Background Health literacy is a key asset, defined as the capacity to acquire, understand and use information in ways which promote and maintain good health. Objectives To assess the reliability and validity of the French translation of the Functional, Communicative and Critical Health Literacy (FCCHL) scale. Methods/participants A cross-sectional survey using an online questionnaire was proposed to all members of Seintinelles association. Exploratory and confirmatory factorial analyses were conducted. Results Data from 2342 respondents (45.8% had cancer history) were analysed. The FCCHL scale was well-accepted (missing value by item ≤0.7%). Factor analysis revealed an acceptable fit of three-factor model (comparative fit index = 0.922, root mean square error of approximation = 0.065 and standardized root mean square residual = 0.052). The FCCHL showed satisfactory reliability (α = 0.77) and scalar invariance was reached for education and deprivation, but not for age. Known group validity was verified as mean scale scores differed according to education, deprivation and age, as expected. Conclusion The French version of the FCCHL provides a brief reliable and valid measure to explore the dimensions of health literacy. It could be used by health professionals to screen for health literacy level in order to develop this skill and to tailor health communication. Electronic supplementary material The online version of this article (10.1186/s41687-018-0027-8) contains supplementary material, which is available to authorized users.
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S H O R T R E P O R T Open Access
Validation of the French version of the
Functional, Communicative and Critical
Health Literacy scale (FCCHL)
Youssoufa M. Ousseine
, Alexandra Rouquette
, Anne-Déborah Bouhnik
, Laurent Rigal
, Virginie Ringa
Allan BenSmith
and Julien Mancini
Background: Health literacy is a key asset, defined as the capacity to acquire, understand and use information in
ways which promote and maintain good health.
Objectives: To assess the reliability and validity of the French translation of the Functional, Communicative and
Critical Health Literacy (FCCHL) scale.
Methods/participants: A cross-sectional survey using an online questionnaire was proposed to all members of
Seintinelles association. Exploratory and confirmatory factorial analyses were conducted.
Results: Data from 2342 respondents (45.8% had cancer history) were analysed. The FCCHL scale was well-accepted
(missing value by item 0.7%). Factor analysis revealed an acceptable fit of three-factor model (comparative fit index = 0.
922, root mean square error of approximation = 0.065 and standardized root mean square residual = 0.052). The FCCHL
showed satisfactory reliability (α= 0.77) and scalar invariance was reached for education and deprivation, but not for age.
Known group validity was verified as mean scale scores differed according to education, deprivation and age, as expected.
Conclusion: The French version of the FCCHL provides a brief reliable and valid measure to explore the dimensions of
health literacy. It could be used by health professionals to screen for health literacy level in order to develop this skill and
to tailor health communication.
Keywords: Health literacy, Measurement, Validation studies, Psychometrics, Cancer, France
Health literacy (HL) is a key asset, defined as the indi-
viduals' capacity to obtain, process and understand basic
health information and services needed to make appro-
priate health decisions[1, 2]. Consistently, authors like
Nutbeam [3] distinguish three skills: functional literacy,
which includes basic skills in reading and writing neces-
sary to understand health information; communicative
literacy, which corresponds to the necessary advanced
skills to communicate or interact with the healthcare
system; and critical literacy to analyse the information
obtained to act at best. Accordingly, the Functional,
Communicative and Critical Health Literacy scale
(FCCHL) measures all three distinguished dimensions of
HL [4]. A generic tool [5] was adapted from the first ver-
sion developed to specifically evaluate HL in diabetic pa-
tients [4] and has been validated in several populations
including Dutch/German citizens [68], and Australian
Adolescents and Young Adults with cancer [9]. This
brief instrument (14-items) has demonstrated relevance
to patients and ease of administration [9]. However, no
validation of FCCHL exists in French.
Validated translations of HL measures are needed, as a
growing literature has shown the importance of evaluat-
ing HL in both patients and general population. Indeed,
limited HL predicts poorer health and has demonstrated
associations with several patient-reported outcomes,
* Correspondence:
Aix-Marseille Univ, INSERM, IRD, UMR912, SESSTIM, Institut Paoli-Calmettes,
Cancers, Biomedicine & Societygroup, 232, Bd Ste Marguerite, BP 156,
13273 Marseille Cedex 9, France
APHM, Timone Hospital, Public Health Department (BIOSTIC), Marseille,
Full list of author information is available at the end of the article
Journal of Patient-
Reported Outcomes
© The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (, which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
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Ousseine et al. Journal of Patient-Reported Outcomes (2018) 2:3
DOI 10.1186/s41687-018-0027-8
such as poorer health-related quality of life and more
mental distress among cancer patients [10].
Our aim was the psychometric evaluation of the
French translation of the FCCHL scale.
The FCCHL was translated from English to French by
three independent researchers. The final version of each
item was then chosen with the help of a bilingual psych-
ologist. Individual cognitive interviews were then con-
ducted with six cancer patients to evaluate the wording
and understanding of the translated items. Minor refine-
ments were then made comparing our translation with
the translation from the Japanese to French made by
other French researchers.
Data were collected using a self-administered online
questionnaire proposed to all adult members of Seinti-
nelles ( between June 16th and
30th, 2016. Seintinelles is a French national association
including 12,747 members (participant numbers as de-
clared on January 15th 2016) who are cancer patients,
cancer survivors and/or other people (e.g. caregivers)
wishing to help cancer research[11]. They are mostly
breast cancer patients because it was initially created
based on the model of Army of Women®. Use of Seinti-
nelles enabled the rapid recruitment of a large sample
for psychometric validation of the French translation of
the FCCHL scale. The final sample size was larger than
the minimum of 500 to 800 respondents needed to per-
form exploratory factorial analysis for a three-factor
scale with 10 to 15 items [12].
Floor or ceiling effects at the scale level were consid-
ered to be present if more than 15% of respondents
achieved the lowest or highest possible score, respect-
ively [13]. At the item level, these effects were consid-
ered to be present if more than 95% answered the lowest
or highest response category [14]. Reliability was
assessed by Cronbachs alpha (α) with values α0.7 con-
sidered satisfactory [15].
An exploratory factor analysis (EFA) was performed
on one third of the sample, randomly selected. To assess
construct validity, confirmatory factor analysis (CFA),
based on the factorial structure found using EFA and in
literature, was subsequently conducted on the other
two-thirds of the sample. Multiple-group CFA and
nested model comparisons were used to evaluate meas-
urement invariance across age groups, education levels
and deprivation using the following sequence: configural,
metric and scalar invariance. The robust weighted least
squares (WLSMV) estimator was used for both EFA and
CFA [16, 17]. The root mean square error of approxima-
tion (RMSEA, good fit if <0.06, poor fit if 0.10, accept-
able elsewhere), the comparative fit index (CFI) and the
Tucker-Lewis index (CFI and TLI, good fit if >0.95, poor
fit if <0.90, acceptable elsewhere) were used to exam-
ine model fit [18]. For measurement invariance, each
level of invariance was considered to be met if the fit
indices difference between each level was equal or
less than 0.01 for ΔCFI and equal or less than 0.015
for ΔRMSEA [19, 20]. When a level of invariance was
not met, non-invariant items were identified by
reviewing modification indices in order to release
equality constraints concerning these items until par-
tial invariance was met.
Our a priori hypotheses were that a higher HL would
be associated with higher education, younger age, French
as mother language and lack of deprivation [4, 21, 22].
Students t tests and ANOVAs were used to compare
mean FCCHL levels.
All analyses were two-tailed and performed using SPSS
PAWS Statistics 18.0 and Mplus software version 7.4. P-
values <0.05 were considered significant.
In June 2016, 2444 participants were surveyed after ex-
cluding 124 participants (4.8%) who only completed
their sociodemographic characteristics. Missing values
by item ranged from 0.1% (FCCHL6) to 0.7% (FCCHL3
and FCCHL5) and 2342 participants (95.8%) answered
all 14 items of the FCCHL scale. The following results
were obtained from participants with complete data of
FCCHL (n= 2342).
The mean age of those 2342 participants was 47.6 years
(SD = 13.6), 96.4% of participants were women, 45.8% had
a history of cancer and 18.1% were deprived (Table 1).
The lowest total score was 27 (versus a possible 14)
and 32 respondents (1.4%) had the highest score possible
(70) indicating no floor or ceiling effect at the scale level.
The percentages of respondents for each of the response
categories range from 1% to 72% over the 14 items, indi-
cating no floor or ceiling effects at the item level. Glo-
bally, correlations between the different items within
each dimension were >0.4 (ranging from 0.41 to 0.76)
(Additional file 1: Table S1).
The EFA with promax rotation revealed three factors,
explaining 55% of the variance. The loading matrix ob-
tained is shown in Table 2. Among the four items for crit-
ical HL, three clearly loaded on the third factor but the
last item (FCCHL14) loaded on the second factor (0.42).
CFA indicated reasonable fit indices for a 3-factor model
(with correlation between 3-factors, Fig. 1): RMSEA = 0.087
(90% confidence interval 0.0820.092), CFI = 0.946 and
TLI = 0.933. When the item FCCHL14 was modelled in the
second dimension, fit indices were: RMSEA = 0.086
(90% confidence interval 0.0810.091) and CFI = 0.947
and TLI = 0.935. A significant decrease (3 and 2
factor nested model test, p< 0.001) in model fit was
observed when communicative and critical dimensions
Ousseine et al. Journal of Patient-Reported Outcomes (2018) 2:3 Page 2 of 6
were merged in a single processingdimension
(RMSEA = 0.123, CFI = 0.888 and TLI = 0.866).
Cronbachsαwere >0.7 for the overall scale (α= 0.77)
and subscales (α= 0.79, α= 0.74 and α= 0.77 for func-
tional, communicative and critical dimensions respect-
ively). Communicative and critical HL were moderately
linked together (r= 0.46) and weakly correlated with the
functional dimension (r= 0.15 and r= 0.03).
Scalar invariance was reached for education levels and
deprivation, but not for age (Additional file 1: Table S2).
However, partial scalar invariance was reached in releas-
ing the fourth threshold of FCCHL2 in the 1840 years-
old age group. That means that this threshold was
significantly lower (0.049) than in the older age groups
(0.691), i.e. at the same level of functional HL, older
people responded more frequently than younger people
that they agreed with the fact that they felt the print was
too small for them to read.
Age showed negative associations with FCCHL but not
with the communicative dimension (Table 3). When the
functional HL or FCCHL score was calculated using the
four or thirteen age-invariant items only (without FCCHL2),
no association was observed with age (p-value = 0.411
or p-value = 0.053). A higher education level and lack
of deprivation were significantly associated with higher
levels of HL, except that deprivation was not associated
with critical HL. In contrast having French as mother lan-
guage (97.8%) was only associated with higher functional
HL. No gender differences were observed.
Our results confirmed similar or better psychometric
properties of the French version of the FCCHL scale
compared with the original version [5].
Consistent with previous studies [57], exploratory
analysis revealed a 3-factor model confirming the overall
structure of the scale, with satisfactory internal
consistency of each FCCHL dimension. Similar to results
among German citizens showing a 2-factor model com-
bining communicative and critical HL into processing
HL[8], these two dimensions were the most correlated
here. A single item of the critical dimension (FCCHL14)
primarily loaded on the communicative dimension. This
dual loading might be explained in light of the wording
of this item, because collectcan reflect accessing infor-
mation by communication, while makerefers more to
critical aspects needed for making decisions. As no
major differences in fit indices were observed when
FCCHL14 was included in the communicative dimen-
sion, this item was left in the critical dimension to be
more consistent with the original version.
The internal consistency of each FCCHL dimension was
satisfactory. Our findings differ slightly from previous
findings in Dutch citizens [6] and young Australian cancer
patients [9], which found that internal consistency of the
communicative dimension was less satisfactory (α=0.63
in both studies). These differences may be explained by
fewer items (n= 3) in the FCCHL-AYAC for the commu-
nicative dimension and difficulties answering items
reported by Dutch citizens. In the latter study, items
seemed to be too abstract and citizens clearly underlined
that they did not understand what was meant by applying
information to their daily lifeor by considering whether
information was applicable.
As hypothesized and in line with previous studies [4, 21,
22], people with lower education had lower HL compared
to people with higher education. Furthermore, socioeco-
nomic deprivation tended to be associated with lower HL,
except for the critical dimension as previously reported [4,
22]. Only the functional dimension of FCCHL was able to
discriminate the few participants who had a mother lan-
guage other than French highlighting difficulties under-
standing health information associated with potential
difficulties understanding French generally.
The negative association between age and functional
HL or FCCHL total score disappeared when those scores
Table 1 Main participantscharacteristics (n= 2342)
Sociodemographic and medical history n %
1840 777 33.2
4160 1111 47.4
6183 454 19.4
Female Gender 2258 96.4
French maternal language 2269 97 .8
Education level
Primary/secondary 279 11.9
Three-years higher education 958 40.9
> Three-years higher education 1105 47.2
Deprivation (EPICES Index) 409 18.1
Cancer history 1073 45.8
Difficulties in asking physicians questions
Always (1) 37 1.6
Often (2) 229 9.8
Sometimes (3) 735 31.4
Rarely (4) 669 28.6
Never (5) 632 27
Missing values 40 1.7
Health literacy Possible range Mean SD
FCCHL 1470 55.58 7.06
Functional dimension 525 18.95 4.18
Communicative dimension 525 20.66 3.01
Critical dimension 420 15.96 3.08
FCCHL Functional, Communicative and Critical Health Literacy
Ousseine et al. Journal of Patient-Reported Outcomes (2018) 2:3 Page 3 of 6
were computed without the FCCHL2 item found to be
non-invariant across age groups. This is likely due to
differing interpretations of this item between younger
and older people and highlights that spurious age differ-
ences may be observed when FCCHL2 is used. It also
questions the association between age and FCCHL that
was observed in a previous study [4] and suggests that
measurement invariance across age should also be stud-
ied for FCCHL versions in other languages, as recom-
mended in the guidelines [23]. In our study, the critical
HL score was thus the only one that was significantly
negatively associated with age and it might reflect lower
empowerment among older people [24]. The lack of
impact of age on the communicative dimension was ex-
pected [4]. It might also be explained by our recruitment
of persons, very involved in research and registered to
participate in mainly online surveys, who might not have
difficulties communicating no matter their age.
Our study has some limitations. We were unable to
compare the translated FCCHL against an objective test
of functional HL. Moreover, our sample included mainly
women (96%), who were highly educated and had
French as their mother language. However the sample
was more heterogeneous regarding age and cancer his-
tory and the FCCHL showed variability despite them be-
ing negatively skewed (Additional file 1: Figure S1).
Table 2 Factor structure of the FCCHL scale. (n= 781, Training sample)
Factor Communality
Functional health literacy
FCCHL1 Find characters that I cannot read 0.75 0.01 0.08 0.66
FCCHL2 Feel that the print is too small for me to read 0.59 0.09 0.08 0.43
FCCHL3 Feel that the content is too difficult for me to understand 0.93 0.03 0.02 0.88
FCCHL4 Feel that it takes a long time to read them 0.70 0.02 0.01 0.50
FCCHL5 Need someone to help me read them 0.66 0.03 0.05 0.46
Communicative health literacy
FCCHL6 Collect information from various sources 0.02 0.78 0.04 0.66
FCCHL7 Extract the information I want 0.03 0.71 0.03 0.52
FCCHL8 Understand the obtained information 0.24 0.62 0.06 0.48
FCCHL9 Communicate my opinion about my illness 0.08 0.73 0.08 0.46
FCCHL10 Apply the obtained information to my daily life 0.02 0.68 0.04 0.45
Critical health literacy
FCCHL11 Consider whether the information is applicable to me 0.02 0.23 0.71 0.73
FCCHL12 Consider whether the information is credible 0.01 0.07 0.97 0.86
FCCHL13 Check whether the information is valid and reliable 0.01 0.09 0.68 0.54
FCCHL14 Collect information to make my healthcare decisions 0.04 0.42 0.27 0.37
Loading values higher than 0.4 are bolded
Fig. 1 Standardized parameter estimates for the 3-factor model of FCCHL (n= 1561, validation sample). Rectangles represent the observed variables
(items) and ellipses represent the latent constructs (factors). Values on the single-headed arrows leading from the factors to the items are standardized
factor loadings. Values on the curved double-headed arrows are correlations between factors terms
Ousseine et al. Journal of Patient-Reported Outcomes (2018) 2:3 Page 4 of 6
FCCHL also presented good acceptability, as indicated
by low levels of missing data, which might be attribut-
able to respondentshigh HL.
In this first validation study of a self-report multidi-
mensional health literacy scale in France, the French ver-
sion of the FCCHL demonstrated adequate reliability
and validity among cancer patients and general popula-
tion. It highlighted that measurement invariance across
age should be studied more systematically when validat-
ing HL measures. Further studies are needed to examine
the French FCCHL stability among less educated, less
literate samples including more men and those without
French as their mother language. This relatively brief
measure could be used among both patients and general
population to allow identification of people with low HL
in order to develop this skill and to tailor health com-
munication accordingly.
Additional file
Additional file 1: Table S1. Distribution of the responses to the different
items on the questionnaire and polychoric correlations between the various
FCCHL items (n= 2342). Table S2. Measurement invariance across age
groups, education levels, and deprivation. Figure S1. Distribution of FCCHL
score and subscores. (DOCX 77 kb)
We particularly thank all members of Seintinelles association. We are also
grateful to Cyril Berenger for his help to implement the e-survey.
The project leading to this publication has received funding from Excellence
Initiative of Aix-Marseille University - A*MIDEX, a French Investissements
dAvenirprogram. This work was supported by the French National Cancer
Institute (grant number INCA_8102); IRESP (grant number RINGA-AAP16-HSR-13)
for French teams collaboration; the funding partners of the IRESP in the
framework of the 2016 call for general project Health services.
All authors of this research paper have made substantial contributions to all
of the following: (1) the conception and design of the study, or acquisition
of data, or analysis and interpretation of data, (2) drafting the article or revising
it critically for important intellectual content. All authors have read and
Ethics approval and consent to participate
This study has been approved by the Inserm Ethics Committee (IRB00003888, N
Competing interests
The authors declare that they have no competing interests.
Springer Nature remains neutral with regard to jurisdictional claims in published
maps and institutional affiliations.
Author details
Aix-Marseille Univ, INSERM, IRD, UMR912, SESSTIM, Institut Paoli-Calmettes,
Cancers, Biomedicine & Societygroup, 232, Bd Ste Marguerite, BP 156,
13273 Marseille Cedex 9, France.
Public Health and Epidemiology
Department, APHP, Bicêtre Hospital, Le Kremlin-Bicêtre, France.
Paris-Saclay, Univ. Paris-Sud, UVSQ, CESP, INSERM, Le Kremlin Bicêtre, France.
Centre for Oncology Education and Research Translation (CONCERT),
Ingham Institute for Applied Medical Research & South Western Sydney
Clinical School, University of New South Wales, Liverpool, NSW, Australia.
Psycho-Oncology Co-operative Research Group (PoCoG), School of
Psychology, University of Sydney, Sydney, Australia.
APHM, Timone Hospital,
Public Health Department (BIOSTIC), Marseille, France.
Table 3 Bivariate relationships between FCCHL and sociodemographic characteristics (n= 2342)
Functional HL Communicative HL Critical HL FCCHL
Mean ± SD P Mean ± SD P Mean ± SD P Mean ± SD P
1840 19.57 ± 3.93 <0.001
20.63 ± 2.78 0.617 16.32 ± 2.75 <0.001 56.53 ± 6.32 <0.001
4160 18.70 ± 4.27 20.62 ± 3.12 15.86 ± 3.13 55.20 ± 7.34
6183 18.49 ± 4.27 20.78 ± 3.15 15.60 ± 3.43 54.88 ± 7.38
French maternal Language
No 17.35 ± 4.95 0.006 20.96 ± 2.96 0.472 16.68 ± 2.36 0.094 55.59 ± 7.04 0.548
Yes 18.98 ± 4.16 20.65 ± 3.01 15.95 ± 3.09 55.00 ± 6.95
Primary/secondary 17.36 ± 4.36 <0.001 20.11 ± 3.30 <0.001 15.57 ± 3.23 <0.001 53.05 ± 7.47 <0.001
Three-years higher education 18.71 ± 4.12 20.48 ± 2.95 15.63 ± 3.15 54.84 ± 6.78
> Three-years higher education 19.56 ± 4.05 20.94 ± 2.96 16.34 ± 2.94 56.86 ± 6.92
Deprivation (EPICES Index)
No 19.13 ± 4.08 <0.001 20.73 ± 3.02 0.003 15.97 ± 3.06 0.721 55.84 ± 7.00 <0.001
Yes 18.29 ± 4.42 20.25 ± 2.98 15.91 ± 3.17 54.46 ± 7.02
HL Health Literacy, FCCHL Functional, Communicative and Critical Health Literacy
p-value = 0.411 if functional HL score computed without FCCHL2, item found to be non-invariant across age groups
p-value = 0.053 if FCCHL score computed without FCCHL2, item found to be non-invariant across age groups
Ousseine et al. Journal of Patient-Reported Outcomes (2018) 2:3 Page 5 of 6
Received: 9 August 2017 Accepted: 4 January 2018
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... FCCHL has been validated in several populations including French/Dutch/German/ Australian/Japanese/Norwegian citizens [21,[30][31][32][33][34][35]. However, no validation of FCCHL exists in Serbian. ...
... Like in other studies investigating the FCCHL [29][30][31][32][33][34][35] our results indicate that, after translating and adapting the FCCHL instrument to Serbian, the FCCHL-SR12 is a valid instrument, ready to be used in Serbia, and opening possibilities to study HL in Serbia and compare the results internationally. ...
... In accordance with previous studies [29,30,33], exploratory analysis revealed a 3factor model confirming the overall structure of the scale, with satisfactory internal consistency of each FCCHL dimension. ...
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Thoroughly validated instruments can provide a more accurate and reliable picture of how the instrument works and of the level of health literacy in people with type 2 diabetes mellitus (T2DM). The present work aimed at cross-cultural adaptation and validation of the Functional, Communicative and Critical Health Literacy Instrument (FCCHL) in patients with T2DM in Serbia. After translation and back-translation, views from an expert group, one cognitive interview study (n = 10) and one survey study (n = 130) were conducted among samples of diabetic patients. Item analysis, internal consistency, content validity, confirmatory factor analysis (CFA) and reliability testing were performed. When all 14 items were analyzed, loading factors were above 0.55, but without adequate model fit. After removing two items with the lowest loadings FHL1 and IHL2 the fit indexes indicated a reasonable normed χ2 (SB scaled χ2/df = 1.90). CFI was 0.916 with SRMR = 0.0676 and RMSEA = 0.0831. To determine internal consistency, Cronbach’s alpha coefficient was 0.796 for the whole FCCHL-SR12. With only minor modifications compared to the English version, the 12-item FCCHL instrument is valid and reliable and can be used to measure health literacy among Serbian diabetic patients. However, future research on a larger population in Serbia is necessary for measuring the levels of HL and their relationship with other determinants in this country.
... Participants completed an online battery that included five surveys about (i) their demographic information (e.g. gender, age, education and employment situation), (ii) NIS behavior: one question about the frequently participants checking the news on a 5-point Likert scale (all the time continuously, several times a day, once a day, several times a week, once a week, never), (iii) the adoption of PBs to prevent COVID-19: 13 items about the frequencies to perform protective measures, including keeping social distance, use of sanitary mask (and gloves) and washing behaviors, on a 7-point Likert scale from 'never' to 'all the time', (iv) the LoC about being infected by COVID-19: 4 items about how they would attribute the cause of COVID-19 infection to the following dimensions if they get infected: 'self', 'the others', 'the government', and the chance (implying the influence of external factors, such as luck or chance) on a 7-point Likert scale from 'strongly disagree' to 'strongly agree', (v) CoHL: eight remaining items from the French version of the Functional, Communicative and Critical Health Literacy scale (FCCHL) which was validated by Ousseine et al. [25]. ...
... Having adequate CoHL could enable individuals to access, obtain and process appropriate COVID-19-related information and adopt the recommended PB for oneself and others. To this end, the current article aimed (i) to validate the development of the CoHL scale from a prior general HL scale [25] and (ii) to examine the relationships among CoHL, LoC (internal and external), NIS and the adoption of PBs, such as social and physical distancing. ...
... Secondly, the CoHL scale provides a framework that can be used to develop HL measures for other health topics. Given that CoHL is developed based on the French version of the Functional, Communicative and Critical (FCCHL) validated by Ousseine [25], FCCHL is a generic HL scale initially developed in English by Ishikawa et al. [46], validated by various populations and languages (e.g. van der Vaart et al. [47] in German; [48] for young adults and teenagers with cancers), CoHL can also be adapted for other specific health topics following the original constructs (Cholera, Ebola, Yellow fever, Meningitis, Influenza, etc.). ...
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Health literacy (HL) is critical to find, understand and use health information for adopting appropriate health behavior, especially during a pandemic crisis in which people can be exposed to an overwhelming amount of information from different media. To this end, we conducted an online study to first validate the measure of COronaVIrus Disease appeared in 2019 (COVID-19) health literacy (CoHL) and then investigated its relationships with locus of control (LoC), news information search and the adoption of protective behaviors (PBs) during the first lockdown in France. We first showed the good structural and psychometric qualities of the CoHL scale on a 3-dimensional structure: the Critical dimension, the Extraction/Communicative and the Application/Communicative dimension. We then found that CoHL was associated with the adoption of PBs suggesting that people with higher CoHL tended to adopt more PBs during the first lockdown, regardless of their LoC. However, people with low CoHL would be more likely to adopt PBs if they believe that they may get COVID-19 due to the behavior and health conditions of others (high external LoC). The study has implications for the design of public health campaigns for people with inadequate HL and with a different LoC.
... In addition, to test and get feedback on the developed system and validate the player's experience in a VR activity, informed consent was applied to a group of healthy individuals for them to participate in the research study. This was followed by a validation questionnaire, designed by the research team to collect sociodemographic data and assess three components: functional literacy, communication literacy, and motivational literacy [7,8]. ...
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Background: This work presents Com@Rehab, a technological patient-centred activity for individuals needing a physical rehabilitation approach and with a specific loss of functionality. Within this scope, this paper focuses on the description of the activity in virtual reality (VR), its components, design and user profile, and its versatility and future adaptability regarding different ages, pathologies and rehabilitation contexts. Methods: The VR activity has been customised according to the patient's clinical needs while replicating an activity of daily living, namely showering. In addition, to validate and get feedback on the developed system, a validation questionnaire was applied to a group of healthy individuals to test the efficiency of the technology that supports the VR activity. Results: Preliminary results show that 94% of the participants recommended the experience, the performance of the various components of the system was successfully implemented, participants quickly adhered to the VR technology, and the UI assistant’s functionality should be improved. Conclusion: This solution creates a more effective, interactive, humanised rehabilitation approach based on a Virtual Reality (VR) activity. The Com@Rehab Communication Module improves human-human and human-machine communication while contributing to health literacy.
... Specifically, low SES has been associated with low HL (van der Heide, Rademakers, et al., 2013). In France, various recent studies showed similar results in this context, with a low level of HL in people with low education levels and low income (Debussche et al., 2018;Ousseine et al., 2018Ousseine et al., , 2020. However, studies investigating the relationship between SES, HL, and preventive behaviors are rare. ...
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Background: In recent decades, several research studies have mentioned a potential mediating effect of health literacy (HL) on the relationship between socioeconomic position and health prevention behaviors. However, no study to date has investigated this hypothesis on HIV prevention behaviors. Objective: The present study aimed to evaluate whether HL mediates the relationship between socioeconomic status (SES) and pre-exposure prophylaxis (PrEP) uptake in men who have sex with men (MSM). Methods: The study is based on data collected in the Enquête Rapport au Sexe [report to sex] 2019 survey, an anonymous, self-administered online cross-sectional survey in France conducted between February 16, 2019 and March 31, 2019. Data on education level and perceived financial situation were used as measures of SES, whereas HL was assessed from the Health Literacy Questionnaire's "ability to actively engage with health care providers" scale. Mediation analyses were performed with a model-based causal moderated mediation analysis package in R software. Analyses were adjusted for age, place of residence, marital status, and social support. Key results: The study sample included 13,629 MSM. Median age was 32 years. The majority had an education level higher than upper secondary school (78%) and an adequate HL level (73%). Almost two-thirds perceived their financial situation as comfortable (62%). Overall, PrEP uptake was low (9.5%). The analyses did not show a mediating effect of HL on the relationship between education and PrEP uptake. However, a total mediation effect of HL was observed on the relationship between perceived financial situation and uptake. Conclusions: In the context of PrEP uptake, MSM ability to actively engage with health care providers may offset the effect of a difficult financial situation. In the current French context, where PrEP is now also available in general practitioner settings, this result could inform the development of training and support policies for health professionals and the way in which sexual health issues are addressed in consultations. [HLRP: Health Literacy Research and Practice. 2023;7(1):e61-e70.].
... Among them, the most frequent approach has been direct testing of individual literacy skills such as reading ability and comprehension as well as numeracy skills. The most commonly used instruments include the National Assessment of Adult Literacy (NAAL) [17], the Rapid Estimate of Adult Literacy in Medicine (REALM) [18], the Test of Functional Health Literacy in Adults (TOFHLA) [19], the Newest Vital Sign (NVS) [20], the Health Literacy Skills Instrument (HLSI) [21], and the Functional, Communicative, and Critical Health Literacy scale (FCCHL) [22]. However, these instruments take time to administer and may require in-person testing by trained staff, both conditions less adapted to primary care settings. ...
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Background: The Brief Health Literacy Screening (BHLS) is a short self-report instrument developed to identify patients with inadequate health literacy. This study aimed to translate the BHLS into French Canadian (BHLS-FCv) and to evaluate its psychometric properties among patients with chronic conditions in primary care. Methods: The BHLS was translated into French using the Hawkins and Osborne's method. Content validity was evaluated through cognitive interviews. A validation study of the BHLS-FCv was conducted in two primary care clinics in the province of Quebec (Canada) among adult patients with chronic conditions. Psychometric properties evaluated included: internal consistency (Cronbach's alpha); test-retest reliability (intraclass correlation coefficient); and concurrent validity (Spearman's correlations with the Health Literacy Questionnaire (HLQ)). Results: 178 participants completed the questionnaire at baseline and 47 completed the questionnaire two weeks later over the telephone. The average score was 13.3. Cronbach's alpha for internal consistency was 0.77. The intraclass correlation coefficient for test-retest reliability was 0.69 (95% confidence interval: 0.45-0.83). Concurrent validity with Spearman's correlation coefficient with three subscales of HLQ ranged from 0.28 to 0.58. Conclusions: The BHLS-FCv demonstrated acceptable psychometric properties and could be used in a population with chronic conditions in primary care.
... In addition, almost all the studies to date which have included men have also included women and therefore study designers have had no difficulty recruiting quickly the minimum number of participants required, the vast majority of which being women. This is illustrated by the study by Ousseine et al. (2017), which aimed to validate a health literacy scale (FCCHL) with the population of Seintinelles: women comprised 96.7% of the study sample. Since 2015, the platform's recruitment strategy has encouraged women already registered to promote the platform to their close family and friends, especially men. ...
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The French collaborative research platform Seintinelles was developed out of a desire to promote health democracy. The objective of the present study was to understand the profile of men registered on the platform from the point of view of their socio-demographic and psychosocial characteristics, as well as their motivations for registering. The present study analyzed data collected in the Seintinelles 2018 Barometer study. A total of 5707 individuals, including 366 men completed the questionnaire. On average, men registered on the platform were older than women (mean age men = 42.4 years; mean age women = 40.1 years; p = .003) and less likely to currently have or previously had cancer (20.8 vs. 32.8%; p = .000). In terms of motivation to register, men were more likely to register because someone advised them to (5.7 vs. 3.2% of women, p = .01). Finally, women, more than men, appeared to want to see a greater number of new research studies implemented. Men—more than women—become volunteers to participate in research on the collaborative research platform Seintinelles to support a loved one.
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Background: Health literacy is a critical health determinant. To implement initiatives aiming at improving health literacy among children, adapted measurement tools are needed. Objective: This study aimed to translate, adapt, and test the Health Literacy Survey Child Questionnaire-15 (HLS-Child-Q15) to assess health literacy among French-speaking 8- to 11-year-old pupils. Methods: The HLS-Child-Q15 was translated and adapted to the French context to become the HLS-Child-Q15-FR. A cross-sectional survey was carried out using a written, self-reported questionnaire to assess the psychometric properties of the HLS-Child-Q15-FR. Key results: Translation and adaptation of the HLS-Child-Q15 German-French translated versions were cross-referenced. Back-translation led to minor refinements. Qualitative pre-test among children led to simplifications in wording and structure. Validation of the HLS-Child-Q15-FR. Four trained interviewers collected data among 3,107 pupils in 74 elementary schools of the Auvergne-Rhône-Alpes region. HLS-Child-Q15-FR showed good reliability (alpha = 0.83). Exploratory factor analysis showed a two-factor model related to health care and primary prevention. Construct validity analyses suggested removing 3 items. External validity analyses indicated a significant and moderate relationship with perceived self-efficacy. Conclusion: This study aimed to address the issue of measuring health literacy among French-speaking 8- to 11-year-old pupils. The HLS-Child-Q15-FR showed a high internal consistency. Statistics suggested a two-dimensional thematic scale. These findings should be further investigated. [HLRP: Health Literacy Research and Practice. 2023;7(3):e144-e153.].
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The purpose of this study was to investigate the factorial structure of the food selection related health literacy scale developed by the researchers in a previous study. The 16-item scale was evaluated on 160 individuals who were prescribed warfarin after heart valve surgery. The Kaiser Meyer Olkin (KMO) test was used to determine sample adequacy, and Bartlett's test was employed to determine whether the data were suitable for factor analysis. Exploratory factor analysis (EFA) using Varimax rotation and confirmatory factor analysis (CFA) was used to analyze the factorial structure. The KMO test result was 0.77, indicating the average sample adequacy. The Bartlett’s test of Sphericity gave a p-value of < 0.05, χ2 62.77, (df 127), demonstrating the data suitability for factor analysis. The EFA revealed that there were factors with eigenvalues greater than one that explained 59.93 percent of the variance. In the EFA, a new factor of the model has developed processing health literacy. However, the CFA produced a relative χ2 of 2.33, an SRMR of 0.08, an RMSEA of 0.09, a GFI of 0.84, and a CFI of 0.75. After model adjustment, the CFA recommended model 2, which consisted of 4 factors and 14 items and yielded a relative χ2 of 1.50, an SRMR of 0.06, an RMSEA of 0.06, a GFI of 0.92, and a CFI of 0.93. As a result, model 2 produced a superior model fit. This study indicated the need for further refinement of the factorial structure of the food selection related health literacy scale to be utilized among patients taking warfarin following heart valve surgery. Keywords: factorial structure analysis, health literacy, food selection, warfarin
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Background It has been about 30 years since the first health literacy instrument was developed. This study aimed to review all existing instruments to summarize the current knowledge on the development of existing measurement instruments and their possible translation and validation in other languages different from the original languages. Methods The review was conducted using PubMed, Web of Science, Scopus, and Google Scholar on all published papers on health literacy instrument development and psychometric properties in English biomedical journals from 1993 to the end of 2021. Results The findings were summarized and synthesized on several headings, including general instruments, condition specific health literacy instruments (disease & content), population- specific instruments, and electronic health. Overall, 4848 citations were retrieved. After removing duplicates (n = 2336) and non-related papers (n = 2175), 361 studies (162 papers introducing an instrument and 199 papers reporting translation and psychometric properties of an original instrument) were selected for the final review. The original instruments included 39 general health literacy instruments, 90 condition specific (disease or content) health literacy instruments, 22 population- specific instruments, and 11 electronic health literacy instruments. Almost all papers reported reliability and validity, and the findings indicated that most existing health literacy instruments benefit from some relatively good psychometric properties. Conclusion This review highlighted that there were more than enough instruments for measuring health literacy. In addition, we found that a number of instruments did not report psychometric properties sufficiently. However, evidence suggest that well developed instruments and those reported adequate measures of validation could be helpful if appropriately selected based on objectives of a given study. Perhaps an authorized institution such as World Health Organization should take responsibility and provide a clear guideline for measuring health literacy as appropriate.
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Background: Health literacy concerns the knowledge and competences of persons to meet the complex demands of health in modern society. Although its importance is increasingly recognised, there is no consensus about the definition of health literacy or about its conceptual dimensions, which limits the possibilities for measurement and comparison. The aim of the study is to review definitions and models on health literacy to develop an integrated definition and conceptual model capturing the most comprehensive evidence-based dimensions of health literacy. Methods: A systematic literature review was performed to identify definitions and conceptual frameworks of health literacy. A content analysis of the definitions and conceptual frameworks was carried out to identify the central dimensions of health literacy and develop an integrated model. Results: The review resulted in 17 definitions of health literacy and 12 conceptual models. Based on the content analysis, an integrative conceptual model was developed containing 12 dimensions referring to the knowledge, motivation and competencies of accessing, understanding, appraising and applying health-related information within the healthcare, disease prevention and health promotion setting, respectively. Conclusions: Based upon this review, a model is proposed integrating medical and public health views of health literacy. The model can serve as a basis for developing health literacy enhancing interventions and provide a conceptual basis for the development and validation of measurement tools, capturing the different dimensions of health literacy within the healthcare, disease prevention and health promotion settings.
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Nearly half of all American adults—90 million people—have difficulty understanding and acting upon health information. The examples below were selected from the many pieces of complex consumer health information used in America. • From a research consent form: “A comparison of the effectiveness of educational media in combination with a counseling method on smoking habits is being examined.” (Doak et al., 1996) • From a consumer privacy notice: “Examples of such mandatory disclosures include notifying state or local health authorities regarding particular communicable diseases.” • From a patient information sheet: “Therefore, patients should be monitored for extraocular CMV infections and retinitis in the opposite eye, if only one infected eye is being treated.” Forty million Americans cannot read complex texts like these at all, and 90 million have difficulty understanding complex texts. Yet a great deal of health information, from insurance forms to advertising, contains complex text. Even people with strong literacy skills may have trouble obtaining, understanding, and using health information: a surgeon may have trouble helping a family member with Medicare forms, a science teacher may not understand information sent by a doctor about a brain function test, and an accountant may not know when to get a mammogram. This report defines health literacy as “the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions” (Ratzan and Parker, 2000). However, health literacy goes beyond the individual obtaining information. Health literacy emerges when the expectations, preferences, and skills of individuals seeking health information and services meet the expectations, preferences, and skills of those providing information and services. Health literacy arises from a convergence of education, health services, and social and cultural factors. Although causal relationships between limited health literacy and health outcomes are not yet established, cumulative and consistent findings suggest such a causal connection. Approaches to health literacy bring together research and practice from diverse fields. This report examines the body of knowledge in this emerging field, and recommends actions to promote a health-literate society. Increasing knowledge, awareness, and responsiveness to health literacy among health services providers as well as in the community would reduce problems of limited health literacy. This report identifies key roles for the Department of Health and Human Services as well as other public and private sector organizations to foster research, guide policy development, and stimulate the development of health literacy knowledge, measures, and approaches. These organizations have a unique and critical opportunity to ensure that health literacy is recognized as an essential component of high-quality health services and health communication.
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Health literacy can influence long-term health outcomes. This study aimed to validate an adapted version of the Functional, Communicative and Critical Health Literacy measure for adolescent and young adult (AYA) cancer patients and survivors (N= 105; age 12–24 years). Exploratory factor analysis was used to validate the measure, and indicated that a slightly modified item structure better fit the results. Furthermore, item response theory analysis highlighted location and discrimination parameter differences among items. Acceptability of the measure was high. This is the first validation of a health literacy measure among AYAs with an illness such as cancer.
Objectives: Most people deal with intrusive life events such as cancer and the care trajectory together with their intimate partners. To our knowledge, no research has studied the involvement of the partner in the decision-making process regarding breast reconstruction (BR) after cancer. This study aimed to gain a better understanding of the couples' decision-making process for BR in the cancer context and particularly to investigate the partners' involvement in this process. Method: Eighteen participants (nine women who underwent a mastectomy following a first breast cancer and their intimate partners) took part in this study. We conducted semidirective interviews, and a general inductive approach was chosen to capture the representations of the couples. Results: The women in the sample were aged between 33 and 66 years (M = 54, SD = 7.5) and their partner between 40 and 76 years (M = 59, SD = 11.6). The duration of their intimate relationship was on average 18 years (SD = 10.4; minimum = 4; maximum = 33). The analysis revealed 11 major themes. The two most salient ones were 'external influence' and 'implication of the partner'. The exploration of the subthemes revealed that the decision-making process is often reported as an interrelated experience by the couples and as a dyadic stressor. The partner's role is depicted as consultative and mostly supportive. Conclusion: These results provide new insights on the involvement of the partner in decision-making. Thus, it now seems crucial to develop a prospective study, which will help understand the progression of the decision-making process over time. Statement of contribution What is already known on this subject? Most people deal with intrusive life events such as cancer and the care trajectory together with their intimate partners. Shared decision-making between patients and physicians is now the 'gold standard' in Western Europe and the United States. However, in the context of breast reconstruction (BR) after cancer, factors guiding the decision-making process for BR, especially the potential involvement of the partner, are not very well understood. What does this study add? Provides a qualitative insight on the specific nature of heterosexual couples' representations regarding the decision-making process for breast reconstruction after cancer. Reveals that the decision-making process is often reported as an interrelated experience by the couples and as a dyadic stressor. Underlines the consultative function of partners with women engaged in breast reconstruction.
The success of the Apgar score demonstrates the astounding power of an appropriate clinical instrument. This down-to-earth book provides practical advice, underpinned by theoretical principles, on developing and evaluating measurement instruments in all fields of medicine. It equips you to choose the most appropriate instrument for specific purposes. The book covers measurement theories, methods and criteria for evaluating and selecting instruments. It provides methods to assess measurement properties, such as reliability, validity and responsiveness, and interpret the results. Worked examples and end-of-chapter assignments use real data and well-known instruments to build your skills at implementation and interpretation through hands-on analysis of real-life cases. All data and solutions are available online. This is a perfect course book for students and a perfect companion for professionals/researchers in the medical and health sciences who care about the quality and meaning of the measurements they perform. © H. C. W. de Vet, C. B. Terwee, L. B. Mokkink and D. L. Knol 2011.
Background: The objectives of the study were to examine the prevalence of health literacy (HL) among colorectal cancer (CRC) survivors and the relation between HL and health behaviors and to explore whether or not HL and health behaviors are independently associated with health-related quality of life (HRQoL) and mental distress. Methods: This analysis is part of a longitudinal, population-based survey among CRC survivors diagnosed between 2000 and 2009 and registered by the Eindhoven Cancer Registry. Data collected during the second data wave was used (n = 1643; response rate 83%). Patients filled out a screening question on subjective functional HL, questions on health behaviors, HRQoL (European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire C30), and mental distress (Hospital Anxiety and Depression Scale). Results: Subjective HL was low among 14%, medium among 45%, and high among 42% of the participants. CRC survivors with low HL were more often smokers and did not meet the prescribed physical activity guidelines compared with survivors with medium or high HL. CRC survivors with low HL reported statistically significantly lower levels of mental and physical HRQoL and higher distress levels compared with survivors with medium and high HL. HL, in addition to sociodemographic and clinical characteristics and health behaviors, significantly explained 1.5-6.2% of the variance in HRQoL and mental distress levels. Partial mediation is indicated for HRQoL and feelings of depression, but not for anxiety. Conclusion: Low subjective functional HL among CRC survivors is associated with lower levels of physical activity, higher frequency of smoking, poorer HRQoL, and more mental distress. HL and health behaviors have both a unique as well as an overlapping contribution to the explained variances of HRQoL and mental distress.
Background The patients' task to find, evaluate and transfer health information to one's individual condition and life requires competences that are summarized by the term ‘health literacy’. Poor health literacy is associated with poorer health outcomes, like a higher rate of rehospitalization, lower receipt of screenings and a higher frequency of doctor visits.Objective Three levels of health literacy are distinguished: functional, communicative and critical health literacy. Aim of this study was to translate and adapt the ‘Functional Communicative Critical Health Literacy’ (FCCHL) questionnaire to German, and assess its psychometric properties.Methods/DesignThe FCCHL was sent to 9075 participants enrolled in a RCT on health coaching. 4040 participants responded. Besides descriptive and reliability analysis, confirmatory factor analysis was performed to test the questionnaire's postulated scale structure in a calibration (N = 3000) and a validation sample (N = 1040) for cross-validation.ResultsThe instrument was well accepted (missing values ≤2.1% per item) and showed acceptable or good internal consistency for the entire scale (α = 0.77) and the subscales (α = 0.75–0.80). The proposed three-factor model did not fit the German data sufficiently. As the scales ‘communicative health literacy’ and ‘critical health literacy’ showed high intercorrelation (0.98), they were combined to a new scale called ‘processing health literacy’. The fit indices for the amended two-factor model were satisfying in both subgroups.Conclusions Reliability and acceptance of the German FCCHL are satisfying. An amended two-factor structure showed better validity than the original factor structure. Further research regarding the FCCHL and the underlying construct is needed.