Summary of results
The present study investigated the psychometric properties of the Italian heiQ in adults with chronic conditions. Key findings included the evidence that a model with eight correlated dimensions showed good fit. A strength of this finding is that it further confirms that the heiQ has strong properties and can be used routinely also in the Italian healthcare contexts. In addition, evidence of good fit of the questionnaire is important in Italy, like in other European countries, where the relationship between the medical staff and the patients is still asymmetrical, and there is a need of tools with well-established properties capable to assess self-management skills. The inclusion of covariances between the residuals of some items improved the fit of the eight-correlated factor model. Covariances between within-scale residuals were added between the item 15 (“I feel like I am actively involved in life”) and the item 8 (“I am doing interesting things in my life”), both loading on 1. Positive and active engagement in life dimension. This improved result could be explained by the fact that the content of the two items is largely overlapping, since in the Italian language the translation of the statement “To be actively involved” is very similar to the translation of that one “To do interesting things”. Covariances were added also between the residuals of the item 32 (“I confidently give healthcare professionals the information”) loading on 6. Health service navigation and those of the item 16 (“When I have health problems, I have a clear understanding”) loading on 5. Self-monitoring and insight. It could be that for Italian patients, giving healthcare professionals information implies also having a clear understanding of their disease and symptoms, and maybe this overlapping between these two concepts could explain such result in the Italian version of the heiQ.
In addition, covariances were added also between the residuals of the item 3 (“As well as seeing my doctor, I regularly monitor changes in my health”) and those of the item 17 (“I carefully watch my health and do what is necessary to keep healthy”), which both loaded on the 5. Self-monitoring and insight. Probably, this overlap could be attributed to the presence of a very similar concept in the Italian translation of the items (i.e., the concept of checking health/changes in health). The two verbs “to monitor” and “to watch” can be translated in Italian with the same verb, since in Italian there is no distinction between the two verbs. This result was consistent with the finding reported in the German validation study [
11], where the inclusion of the covariances between these two items improved the model, as well. Covariances were added also between the residuals of the item 3 and those of the item 37 (“I get enough chances to talk about my health”).
Finally, covariances were added between the residuals of the item 34 (“My health problems do not ruin my life”) and those of the item 39 (“I do not let my health problems control my life”), which both loaded on 4. Constructive attitudes and approaches. It could be hypothesized that in the Italian translation the meaning of the term “problems” can determine the overlapping of the content in the two items.
Reliability, assessed as internal consistency, was acceptable for 1. Positive and active engagement in life, 4. Constructive attitudes and approaches, 3. Skill and technique acquisition, and 6. Health service navigation subscales. It was good for 2. Health directed activities, 8. Emotional distress, and 7. Social integration and support subscales. It should be noted that reliability for 5. Self-monitoring and insight was not acceptable and requires further evaluation.
Evidence about concurrent validity suggested that higher constructive attitudes and approaches were associated moderately with better physical functioning, perceived general health, vitality, social functioning, perceived mental health and lower role limitations due to physical and emotional problems. Higher self-monitoring and insight, health directed activities and social integration and support were associated with higher physical functioning, vitality and perceived mental health. Higher emotional distress was related to lower perceived general mental health, physical and social functioning.
However, concurrent validity was not supported by the absence of correlation between scores on 7. Social integration and support subscale and those on the SF-36 social functioning and by the almost weak correlation between emotional distress and perceived mental health.
Comparison with other transcultural validations
Overall, the present findings on structural validity appear in line with the validation studies in the other countries and settings [
6‐
12], conducted through highly restrictive tests such as confirmatory factor analyses, which suggested that the questionnaire performs well, the eight scales are distinct, despite it should be noted that the data rarely supported perfect fit and some items present intercorrelated residuals.
Values of reliability of the subscales were consistent with those shown in all the validation studies, conducted in Australia, Germany, Norway, The Netherlands, and France [
6‐
12]. The reliability value did not appear acceptable for 5. Self-monitoring and insight subscale and this result may be considered in line with the original study where it was borderline and also with the studies on other languages where it was not acceptable [
6].
Consistent with the study hypotheses and previous evidence [
11], to support convergent and divergent validity, moderate associations emerged between 1. Positive and active engagement in life, 4. Constructive attitudes and approaches, and 7. Social integration and support, moderate associations between 3. Skill and technique acquisition and 6. Health service navigation were found, and weak associations between 8. Emotional distress and all the other self-management skills emerged.
Overall, the findings about concurrent validity were in line with the study of Schuler et al. [
11] showing that 8. Emotional distress was negatively correlated with all the dimensions of perceived health status assessed by the SF-36 with correlations ranging from − 0.34 to − 0.62. The present results were consistent with that study [
11] reporting moderate associations between 1. Positive and active engagement in life, 4. Constructive attitudes and approaches, and (to a lesser extent) 3. Skill and technique acquisition and general health, social functioning, vitality and mental health outcomes. The present findings were in line also with the study by Schuler et al. [
11] where 5. Self-monitoring and insight, 6. Health service navigation and 2. Health directed activities were generally only weakly associated with health status outcomes.
In conclusion, the use of the heiQ may be introduced in Italian clinical contexts. For example, it may be useful for practitioners in healthcare services to assess whether a patient with a chronic condition needs to be included in a health education program focused on improving specific self-management skills with the aim to personalize care pathways.
Limits and future directions
A first issue concerns the heterogeneity of the sample which included patients with different chronic diseases and the relatively limited number of participants. Future research should provide additional evidence about the factor invariance of the scale across different diagnoses and should explore the model fit in other chronic conditions such as chronic pain diseases which are affected by a severe impairment in perceived health status [
27,
28]. In addition, despite acceptable fit was reached for the CFI and the TLI indices, as their values were equal to or higher than .90, good fit would require values equal to or higher than .95. Reliability indices were not acceptable for 5. Self-monitoring and insight subscale. Finally, other measures of concurrent validity may be used in further studies such as questionnaires aimed to assess health literacy, health locus of control, optimism, and self-efficacy [
29,
30].