Journal of Health Literacy

Journal of Health Literacy

Reliability and Validity of the Persian Version of the Short Health Literacy Questionnaire for Musculoskeletal Patients

Document Type : Original Article

Authors
Hanieh Jormand 1
Zahra Basiri 2
Majid Barati 3
Mahzad Roostaei 1
Salman Khazaei 4
Nafiseh Mohebinazar 5
1 Urology and Nephrology Research Center, Hamadan University of Medical Sciences, Hamadan, IR, Iran
2 Department of Rheumatology, School of Medicine, Hamadan University of Medical Science, Hamadan, Iran.
3 Social Determinants of Health Research Center, Hamadan University of Medical Sciences Hamadan, IR, Iran.
4 Research Center for Health Sciences, Hamadan University of Medical Sciences, Hamadan, Iran.
5 Department of Nursing, Faculty of Nursing, Hamadan University of Medical Sciences, Hamadan, Iran.
10.22038/jhl.2025.89954.1824
Abstract
Background and Objective: This study aimed to evaluate the reliability and validity of the Persian version of the osteoarthritis short health literacy questionnaire (OSHL) for musculoskeletal patients (LiMP) among individuals with osteoarthritis in Iran.

Material and Methods: A cross-sectional validation study was conducted with 420 patients aged 45–75 years, recruited from the rheumatology clinic of Shahid Beheshti Hospital in Hamadan. The LiMP questionnaire underwent a rigorous translation and back-translation process. Psychometric evaluation included assessments of face validity (qualitative interviews and item impact scores), content validity (expert panel review, Content Validity Ratio [CVR], and Content Validity Index [CVI]), and construct validity (exploratory and confirmatory factor analyses). Reliability was examined using Cronbach’s alpha for internal consistency and the intraclass correlation coefficient (ICC) for test-retest stability.

Results: The Persian LiMP demonstrated strong face and content validity, with all items achieving impact scores above 1.5, a CVR of 0.86, and a CVI of 0.95. Exploratory factor analysis identified a three-factor structure: Musculoskeletal Conditions, F2: Musculoskeletal Diagnosis and treatment, and F3:Anatomy and terminology; accounting for 71.07% of the variance, confirmed by confirmatory factor analysis with good model fit indices (e.g., the Comparative Fit Index  = 0.962, the root mean square error of approximation = 0.083). All subscales showed high internal consistency (Cronbach’s alpha > 0.70) and satisfactory test-retest reliability (mean the Intraclass correlation coefficient = 0.789). Convergent and discriminant validity were generally supported.

Conclusions: The Persian version of the LiMP for musculoskeletal patients is a reliable and valid instrument for assessing health literacy in this population. Its use can facilitate targeted interventions and improve patient outcomes. 
Keywords
Musculoskeletal
Health literacy
Psychometric properties

Acknowledgements: We express appreciation to the participants in this study.


Availability of Data and Materials: The datasets used and/or analyzed during the current study can be made available by the corresponding author on reasonable request.


Conflicts of interest: The authors have no conflicts of interest to declare.


Consent for publication: Not applicable.


Ethical Approval and consent to participate: The study procedures were carried out following the Declaration of Helsinki. This study was approved by the Ethics Committee of Hamadan University of Medical Sciences with special code IR.UMSHA.REC.1401.390. Informed consent was taken from all the participants. There was an emphasis on maintaining privacy in keeping and delivering the information accurately without mentioning the names of the participants. 


Funding: The present study was approved by the Vice-Chancellor for Research and Technology of Hamadan University of Medical Sciences (No, 140105183544), which participated in the financial support of this study. This funding source had no role in the analysis and interpretation of data, in the article's writing, nor in the decision to submit it for publication.


Author Contributions: Authors’ contributions H.J, Z.B, M.B, S.KH, M.R and N.M.N conceived and designed the study. H.J, M.B, S.KH,and Z.B analyzed and interpreted the data, and drafted the manuscript. H.J, Z.B, M.B and S.KH were involved in the composition of the study tool, supervision of the research process, and critical revision and review of the manuscript. All the authors read and approved the final manuscript.

 

Open Access Policy: This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited.To view a copy of this licence, visit https://creativecommons.org/licenses/by/4.0/

  1. Lacey RJ, Campbell P, Lewis M, Protheroe J. The Impact of Inadequate Health Literacy in a Population with Musculoskeletal Pain. Health literacy research and practice. 2018;2(4):e215-e20. https://doi.org/10.3928/24748307-20181101-01 PMid:31294297 PMCid:PMC6608902
  2. Loke YK, Hinz I, Wang X, Rowlands G, Scott D, Salter C. Impact of health literacy in patients with chronic musculoskeletal disease–systematic review. PloS one. 2012;7(7):e40210. https://doi.org/10.1371/journal.pone.0040210 PMid:22792242 PMCid:PMC3391211
  3. Lum ZC, Lyles CR. What’s Important: Health Literacy in Orthopaedics. JBJS. 2024;106(21):2042-4. https://doi.org/10.2106/JBJS.24.00367 PMid:38896658 PMCid:PMC11554245
  4. Kirchner GJ, Kim RY, Weddle JB, Bible JE. Can artificial intelligence improve the readability of patient education materials? Clinical Orthopaedics and Related Research®. 2023;481(11):2260-7. https://doi.org/10.1097/CORR.0000000000002668 PMid:37116006 PMCid:PMC10566892
  5. Edwards PK, Mears SC, Lowry Barnes C. Preoperative education for hip and knee replacement: never stop learning. Current reviews in musculoskeletal medicine. 2017;10(3):356-64. https://doi.org/10.1007/s12178-017-9417-4 PMid:28647838 PMCid:PMC5577053
  6. Rosenbaum AJ, Tartaglione J, Abousayed M, Uhl RL, Mulligan MT, Alley Jr M, et al. Musculoskeletal Health Literacy in Patients With Foot and Ankle Injuries: a cross-sectional survey of comprehension. Foot & Ankle Specialist. 2016;9(1):31-6. https://doi.org/10.1177/1938640015593078 PMid:26123548
  7. Johnson CK, Alley MC, Talwar A, Tirrell J, Leinhart A, Pauze DR, et al. Does musculoskeletal health literacy differ between urban and rural orthopaedic patients? Current Orthopaedic Practice. 2017;28(6):544-8. https://doi.org/10.1097/BCO.0000000000000562
  8. Narayanan AS, Stoll KE, Pratson LF, Lin F-C, Olcott CW, Del Gaizo DJ. Musculoskeletal health literacy is associated with outcome and satisfaction of total knee arthroplasty. The Journal of Arthroplasty. 2021;36(7):S192-S7. https://doi.org/10.1016/j.arth.2021.02.075 PMid:33812715
  9. Sousa VD, Rojjanasrirat W. Translation, adaptation and validation of instruments or scales for use in cross‐cultural health care research: a clear and user‐friendly guideline. Journal of evaluation in clinical practice. 2011;17(2):268-74. https://doi.org/10.1111/j.1365-2753.2010.01434.x PMid:20874835
  10. Bundgaard K, Brøgger MN. Who is the back translator? An integrative literature review of back translator descriptions in cross-cultural adaptation of research instruments. Perspectives. 2019;27(6):833-45. https://doi.org/10.1080/0907676X.2018.1544649
  11. Colton D, Covert RW. Designing and constructing instruments for social research and evaluation: John Wiley & Sons; 2015. Access in : https://scholar.google.com/scholar_lookup?hl=en&publication_year=2015&author=D.+Colton&author=R.+W.+Covert&title=Designing+and+constructing+instruments+for+social+research+and+evaluation
  12. Taghizadeh Z, Ebadi A, Montazeri A, Shahvari Z, Tavousi M, Bagherzadeh R. Psychometric properties of health related measures. Part 1: Translation, development, and content and face validity. Payesh (Health Monitor). 2017;16(3):343-57.
  13. Hajizadeh E AM. Statistical methods and analyses in health and biosciences: a research methodological approach using SPSS guide. 1st ed: Tehran: Publications of the Academic Jihad Organization; 2011.
  14. Lenz E. Measurement in nursing and health research: Springer publishing company; 2010.Access in: https://scholar.google.com/scholar?hl=en&as_sdt=0%2C5&q=Lenz+E.+Measurement+in+nursing+and+health+research%3A+Springer+publishing+company+%3B+2010&btnG=Az123rte
  15. Lawshe CH. A quantitative approach to content validity. Personnel psychology. 1975;28(4). https://doi.org/10.1111/j.1744-6570.1975.tb01393.x
  16. Chaleshgar kordasiabi M, Akhlaghi M, Askarishahi M, Sabzmakan L, Abbasi shavazi M. Quality of life and Related Factors in Rheumatoid Arthritis Patients. Journal of health research in community.2(3):1-11.
  17. Worthington RL, Whittaker TA. Scale development research: A content analysis and recommendations for best practices. The counseling psychologist. 2006;34(6):806-38. https://doi.org/10.1177/0011000006288127
  18. Ebadi A, Taghizadeh Z, Montazeri A, Shahvari Z, Tavousi M, Bagherzadeh R. Translation, development and psychometric properties of health related measures-Part 2: construct validity, reliability and responsiveness. Payesh (Health Monitor). 2017;16(4):445-55.
  19. Plichta SB, Kelvin EA. Munro's Statistical Methods for Health Care Research: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2012. Access in : https://books.google.com/books?id=iLpSXwAACAAJ
  20. Ebadi A, Zarshenas L, Rakhshan M, Zareiyan A, Sharifnia S, Mojahedi M. Principles of scale development in health science. Tehran: Jame-e-negar. 2017;6(1):402.
  21. Osborne JW. Best practices in quantitative methods: Sage; 2008. https://doi.org/10.4135/9781412995627
  22. Osborne J, Costello A, Kellow J. Best practices in exploratory factor analysis (pp. 86-99). Louisville, KY: CreateSpace Independent Publishing Platform. 2014;10(9781412995627):d8. https://doi.org/10.4135/9781412995627.d8
  23. Child D. The essentials of factor analysis: A&C Black; 2006.
  24. Field A. Discovering statistics using spss. 3rd edn SAGE Publications Limited: London. The UK. 2009.
  25. Kline RB. Principles and practice of structural equation modeling: Guilford publications; 2023.
  26. Marsh HW, Hau K-T, Wen Z. In search of golden rules: Comment on hypothesis-testing approaches to setting cutoff values for fit indexes and dangers in overgeneralizing Hu and Bentler's (1999) findings. Structural equation modeling. 2004;11(3):320-41. https://doi.org/10.1207/s15328007sem1103_2
  27. Hu Lt, Bentler PM. Cutoff criteria for fit indexes in covariance structure analysis: Conventional criteria versus new alternatives. Structural equation modeling: a multidisciplinary journal. 1999;6(1):1-55. https://doi.org/10.1080/10705519909540118
  28. Tavousi M, Haeri-Mehrizi A, Rakhshani F, Rafiefar S, Soleymanian A, Sarbandi F, et al. Development and validation of a short and easy-to-use instrument for measuring health literacy: the Health Literacy Instrument for Adults (HELIA). BMC public health. 2020;20(1):656. https://doi.org/10.1186/s12889-020-08787-2 PMid:32397970 PMCid:PMC7216550
  29. Fornell C, Larcker DF. Evaluating structural equation models with unobservable variables and measurement error. Journal of marketing research. 1981;18(1):39-50. https://doi.org/10.2307/3151312
  30. Yen M, Lo L-H. Examining test-retest reliability: an intra-class correlation approach. Nursing research. 2002;51(1):59-62. https://doi.org/10.1097/00006199-200201000-00009 PMid:11822570
  31. Kor PPK, Yu CTK, Li Y, Tsang APL, Tan LHZ, Lam SC, et al. Development and validation of a health literacy scale for family caregivers of older people with chronic illness. BMC nursing. 2024;23(1):447. https://doi.org/10.1186/s12912-024-02057-x PMid:38951836 PMCid:PMC11218080
  32. Rosenbaum AJ, Pauze D, Pauze D, Robak N, Zade R, Mulligan M, et al. Health literacy in patients seeking orthopaedic care: results of the literacy in musculoskeletal problems (LIMP) project. The Iowa orthopaedic journal. 2015;35:187.
  33. Gruson K, Mahmoud S, Zhu N, Lo Y, Gruson HT, Schwartz B. The relationship between musculoskeletal health literacy and upper extremity patient-reported outcome measures (PROMs) in the setting of atraumatic shoulder pain. Orthopaedics & Traumatology: Surgery & Research. 2022;108(5):103165. https://doi.org/10.1016/j.otsr.2021.103165 PMid:34871797
  34. Briere JL. Determining the Psychometric Properties of the Retrieval-Induced Forgetting Procedure: University of Saskatchewan; 2011. https://doi.org/10.1037/e520602012-950
  35. Oliveira L, Zandonadi RP, Nakano EY, Almutairi S, Alzghaibi H, Lima MJ, et al., editors. From validation to assessment of e-health literacy: a study among higher education students in Portugal. Healthcare; 2024: MDPI. https://doi.org/10.3390/healthcare12161626 PMid:39201184 PMCid:PMC11353653
  36. Rababah JA, Al-Hammouri MM, Aldalaykeh M. Validation and measurement invariance of the Arabic Health Literacy Questionnaire. Heliyon. 2022;8(4):e09301. https://doi.org/10.1016/j.heliyon.2022.e09301 PMid:35497048 PMCid:PMC9043993
  37. Avidan MS, Ioannidis JPA, Mashour GA. Independent discussion sections for improving inferential reproducibility in published research. British Journal of Anaesthesia. 2019;122(4):413-20. https://doi.org/10.1016/j.bja.2018.12.010 PMid:30857597 PMCid:PMC6435840
  38. Phanniphong K, Na-Nan K. Development and validation of a factor analysis-validated comprehensive scale for measuring innovative work behavior. Sustainable Futures. 2025;9:100704. https://doi.org/10.1016/j.sftr.2025.100704
  39. Paudel S, Chalise A, Shakya P, Bhandari TR. Development and validation of Mental Health Literacy Assessment Scale among community health workers in Nepal. SAGE open medicine. 2025;13:20503121251341423. https://doi.org/10.1177/20503121251341423 PMid:40529609 PMCid:PMC12171251
  40. Rönkkö M, Cho E. An updated guideline for assessing discriminant validity. Organizational research methods. 2022;25(1):6-14. https://doi.org/10.1177/1094428120968614
  41. Kor PPK, Yu CTK, Li Y, Tsang APL, Tan LHZ, Lam SC, et al. Development and validation of a health literacy scale for family caregivers of older people with chronic illness. BMC nursing. 2024;23(1):447. https://doi.org/10.1186/s12912-024-02057-x PMid:38951836 PMCid:PMC11218080
  42. Kripalani S, Jacobson TA, Mugalla IC, Cawthon CR, Niesner KJ, Vaccarino V. Health literacy and the quality of physician‐patient communication during hospitalization. Journal of hospital medicine. 2010;5(5):269-75. https://doi.org/10.1002/jhm.667 PMid:20533572 PMCid:PMC3468649
  43. Wang C, Lang J, Xuan L, Li X, Zhang L. The effect of health literacy and self-management efficacy on the health-related quality of life of hypertensive patients in a western rural area of China: a cross-sectional study. International journal for equity in health. 2017;16(1):58. https://doi.org/10.1186/s12939-017-0551-9 PMid:28666443 PMCid:PMC5493849
  44. Shahid R, Shoker M, Chu LM, Frehlick R, Ward H, Pahwa P. Impact of low health literacy on patients' health outcomes: a multicenter cohort study. BMC health services research. 2022;22(1):1148. https://doi.org/10.1186/s12913-022-08527-9 PMid:36096793 PMCid:PMC9465902
  45. Rademakers J, Heijmans M. Beyond reading and understanding: health literacy as the capacity to act. International journal of environmental research and public health. 2018;15(8):1676. https://doi.org/10.3390/ijerph15081676 PMid:30087254 PMCid:PMC6121645
  46. Petrič G, Atanasova S. Validation of the extended e-health literacy scale: structural validity, construct validity and measurement invariance. BMC Public Health. 2024;24(1):1991. https://doi.org/10.1186/s12889-024-19431-8 PMid:39054541 PMCid:PMC11271034