BACKGROUND: Sufficient communicative health literacy (COM-HL) is important for patients actively participating in dialogue with physicians, expressing their needs and desires for treatment, and asking clarifying questions. There is a lack of instruments combining communication and HL proficiency. Hence, the aim was to establish an instrument with sufficient psychometric properties for measuring COM-HL. METHODS: The HLS19-COM-P instrument was developed based on a conceptual framework integrating HL with central communicative tasks. Data were collected using different data collection modes in nine countries from December 2019 to January 2021 (n = 18,674). Psychometric properties were assessed using Rasch analysis and confirmatory factor analysis. Cronbach's alpha and Person separation index were considered for reliability. RESULTS: The 11-item version (HLS19-COM-P-Q11) and its short version of six items (HLS19-COM-P-Q6) fit sufficiently the unidimensional partial credit Rasch model, obtained acceptable goodness-of-fit indices and high reliability. Two items tend to under-discriminate. Few items displayed differential item functioning (DIF) across person factors, and there was no consistent pattern in DIF across countries. All items had ordered response categories. CONCLUSIONS: The HLS19-COM-P instrument was well accepted in nine countries, in different data collection modes, and could be used to measure COM-HL.

Aix Marseille University APHM INSERM IRD ISSPAM SESSTIM Cancer Biomedicine and Society Group Ligue 2019 Accredited Team F 13009 Marseille France

Communication Unit National Institute of Public Health Trubarjeva 2 1000 Ljubljana Slovenia

Competence Centre for Health Promotion and Health System Austrian National Public Health Institute A 1010 Vienna Austria

Czech Health Literacy Institute Sokolská 490 31 120 00 Prague Czech Republic

Department of Health and Nursing Sciences Faculty of Social and Health Sciences Inland Norway University of Applied Sciences P O Box 400 2418 Elverum Norway

Department of Public Health and Epidemiology Faculty of Medicine University of Debrecen H 4028 Debrecen Hungary

Department of Public Health and Epidemiology Sciensano 1050 Brussels Belgium

Department of Quality Measurement and Patient Survey Austrian National Public Health Institute A 1010 Vienna Austria

Interdisciplinary Centre for Health Literacy Research [ICHL] School of Public Health Bielefeld University 33615 Bielefeld Germany

Public Health and Epidemiology Department of Health Science and Technology Aalborg University 9220 Aalborg Denmark

WHO CC Health Promotion in Hospitals and Health Care Austrian National Public Health Institute A 1010 Vienna Austria

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HLS19-DIGI - a new instrument for measuring digital health literacy: development, validation and associations with determinants and health outcomes in 13 countries

Communicative health literacy and associated variables in nine European countries: results from the HLS19 survey