Psychometric Analysis of the German Version of the Barriers to Healthcare Checklist—Short Form

Abstract

Background:

Autistic people face multiple barriers to health care. To recognize specific barriers in a standardized way, autistic people, health care providers, and researchers need a suitable measure. The Academic Autistic Spectrum Partnership in Research and Education successfully developed the Barriers to Healthcare Checklist—Short Form (BHC-SF). It remains unclear whether (1) a German version of the BHC-SF performs well in terms of psychometric properties and (2) the BHC-SF consists of multiple constructs (i.e., assessing structural validity).

Methods:

We created a translated and culturally adapted version of the 17-item BHC-SF and used it with 345 autistic people in Germany. Psychometric analyses included calculations to test for internal consistency reliability (Cronbach’s α) and construct validity (i.e., a priori hypothesis tests for correlations with previous treatment termination and statements about barriers to health care in terms of lack of knowledge, participation, autism-specific needs, lack of services, access/financing and collaboration). We conducted an exploratory factor analysis (EFA) to investigate the presence of BHC-SF subscales (i.e., structural validity) and performed reliability and validity calculations where appropriate.

Results:

The average BHC-SF total score was mean = 8.05 (standard deviation = 4.05), with more barriers for persons who identified as female compared with males. The BHC-SF total score revealed good internal consistency reliability (Cronbach’s α = 0.82). The assessment of construct validity mainly supported the hypothesized associations. The EFA identified four BHC-SF subscales, for which we found lower psychometric support with respect to internal consistency reliability and construct validity.

Conclusions:

The German version of the BHC-SF demonstrates good internal consistency reliability and construct validity. We identified four different constructs underlying the BHC-SF. The derived subscales need further psychometric testing. Use of the BHC-SF total score could potentially help health care providers and researchers systematically identify and address barriers to health care for autistic patients.

Community Brief

Why is this an important issue?

Autistic people often have trouble getting health care. A questionnaire about previous problems could help make appointments in the future easier and reduce barriers.

What was the purpose of this study?

The Barriers to Healthcare Checklist—Short Form (BHC-SF) is a short questionnaire developed by the Academic Autistic Spectrum Partnership in Research and Education. This questionnaire lists 17 barriers to healthcare that autistic people often face. People report whether or not they have experienced each barrier. The purpose of the study was to see if a German translation of the questionnaire works well. We also wanted to understand whether we should treat all barriers listed in the BHC-SF questionnaire as one big group or whether it is better to think of them as smaller groups.

What did the researchers do?

We created a German version of the BHC-SF questionnaire and tested it on 345 autistic adults. We counted the number of barriers each participant experienced (BHC-SF total score) and used these data to investigate if the BHC-SF total score changed with respect to age or gender. We checked the psychometric properties of the BHC-SF questionnaire (internal consistency reliability and construct validity) to see if the German version works well. In addition, we examined whether the BHC-SF questionnaire has subscales (representing smaller groups of barriers) and checked their psychometric properties (reliability and validity), too.

What were the results and conclusions of the study?

We successfully developed a German version of the BHC-SF questionnaire. The mean number of reported barriers was 8 out of 17. Women reported more barriers to health care than men. The psychometric analyses revealed very good results regarding the test’s global ability to measure barriers to health care. As predicted, people who reported more barriers in the BHC-SF questionnaire more often reported treatment termination and higher agreement with other statements about barriers to health care (i.e., in terms of lack of knowledge, autism-specific needs, and access/financing). Thus, the BHC-SF total score seems to be a good tool to assess barriers to health care in a structured way. In addition, we identified four potential BHC-SF subscales, reflecting different types of barriers. However, the results of psychometric analyses for these subscales were not as strong. Further research is needed to check if these subscales can be improved. In conclusion, the German version of the BHC-SF works well and is a brief tool for identifying barriers to health care for autistic people. Use of the BHC-SF could provide health care professionals with important information about barriers experienced by autistic people.

What is new or controversial about these findings?

This is the first assessment of the German translation of the BHC-SF. At the moment, it seems more reasonable to see the barriers listed in the BHC-SF as one large group. We found the first hints that different smaller groups are represented in the BHC-SF list, but the questionnaire’s structure might need improvement to reliably measure them.

What are potential weaknesses in the study?

The results reflect only a subsample of autistic people who were able to participate in a comprehensive online survey.

How will these findings help autistic adults now or in the future?

A better understanding of barriers to health care can help health care professionals try to improve access to health care and reduce barriers for autistic people.