Adaptation and validation of the Japanese version of the Health Education Impact Questionnaire (heiQ-J) for the evaluation of self-management education interventions


  • Conflict of interest: none.


Aim:  In many countries, health education interventions are popular; however, few valid measures exist for evaluation of multifactorial interventions. The aim of the present study was to translate and culturally adapt the widely-used 8 scale Health Education Impact Questionnaire (heiQ) for the evaluation of the Japanese Specific Health Consultation (SHC) in people with metabolic syndrome.

Methods:  A draft was generated using a standardized forward and back translation protocol with independent translators and consensus meetings. Pilot testing included cognitive interviews (n = 12) resulting in question refinements. To explore psychometric properties, 250 participants aged between 40 and 64 years (retest = 116) completed the Japanese version of the heiQ (heiQ-J) and comparator scales, mental health and vitality scales of the Medical Outcomes Study 36 item Short-Form Health Survey, Sense Of Coherence scale, and Social Support Measurement scale.

Results:  Cognitive interviews revealed that the translation was understood as intended by participants. Internal consistency (α) was good to very good for all scales (0.70–0.88) and test–retest intraclass correlation coefficients were high (≥0.83). Concurrent validity was supported by high correlation with like scales and weak correlation with dissimilar scales.

Conclusion:  The translated and adapted heiQ-J has good face and concurrent validity and is reliable. The heiQ-J is likely to be a useful measure of the quality and impact of the SHC and return valuable data to clinicians and commissioners of health education in Japan.


The number of people suffering from chronic disease has been increasing in recent years across developed and developing countries (Hoffman, Rice, & Sung, 1996; Newman, Steed, & Mulligan, 2004). According to a nationwide survey regarding the incidence of diabetes in Japan (Japan Ministry of Health, Labour and Welfare, 2007), the number of people who are suspected to be diabetic or who are already receiving treatment for diabetes has rapidly risen from 7.4 million people in 2002 to 8.9 million in 2007. This is an increase of approximately 20% in a 5 year period. To manage this growing problem, a new health policy targeting metabolic syndrome (MetS) was legislated by the Japanese Ministry of Health, Labor and Welfare in 2008 (Japan Ministry of Health, Labor and Welfare, 2008). The main elements of this policy are Specific Medical Examination (SME) and Specific Health Consultation (SHC), with the former being offered to people aged between 40 and 74 years, and the latter being provided to people who have been identified as having MetS risk factors.

The causes of many common chronic diseases are related to diet, physical activity, and other lifestyle factors, where self-management and self-monitoring behaviors often determine the symptoms and the prognosis of the disease (Kawaguchi, 1993). To address this challenge, many developed countries have begun to adopt self-management education programs (Newman et al., 2004; Osborne, Batterham, & Livingston, 2011). These are gaining in popularity because of their potential to improve the health of those affected by chronic disease as well as their potential to reduce medical costs.

Evaluation of self-management programs often includes clinical outcomes. However, such effects are not necessarily observed due to weak intervention and study design, short follow-up periods, and problematic evaluation tools (Warsi, LaValley, Wang, Avorn, & Solomon, 2003; Warsi, Wang, LaValley, Avorn, & Solomon, 2004). Therefore, there is an increasing need for precise evaluation of self-management program outcomes (Osborne et al., 2011). Faced with a similar lack of appropriate instruments in Australia, Osborne and colleagues developed the Health Education Impact Questionnaire (heiQ) in 2007 to improve the measurement of outcomes of self-management education interventions (Nolte, Elsworth, Sinclair, & Osborne, 2007; Osborne, Elsworth, & Whitfield, 2007). The heiQ was developed through extensive stakeholder consultation and consists of eight independent scales. The most prominent feature of the heiQ is its breadth and its capability of evaluating individuals' ability to manage their chronic condition irrespective of the type of underlying disease.

Metabolic syndrome is a complex range of major risk factors for chronic disease and the aim of the SHC was developed to reduce the risk of chronic disease and improve health outcomes in affected individuals (Japan Ministry of Health, Labor and Welfare, 2008). Importantly, the SHC is outcome-focused. However, the evaluation of outcomes alone is considered insufficient to evaluate the quality of health service delivery. Instead, a combined evaluation of outcomes and the health consultation process is believed to be necessary (Hasegawa, 2002). In view of the considerable overlap between the SHC and self-management education, the present authors recognized the potential of using the heiQ to evaluate the SHC intervention in Japan. MetS, which is the focus of the SHC, is an early stage of lifestyle-related diseases. Compared with the subjects used in the initial development of the heiQ, subjects with MetS may only be consciously aware of a few specific symptoms. In this study, to enable subjects to respond to all heiQ items appropriately, regardless of whether they were aware of the presence of symptoms or their health status, small changes were made to the original questionnaire to ensure the Japanese version was widely applicable across asymptomatic and symptomatic conditions. The aim of the current study, therefore, was to adapt and validate a Japanese version of the heiQ (heiQ-J) for the evaluation of the SHC.


Health Education Impact Questionnaire

The heiQ was developed as a comprehensive evaluation tool to measure the impact of self-management education programs. To date, it has been translated into 20 languages, including German, Italian, Spanish, Mandarin, and Arabic (Osborne et al., 2011). The process of developing the heiQ involved stakeholder interviews, concept mapping workshops, and extensive calibration and validation phases in which the final set of items was tested on two large community samples (Nolte et al., 2007; Osborne et al., 2007).

The revised heiQ ver. 2.0 was used for the Japanese study. It consists of 43 items describing the following eight scales (see Table 1): (i) health-directed activity (four items); (ii) positive and active engagement in life (five items); (iii) emotional distress (six items); (iv) self-monitoring and insight (seven items); (v) constructive attitudes and approaches (five items); (vi) skill and technique acquisition (six items); (vii) social integration and support (five items); and (viii) health service navigation (five items). Response options range from “strongly disagree” to “strongly agree” on a 4 point Likert scale where each scale is standardized to range 1–4. The initial validation of the heiQ was undertaken in people with the following conditions: osteoarthritis (42%); rheumatoid arthritis (23%); anxiety/depression (20%); asthma (17%); heart disease (17%); osteoporosis (16%); diabetes (12%); fibromyalgia (10%); and cancer (4%) (Osborne et al., 2007). The heiQ has undergone extensive psychometric testing across chronic conditions and was found to have a robust psychometric structure (Nolte, Elsworth, Sinclair, & Osborne, 2009). The heiQ has been used in studies with people with osteoporosis (Francis, Matthews, Van Mechelen, Bennell, & Osborne, 2009), stroke (Cadilhac et al., 2011), arthritis (Ackerman, Buchbinder, & Osborne, 2012), and is currently being validated in other countries such as Germany, the Netherlands, and Denmark in people with cancer, chronic pain, heart disease, inflammatory bowel disease, obesity, orthopedic conditions, psoriasis, and respiratory disease.

Table 1. Health Education Impact Questionnaire domains, keywords, and descriptors
Health-directed activity
Key words: healthful behaviors, walking, exercise, relaxation.
This construct relates to the level of functional activity incorporated into lifestyle. The activities may be aimed at either disease prevention and/or health promotion. Many people with chronic conditions do very little or no exercises and this scale is designed to detect small but tangible improvements.
Positive and active engagement in life
Key words: engaged in life, positive affect.
This construct covers motivation to be active and embodies the notion of participants in self-programs engaging or re-engaging in life-fulfilling activities as a result of program involvement. It includes both behavioral elements (participation in life activities) and psychological elements (enthusiasm for life activities).
Emotional distress
Key words: health-related negative affect, anxiety, stress, anger, depression.
This construct measures negative affective responses to illness, including anxiety, anger, and depression (which are attributed to health). The items in this construct are reversed.
Self-monitoring and insight
Key words: self-monitoring, setting reasonable targets, insight into living with a health problem.
This construct captures how an individual engages in self-monitoring of their condition. An important component of this construct is the individuals' acknowledgment of realistic disease-related limitations, and the ability and confidence to adhere to these limits. This may also relate to the monitoring of specific subclinical indicators of disease status.
Constructive attitudes and approaches
Key words: positive attitude, sense of control, empowerment.
This construct is embodied in the statement “I am not going to let this disease control my life” and includes a shift in how individuals' view the impact of their condition(s) on their life.
Skill and technique acquisition
Key words: symptom relief skills, skills and techniques to manage own health.
This construct aims to capture change in the knowledge-based skills and techniques (including the use of equipment) that participants acquire or re-learn to help them manage with disease-related symptoms and health problems.
Social integration and support
Key words: feelings of social isolation as a result of the illness, sense of support, seeking support from others.
This construct aims to capture the positive impact of social engagement and support that evolves through interactions with others. It also involves the confidence to seek support from interpersonal relationships as well as from community-based organizations.
Health service navigation
Key words: communication, decision processes, relationships with health professionals.
This construct is concerned with an individual's understanding of, and ability to confidently interact with, a range of health organizations and health professionals. Further, it measures the confidence and ability to communicate and negotiate with healthcare providers to get needs met.

Translation and cultural adaptation of the heiQ-J

Primary forward translation from international English was performed by three translators, each working independently according to the standard heiQ protocol (Hawkins M & Osborne R. H., unpublished manuscript, Questionnaire translation and cultural adaptation procedure. Version 1.0, 2007): a bilingual nursing educator with work experience in the USA, a bilingual nursing academic with expert language skills, and an author (R. H. O.). The veracity of the primary translation was then evaluated by three additional clinical academics. As a second step, the translators of the primary translation discussed apparent differences between the translated versions. After they agreed on a final version, a professional translator was commissioned to carry out a back translation of the Japanese heiQ into English.

Minor improvements and clarifications were negotiated during a comprehensive consensus meeting, chaired by the developer, between the Japanese team and a psychometrician.

Pilot study

The study was approved by the Ethics Committee of the Division of Health Sciences, Osaka, University Graduate School of Medicine, and the International University of Health and Welfare Ethics Committee.

The draft Japanese heiQ was administered to a convenience sample of 52 people aged 40–65 years between January and March 2008. A 10 day follow-up survey was also administered to evaluate test–retest reliability.

Cognitive interviews were conducted to evaluate whether the questions were understood as intended and to evaluate appropriateness of the heiQ in the Japanese context. The interviews were conducted with eight men and eight women where all the items in the questionnaire were tested in a structured interview (Adamson, Gooberman-Hill, Woolhead, & Donovan, 2004).

Participants first completed a paper-based version of the heiQ-J and then they were asked questions about their answer. For those items that the interviewees considered difficult, they were asked to elaborate on what was problematic and then how they thought the items could be improved. The interview sought to understand if the heiQ-J items were hard to understand and whether they were potentially offensive or culturally inappropriate, and how the wording could be improved. The results of the pilot study were evaluated by the primary translation team and the draft heiQ-J was revised accordingly.

Validation studies

Recruitment and sample size

Participants were recruited by email from a database of registrants held by a market research firm (GOO Research P/L; NTT Resonant, Tokyo, Japan) in July 2008. Within 48 h, 250 participants had been recruited and had completed the heiQ-J online. All respondents were then invited to take part in the second online survey 10 days later as part of the test–retest survey. A total of 116 participants took part in the follow-up survey. There were no significant differences in the data between the full sample and the retest group.

Comparator questionnaires

For assessment of concurrent validity of the heiQ-J scales, several other questionnaires were administered that are well-validated in the Japanese context.

The Medical Outcomes Study 36 item Short-Form Health Survey (SF-36) is a widely used eight scale general health status measure (Hays, Sherbourne, & Mazel, 1993). The reliability and validity of the Japanese version has been reported (Fukuhara, Bito, Green, Hsiao, & Kurokawa, 1998; Fukuhara, Ware, Kosinski, Wada, & Gandek, 1998). Only the mental health (MH) and vitality (VT) scales were administered. Given the item content and construct definitions of each scale, the authors hypothesized that the MH scale would be strongly related to the following heiQ scales: positive and active engagement in life, emotional distress, and constructive attitudes and approaches. Similarly, the authors hypothesized that the VT scale would highly correlate with the heiQ-J scales of health-directed activity, positive and active engagement in life, emotional distress, constructive attitudes and approaches, and skill and technique acquisition.

The Sense of Coherence scale (SOC) is a core construct of a salutogenic theoretical model proposed by Antonovsky (1993) which is concerned with the relationship between health, stress, and coping. Antonovsky) describes the SOC as “a global orientation that expresses the extent to which one has a pervasive, enduring though dynamic feeling of confidence that (i) the stimuli deriving from one's internal and external environments in the course of living are structured, predictable, and explicable; (ii) the resources are available to one to meet the demands posed by these stimuli; and (iii) these demands are challenges worthy of investment and engagement” (Antonovsky, 1993, p. 725). The present authors used the short SOC-13 scale (13 items, three factors) with the following factors: (i) comprehensibility; (ii) manageability; and (iii) meaningfulness. The SOC-13 has been translated into over 10 languages, including Japanese, and has been studied by Yamazaki (1999). It was considered that the SOC-13 would relate to stress coping ability and be comparable with the heiQ-J scale of constructive attitudes and approaches.

The Social Support Measurement (SSM) scale, developed by Dahlem, Zimet, and Walker (1991), covers: (i) support from family; (ii) support from friends; and (iii) support from significant others (Dahlem et al., 1991). The seven item version from which the reliability and validity have been confirmed was used (Iwasa et al., 2007). Based on the work of Shima (2001) who considers that “psychological or substantial support can be obtained from various people surrounding oneself” and that “social support will improve one's mental and physical health and the adaptive state”, it was hypothesized that the SSM scale would be most highly correlated with social integration and support.

Statistical methods

For the reliability analysis, the intraclass correlation coefficient (ICC) and Spearman's rho were used. Further, internal consistency was evaluated using Cronbach's alpha. Concurrent validity analyses were undertaken by computing Spearman's correlation coefficients between the heiQ-J scales and the comparator questionnaires: SF-36; SOC; and SSM. The following ranges were used to qualify the strength of correlations of the heiQ-J with other measures: 0.1 to less than 0.3, small; 0.3 to less than 0.5, medium; and 0.5 or more, large (Cohen, 1992). Subjects were divided into three broad groups on the basis of self-reported health based on responses to the question “my health is excellent”. The groups were healthy (strongly/mostly agree), fair (cannot agree or disagree) or unhealthy (mostly/strongly disagree). The ability of the heiQ-J to detect differences between subgroups (responsiveness) was assessed by exploring differences between the healthy, fair, and unhealthy groups using one-way anova with Tukey's tests (P < 0.05) across scales. To test responsiveness, the sample was divided into three groups. All analyses were performed using SPSS ver. 16.0 for Windows (SPSS, Chicago, IL, USA).


Translation, cultural adaptation, and refinement for the workplace setting

Refinements to the initial draft heiQ-J primary translation are listed in Table 2. In addition, because the heiQ had been developed to evaluate programs for people with chronic disease, some items with wording that directly related to having a disease were modified to reflect having a general “health condition”. Items 4.2, 4.5 and 4.7 were most closely examined. The authors also modified examples in several items to match the Japanese culture (see Table 2).

Table 2. Key cultural adaptations of the Health Education Impact Questionnaire
 ItemOriginal versionJapanese version
Health-directed activity1.1I walk for exercise, for at least 15 min per day, most days of the weekI walk for exercise, for at least 15 min per day, 4 or more times a week
1.2I do at least one type of physical activity every day for at least 30 min (e.g. walking, gardening, housework, golf, bowls, dancing, Tai Chi, swimming)I do at least one type of physical activity every day for at least 30 min (e.g. walking, training gym, housework, golf, commuting on foot, field labor, bicycling)
1.3On most days of the week, I do at least one activity to improve my health (e.g. walking, relaxation, exercise)I do at least one activity to improve my health, 4 or more times a week (e.g. relaxation or stress-release measures, healthy diet, sufficient sleep)
1.4On most days of the week, I set aside time for healthy activities (e.g. walking, relaxation, exercise)I set aside time for healthy activities, 4 or more times a week (e.g. relaxation or stress-release measures, healthy diet, sufficient sleep)
Self-monitoring and insight4.1With my health in mind, I have realistic expectations of what I can and cannot doWith my health in mind, I have realistic expectations of what I can and cannot do (e.g. I can realize amount of meals I should have a day because of my high blood sugar)
4.2As well as seeing my doctor, I regularly monitor changes in my healthI am not only receiving physical examinations, but also regularly check my health condition
4.5I have a very good understanding of when and why I am supposed to take my medicationI have a very good understanding of when and why I am supposed to receive treatment (physical, dietary, and pharmacological)
4.7I know when my lifestyle (e.g. exercise, diet, stress) is creating health problems for meI know when my lifestyle (exercise, diet, and rest) is creating health problems for me
Skill and technique acquisition6.2I am very good at using physical aids to assist with my healthI effectively use health-related equipment (e.g. scales, pedometer) to improve my health condition
Social integration and support7.5When I feel ill, my family and carers really understand what I am going throughWhen I feel ill, the people around me and family really understand what I am going through
Health service navigation8.1I communicate very confidently with my doctor about my healthcare needsI communicate very confidently with my healthcare professionals (i.e. means doctor, nurse, nutritionist, and sports trainer) about my healthcare needs
8.2I have very positive relationships with my healthcare professionalsI have very positive relationships with my healthcare professionals (e.g. doctor, nurse, nutritionist, and sports trainer)
8.3I confidently give healthcare professionals the information they need to help meI confidently give healthcare professionals (e.g., doctor, nurse, nutritionist, and sports trainer) the information they need to help me
8.4I get my needs met from available healthcare resources (e.g. doctors, hospitals, and community services)I get my needs met from available healthcare resources (e.g. doctors, hospitals community services, and Internet)
8.5I work in a team with my doctors and other healthcare professionalsI work in a team with my doctors and other healthcare professionals (e.g. doctor, nurse, nutritionist, and sports trainer)

The forward translation of item 5.3 resulted in a strong cultural preference for “I do not let my health problems control my life” to read “I do not want my health problems to control my life”, but back translation and negotiation between the Japanese and Australian teams revealed that the intent of the original version is not so much a wish but rather a stronger expression of will and the original intent was retained.

Pilot study

Thirty-three individuals provided sufficient data for the pilot analyses (77% response rate). Apart from the scale social integration and support, which showed a low ICC (0.33), all other scales showed satisfactory values between 0.69 and 0.91. The cognitive interviews revealed that most items were clearly understood by all respondents. Some of the interviewees commented they felt it was difficult to answer some questions because they had no specific health problems. One key adaptation was the revision of the phrase “health problem” to “health condition” to prevent disengagement of subjects with MetS who might have low self-awareness of their risk factors.

Following these initial modifications, further cognitive interviews were conducted with three men and one woman to confirm whether the initial problems highlighted had been corrected. The revised items were once again back translated and the research team (including the developer) confirmed that the adaptations were acceptable.

Validation study

A total of 250 respondents completed the online survey and were included in the analyses. Of these, 47.2% were male and the average age was 47.2 years. The majority were office workers (38%) and 30% were women who undertook home duties (see Table 3). For the SF-36, which is standardized to have a mean (standard deviation [SD]) of 50 (10), the means for VT and MH were 52.7 (19.8) and 64.4 (17.5), respectively.

Table 3. Demographic characteristics of participants (n = 250)
Age, yearsMean47.2 ± 7.3 
OccupationCivil servant93.6
Executive officer52.0
Office worker9538.0
Medical worker20.8
Farmer, fisherman10.4


Cronbach's alpha was satisfactory to good for all scales, ranging from 0.70 for constructive attitude and approaches to 0.88 for emotional distress (see Table 4). The test–retest sample (n = 116) demonstrated a high ICC where the coefficient for all scales was 0.83 or higher. The lowest was 0.83 (95% confidence interval [CI] = 0.75–0.88) for both constructive attitude and approaches, and social integration and support, and up to 0.92 (95% CI = 0.89–0.95) for health-directed activity (Table 4).

Table 4. Health Education Impact Questionnaire scores and estimates internal and test–retest
Scales (no. of items)MeanSDCronbach's αICC95% confidence interval
  1. Health Education Impact Questionnaire scores, Cronbach's alpha (n = 250). Intraclass correlation coefficient (ICC), 95% confidence interval (n = 116). SD, standard deviation.

Health-directed activity (4)2.400.770.840.920.89–0.95
Positive and active engagement in life (5 )2.770.510.820.870.82–0.91
Emotional distress (6)2.130.560.880.900.86–0.93
Self-monitoring and insight (7)2.700.380.730.870.81–0.91
Constructive attitudes and approaches (5)2.680.460.700.830.75–0.88
Skill and technique acquisition (6)2.450.480.780.840.77–0.89
Social integration and support (5)2.510.570.840.830.75–0.88
Health service navigation (5)2.130.670.870.870.81–0.91

Concurrent validity

Across all comparisons, the scales that most highly correlated were the heiQ-J social integration and support and the SSM (r = 0.72). Constructive attitudes and approaches correlated with several comparators: SOC (r = 0.46); SSM (r = 0.48); VT (r = 0.52); and MH (r = 0.48). Positive and active engagement in life was correlated with SSM (r = 0.44); VT (r = 0.45); and MH (r = 0.40). Skill and technique acquisition was also correlated with three comparators: SSM (r = 0.42); VT (r = 0.47); and MH (r = 0.42). Emotional distress had medium correlation with VT and MH (r ≥ 0.40), although the correlation of 0.40 with MH suggests that these scales do capture different elements of mental well-being. Finally, three heiQ-J scales were unrelated or very weakly related to all comparators: (i) health-directed activity; (ii) self-monitoring and insight; and (iii) health service navigation (Table 5).

Table 5. Correlations between the heiQ and other questionnaires (n= 250)
  1. Spearman's ρ, **P < 0.01; *P < 0.05. MH, Mental Health; SF-36, 36 item Short-Form Health Survey; SOC-13, 13 item Sense of Coherence scale; SSM, Social Support Measurement; VT, Vitality.

Health-directed activity0.15*0.20**0.34**0.27**
Positive and active engagement in life0.33**0.44**0.45**0.40**
Emotional distress−0.37**−0.16**−0.41**−0.40**
Self-monitoring and insight0.110.21**0.21**0.12
Constructive attitudes and approaches0.46**0.48**0.52**0.46**
Skill and technique acquisition0.35**0.42**0.47**0.42**
Social integration and support0.35**0.72**0.38**0.35**
Health service navigation0.110.24**0.120.08

Differences in the average heiQ-J scale scores were observed across people grouped according to their self-rated health: Healthy (n = 100); fair (n = 103); or unhealthy (n = 47). The clearest differentiation was seen in emotional distress (F[2,247] = 68.5, P < 0.001) and constructive attitudes and approaches (F[2,247] = 18.2, P < 0.001; see Table 6). In contrast, no differences were observed in comparison of even the extreme groups (healthy vs unhealthy) for self-monitoring and insight, and health service navigation.

Table 6. One-way anova comparing Health Education Impact Questionnaire scores across self-perceived well-being subgroups: “healthy” (n = 100), “fair” (n = 103), and “unhealthy” (n = 47)Thumbnail image of



The objectives of this study were to translate, culturally adapt, and validate the English version of the heiQ for evaluation of SME and SHC programs in Japan. The heiQ-J was generated through iterative translation and adaptation procedures, pretested with cognitive interviews using a standardized protocol including negotiation between the local researchers and the developers. These steps helped to assure content and face validity. This is reflected by the heiQ-J displaying good psychometric properties with Cronbach's alpha and ICC showing that it is internally consistent and reliable in this setting.

The authors faced two important issues that required specific attention during the development of the heiQ-J: (i) the differences in cultural backgrounds; and (ii) differences in the disease status and presence of risk factors for diseases. However, possible applications of SHC evaluation in the heiQ-J must consider the ease of response for individuals with various health conditions, including those with few conscious symptoms. In order to bridge the gaps between cultural backgrounds and aid the subjects' understanding, the authors added examples to questionnaire items that Japanese people might feel more familiar with (see Table 2). A second round of cognitive interviews was conducted after the initial revision which resulted in improved comprehension. Moreover, The authors considered that some items had concepts that were not congruent with the Japanese culture, including items such as 5.3 “I do not let my health problems control by life” and 2.5 “I feel like I am actively involved in life”, which contain strong autonomous approaches to life. Although the cultural adaptation approach initially attempted to reframe the concepts into local values, the translation team decided not to revise the original concept and created items that represented the original autonomous version as precisely as possible because these aspects are likely to promote health and behavior change. Consequently, the final cognitive interviews, reliability testing based on the ICC and Cronbach's alpha, and concurrent validity tests suggest that the scales constructive attitudes and approaches, and positive and active engagement in life appear to work reasonably well. However, further work is needed to confirm the utility of these dimensions in Japan.

The original version of the heiQ targets people with chronic diseases (Osborne et al., 2007). In contrast, the Japanese study targets people with MetS. During the adaptation, the authors assumed that Japanese employees would generally have good health and may not have clear self-recognition regarding any actual or potential health issues they may have. The authors therefore partially revised a limited number of items to take the emphasis away from “disease” or “health problem” to the more general concept of “health”.

The investigation of the ability of the heiQ-J to detect differences between groups showed that six of the eight scales were responsive across self-rated health categories. The healthiest group showed the highest average score for all scales except for self-monitoring and insight, and health service navigation. This finding seems reasonable because people with worse health might be expected to have had more experience or challenge in the area of these two apparently non-responsive constructs. If they had been more engaged with health professionals and in thinking about managing their own health, they might be expected to score higher than their healthier counterparts. A further observation is that, across all scales, the means and SD for the subgroups indicates minimal ceiling and floor effects, suggesting that the scales are likely to be responsive in the SME and SHC intervention settings.

Low individual disease burden was also reflected by somewhat high SF-36 VT and MH scores in our data compared with the population average. The self-monitoring and insight scale, and the health service navigation scale had the lowest correlation with VT and MH, supporting the authors contention that these skill-based scales are not strongly related to health status. In MetS, which can be described as the preliminary phase of a chronic condition, it is difficult to define the time of onset (Lubkin & Larsen, 2002) and it is hoped that the SHC will assist people with high MetS to recognize that they have health issues that require attention. It is expected then that some heiQ-J scale scores, including self-monitoring and insight, and health service navigation, will increase as a result of the intervention.

In Japan, the levels of self-management as a compliance behavior are already high. That is, people tend to manage their health conditions for a long period of time, in accordance with their physicians' instructions, and have high dependence on medical healthcare professionals (Long, 1980). The present authors observe that a balanced physician/patient relationship (Yajima & Takayanagi, 1998), as described in the items 8.5 “I work in a team with my doctors and other healthcare professionals” and 8.2 “I have very positive relationships with my healthcare professionals”, may be difficult to identify and establish in the Japanese setting. Despite this, the SHC intervention provided to people with MetS through their health consultations aims to encourage people to make their own decisions and become proactive in managing their health. The authors therefore believe these are important concepts to retain in the heiQ-J to serve as evaluation indices that should provide new insights into both the mechanism and effectiveness of the SHC.

There were some limitations to this study. The subjects of this study were not necessarily people with MetS, and consequently, the investigation was not linked to clinical data. For the authors' future studies, they are planning to use clinical data when evaluating study subjects who have MetS. However, given the strong psychometric data obtained in this study, the questionnaire is likely to be suitable for people with MetS and other chronic conditions. Future work, with larger samples, should include confirmatory factor analyses to further understanding of the structure and construct validity of the heiQ-J, and should also explore cross-cultural stability of the scales.


In this study, the authors completed the translation, cultural adaptation, and validation of the heiQ-J. The heiQ-J was found to have robust psychometric properties and appears to be a valid and reliable measure for evaluation of health education programs. The heiQ-J is useful for the evaluation of health management ability in people with MetS with few conscious symptoms. Given the wide application of the heiQ in other countries, in Japan it is likely to be a useful tool to test a range of patient interventions, for general surveys of well-being and to guide the development of interventions. Finally, it may be useful to compare outcomes across multiple cultures and language groups. It will be important to undertake further study to determine its value in the application to other health conditions.

Practice implications

For comprehensive evaluation of the health consultations for MetS, it is necessary to measure effectiveness through before and after assessments. It is particularly important that such evaluations include not only self-management outcomes but clinical and other process outcomes. The authors predict that using the heiQ-J in the evaluation of specific health consultations will provide important information about intermediate outcomes as well as indications of potential mechanisms of action on biological outcomes. Such data will enhance understanding of the intervention programs and facilitate improvement in their content.


The authors are grateful to all participants who greatly contributed to this study. They would like to thank Yoshie Nishida of the Nursing College of Izumisano Sennan Medical Association.


  • Full version of items are available from the author.

1. Health-directed activity
1 I walk for exercise, for at least 15 . . .
2 I do at least one type of physical activity every day for . . .
3 On most days of the week, I do at least one . . .
4 On most days of the week, I set aside time for . . .
2. Positive and active engagement in life
1 I am doing interesting things in my life
2 Most days I am doing some . . .
3 I try to make the most of life
4 I have plans to do enjoyable . . .
5 I feel like I am actively involved in life
3. Emotional distress
1 If I think about my health, I get depressed
2 I get upset when . . .
3 I often feel angry when . . .
4 My health problems make me very dissatisfied . . .
5 I often worry about my health
6 I feel hopeless because of my . . .
4. Self-monitoring and insight
1 With my health in mind, I have realistic expectations . . .
2 As well as seeing my doctor, I regularly monitor changes . . .
3 I know what things can trigger my health problems . . .
4 When I have health problems, I . . .
5 I have a very good understanding of when and why . . .
6 I carefully watch my health and do what is necessary to keep . . .
7 I know when my lifestyle is creating health problems for me
5. Constructive attitudes and approaches
1 If others can cope with problems . . .
2 I try not to let my health problems stop me from enjoying life
3 I do not let my health problems control my life
4 My health problems do not ruin my life
5 I feel I have a very good life even . . .
6. Skill and technique acquisition
1 When I have symptoms, I have skills that help me cope
2 I am very good at using . . .
3 I have effective skills that help me handle stress
4 I have a very good idea of how to manage . . .
5 I have effective ways to prevent my symptoms . . .
6 I have a good understanding of equipment
7. Social integration and support
1 I have enough friends who help me cope with my health . . .
2 I get enough chances to talk about my health . . .
3 If I need help, I have plenty of people I can rely on
4 Overall, I feel well looked after by friends or family
5 When I feel ill, my family and carers really understand . . .
8. Health service navigation
1 I communicate very confidently with my doctor about . . .
2 I have very positive relationships with my healthcare . . .
3 I confidently give healthcare professionals the information . . .
4 I get my needs met from available healthcare resources . . .
5 I work in a team with my doctors and other healthcare . . .

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