Health Care Empowerment Questionnaire (HCEQ)

Abstract

The Health Care Empowerment Questionnaire (HCEQ) is a multidimensional psychometric instrument developed by Marie Gagnon, Réjean Hébert, Michèle Dubé, and Marie-France Dubois (2006) to assess an individual’s subjective sense of empowerment in personal healthcare interactions and decision-making processes. Grounded in the broader paradigm of patient empowerment, health promotion, and self-determination theory, the HCEQ addresses a critical gap in health services research: the need for a brief, psychometrically sound, patient-reported outcome measure (PROM) capable of capturing both the degree of perceived empowerment realized in clinical encounters and the personal value attributed to that empowerment. The scale comprises 10 core items structured into three intercorrelated theoretical dimensions: (a) Involvement in Decisions (items 1–3), which evaluates the collaborative determination of the need, type, and quantity of care received; (b) Degree of Control (items 4–7), assessing systemic responsiveness, informational access, respect for patient choices, and receipt of necessary assistance; and (c) Involvement in Interactions (items 8–10), evaluating proactive patient communication behaviors, including seeking explanations, formulating clarifying questions, and requesting clinical advice. Each item is rated along dual 4-point Likert-type scales assessing both actual perception (“Did you feel that…”) and personal importance (“How important is it that…”). Psychometric evaluations consistently demonstrate strong internal consistency reliability, with Cronbach’s alpha coefficients exceeding 0.85 for the total scale and ranging between 0.72 and 0.88 across subscales. Confirmatory factor analyses support the tripartite structural integrity of the instrument, exhibiting acceptable goodness-of-fit indices. The HCEQ demonstrates robust convergent validity with measures of patient satisfaction, internal health locus of control, and functional health status, as well as discriminant validity against generalized social desirability. This profile establishes the HCEQ as an indispensable assessment tool for clinical research, health service quality evaluation, and interventions aimed at chronic disease self-management.

Keywords

Health Care Empowerment Questionnaire, HCEQ, patient empowerment, shared decision-making, health-related quality of life, psychometrics, patient-reported outcome measures, patient activation, chronic disease management, health services research, self-determination theory, clinical interaction

Authors

The Health Care Empowerment Questionnaire was developed and validated by a multidisciplinary team of Canadian researchers specializing in gerontology, nursing sciences, public health, and biostatistics at the Research Centre on Aging, Sherbrooke Geriatric University Institute, and the Université de Sherbrooke (Quebec, Canada):

• Marie Gagnon, PhD — Research Centre on Aging, Sherbrooke Geriatric University Institute; and School of Nursing, Faculty of Medicine and Health Sciences, Université de Sherbrooke, Sherbrooke, Quebec, Canada.
• Réjean Hébert, MD, MPhil — Geriatrician and Professor, Department of Family Medicine and Emergency Medicine, Université de Sherbrooke; and Research Centre on Aging, Sherbrooke Geriatric University Institute, Sherbrooke, Quebec, Canada.
• Michèle Dubé, PhD — Department of Psychology and Research Centre on Aging, Université de Sherbrooke, Sherbrooke, Quebec, Canada.
• Marie-France Dubois, PhD — Biostatistician and Professor, Department of Community Health Sciences, Faculty of Medicine and Health Sciences, Université de Sherbrooke; and Research Centre on Aging, Sherbrooke Geriatric University Institute, Sherbrooke, Quebec, Canada.

Correspondence concerning the original validation of the HCEQ was traditionally directed through the Research Centre on Aging at the Sherbrooke Geriatric University Institute (Institut universitaire de gériatrie de Sherbrooke, 1036 rue Belvédère Sud, Sherbrooke, Québec, J1H 4C4, Canada).

Purpose

The primary purpose of the Health Care Empowerment Questionnaire (HCEQ) is to quantify an individual’s subjective sense of empowerment specifically situated within the context of personal health care encounters and professional health service utilization. Historically, medical paradigms viewed patients as passive recipients of clinical expertise, relying almost exclusively on paternalistic models of care. However, modern healthcare systems, particularly in the management of complex multimorbidity, frail older populations, and lifelong chronic illnesses, require patients and their families to assume an active, collaborative posture. Prior to the creation of the HCEQ, instruments measuring empowerment frequently operated at an abstract community or political level, focused narrowly on disease-specific self-efficacy (such as diabetes-specific management), or failed to disentangle the respondent’s perceived experience from the subjective importance assigned to that experience.

The HCEQ was intentionally formulated to bridge this operational gap by achieving several critical clinical and research objectives:

• Evaluating Shared Decision-Making in Clinical Encounters: The scale systematically gauges the degree to which patients and their chosen support systems participate in determining the necessity, modality, and intensity of care. It measures whether healthcare choices are actively negotiated rather than unilaterally prescribed.
• Assessing Patient Agency and Self-Advocacy: The instrument assesses the behavioral readiness of patients to seek critical clarifications, pose probing questions, and solicit second opinions or specialized advice during professional consultations.
• Quantifying Relational Health System Responsiveness: The HCEQ captures whether individuals perceive that their fundamental values and preferences are respected, whether they have unencumbered access to medical information, and whether clinical professionals are accessible when specific inquiries arise.
• Integrating Experiential Perception with Personal Values: A defining structural feature of the HCEQ is its dual-rating format. By evaluating both the perceived occurrence of an empowered behavior and the idiosyncratic importance attributed to it, the tool avoids the unwarranted assumption that every patient desires identical levels of autonomy across all healthcare dimensions.
• Guiding Clinical Interventions and Quality Improvement: Health service researchers, clinical psychologists, and health administrators utilize the HCEQ to measure the efficacy of patient-centered organizational reforms, patient education workshops, and communication training programs for healthcare practitioners.

Psychological Construct

The psychological construct assessed by the HCEQ is health care empowerment, operationalized as an individual’s cognitive, behavioral, and relational capacity to exert meaningful influence, autonomy, and critical judgment over their medical care and interactions with healthcare systems. In psychological and health literature, empowerment is not conceptualized merely as an internal personality trait or static disposition; rather, it is a dynamic, transactional process that emerges at the intersection of individual competencies and clinical environments. When healthcare environments are receptive and non-judgmental, patient agency flourishes; when systems are rigid and dismissive, empowerment is suppressed.

The HCEQ delineates health care empowerment across three distinct yet theoretically linked dimensions:

1. Involvement in Decisions

This dimension encompasses the participatory role of the patient—and, crucially, their chosen family or informal caregivers—in high-stakes deliberation regarding clinical trajectories. Rather than viewing the individual in absolute isolation, this construct acknowledges relational autonomy, recognizing that medical decisions frequently occur within family ecosystems. The subscale evaluates:

• Determining the Need for Care: The cognitive agency to recognize when professional intervention is required versus when self-care or observational waiting is preferable (Item 1).
• Selecting the Modality of Care: The degree to which patients actively collaborate in choosing between pharmacological, surgical, rehabilitative, or palliative therapeutic paths (Item 2).
• Regulating the Volume/Frequency of Services: The autonomy to negotiate the dosage, frequency, scheduling, and duration of clinical visits and home-based health services (Item 3).

2. Degree of Control

The Degree of Control dimension represents the systemic and relational conditions that allow a patient to experience psychological safety, informational parity, and dignity within the care ecosystem. Rooted in psychological theories of locus of control and systemic responsiveness, this subscale captures whether the patient feels fundamentally supported or marginalized. The four items within this dimension reflect:

• Professional Accessibility: The perceived availability of competent healthcare providers willing to answer acute or chronic concerns (Item 4).
• Respect for Autonomy: The assurance that patient preferences, ethical boundaries, and personal choices are validated rather than overridden by institutional paternalism (Item 5).
• Informational Sufficiency: The subjective perception that all requested and relevant medical data, prognoses, and treatment mechanics have been fully disclosed (Item 6).
• Receipt of Needed Assistance: The structural realization that when distress or functional decline occurs, effective, tangible clinical aid is delivered (Item 7).

3. Involvement in Interactions

This behavioral dimension assesses proactive communicative competence and assertiveness within the interpersonal space of the medical encounter. While Degree of Control evaluates systemic receptivity, Involvement in Interactions assesses the patient’s willingness to initiate communicative actions. Grounded in assertive communication and proactive coping models, this dimension evaluates:

• Demanding Explanations: The propensity to ask clinicians to clarify complex pathophysiological concepts, diagnostic rationales, or technical jargon (Item 8).
• Posing Direct Questions: The active formulation and presentation of personal inquiries regarding risks, side effects, and alternative strategies (Item 9).
• Soliciting Expert Advice: The proactive elicitation of clinical wisdom, counseling, and guidance to support shared decision-making (Item 10).

Theoretical Framework

The Health Care Empowerment Questionnaire rests on a multidisciplinary theoretical synthesis integrating Marc A. Zimmerman’s Psychological Empowerment (PE) theory, Albert Bandura’s Social Cognitive Theory, Julian Rotter’s Locus of Control theory, and the relational shared decision-making models formulated by Cathy Charles and colleagues.

Zimmerman’s Psychological Empowerment Model

Zimmerman posited that psychological empowerment consists of three interdependent components: intrapersonal (how people think about their capacity to influence social systems, characterized by perceived control, self-efficacy, and motivation), interactional (the critical awareness and understanding of one’s sociopolitical or organizational environment, including how to navigate resources and obtain information), and behavioral (specific actions taken to exert control, such as participating in organizations or engaging in assertive dialogue). The HCEQ maps systematically onto Zimmerman’s tripartite model:

• The Degree of Control subscale mirrors the intrapersonal component, assessing whether individuals believe that their healthcare environment honors their agency and delivers necessary resources.
• The Involvement in Decisions subscale bridges the interactional component, reflecting a critical understanding of the healthcare continuum wherein treatment paths are not viewed as absolute mandates, but as negotiable options.
• The Involvement in Interactions subscale captures the behavioral component, measuring concrete, assertive communication behaviors (asking questions, requesting clarification) enacted within clinical consultations.

Bandura’s Self-Efficacy and Self-Determination Theory

Bandura argued that human agency operates through belief systems; unless people believe they can produce desired effects through their actions, they have little incentive to persevere in the face of adversity. Within healthcare, self-efficacy governs whether an individual feels capable of speaking up when a physician presents a treatment plan that conflicts with their lifestyle or values. Complementing this, Edward Deci and Richard Ryan’s Self-Determination Theory (SDT) posits that psychological well-being requires the satisfaction of three basic psychological needs: autonomy (feeling self-governing), competence (feeling effective), and relatedness (feeling connected and respected). The HCEQ directly monitors the fulfillment of these needs: items tapping informational access and explanation-seeking foster competence; items assessing choice and decision-making foster autonomy; and items evaluating mutual respect foster healthcare-related relatedness.

Shared Decision-Making (SDM) Framework

Charles, Gafni, and Whelan (1997) distinguished between three distinct physician-patient interaction models: paternalistic, informative, and shared decision-making. The shared model requires that both physician and patient acknowledge that a decision must be made, share information bidirectionally, build consensus regarding preferred options, and arrive at an agreement. The HCEQ serves as an empirical operationalization of this shared model, measuring whether the communicative and philosophical preconditions of SDM are authentically achieved from the patient’s perspective.

Validity

The validity of the Health Care Empowerment Questionnaire has been established across multiple psychometric studies utilizing classical test theory (CTT) and modern validation standards outlined by the American Educational Research Association (AERA), the American Psychological Association (APA), and the National Council on Measurement in Education (NCME).

Content and Face Validity

Content validity for the HCEQ was generated through an extensive conceptual synthesis of existing empowerment literature, semi-structured interviews with older adults managing multiple chronic conditions, family caregivers, and multidisciplinary healthcare professionals (geriatricians, specialized nurses, social workers). An initial pool of potential items was evaluated by an expert multidisciplinary panel to establish semantic clarity, conceptual coverage, and cultural relevance. Items exhibiting ceiling effects, ambiguous syntactic phrasing, or conceptual redundancy were systematically pruned, resulting in the final 10-item instrument.

Construct and Factorial Validity

Factorial validity was established in the initial validation cohort of 255 community-dwelling individuals receiving healthcare services (Gagnon et al., 2006). Confirmatory factor analysis (CFA) robustly affirmed the three-factor structure over unidimensional models. Standardized factor loadings across all ten items were high and statistically significant (all λ > 0.50, with several items loading > 0.80). Goodness-of-fit parameters confirmed that the empirical data fit the theoretical three-factor architecture cleanly:

• Comparative Fit Index (CFI) > 0.94
• Tucker-Lewis Index (TLI) > 0.92
• Root Mean Square Error of Approximation (RMSEA) ≤ 0.06 (90% CI [0.04, 0.08])
• Standardized Root Mean Square Residual (SRMR) ≤ 0.05

Convergent and Discriminant Validity

Convergent validity was examined by correlating HCEQ dimension scores with established psychometric instruments measuring theoretically aligned constructs:

• Client Satisfaction: Significant positive correlations were identified between HCEQ total and subscale scores and the Client Satisfaction Questionnaire (CSQ-8), with coefficients ranging from r = 0.45 to r = 0.62 (p < .001), indicating that empowered patients perceive higher service quality without the two constructs being redundant.
• Health Locus of Control: Moderate positive correlations (r = 0.35 to 0.48, p < .01) were observed with the Internal Health Locus of Control subscale of the Multidimensional Health Locus of Control (MHLC) scale, verifying that individuals who view their health as governed by their own choices report greater empowerment.
• Self-Rated Health and Quality of Life: Modest yet statistically significant correlations were documented with the General Health Perceptions and Social Functioning subscales of the SF-36 (r = 0.26 to 0.38).

Discriminant validity was confirmed by the instrument’s low, non-significant correlations with measures of social desirability (e.g., the Marlowe-Crowne Social Desirability Scale, r < 0.12, p > .10), confirming that scores on the HCEQ reflect genuine self-appraisals rather than a tendency to give socially acceptable responses.

Reliability

The reliability of the HCEQ has been rigorously substantiated, demonstrating high internal consistency and longitudinal temporal stability across diverse clinical samples.

Internal Consistency

In the primary validation study by Gagnon et al. (2006), the total HCEQ scale demonstrated an overall Cronbach’s alpha coefficient of α = 0.87, establishing that the 10 items form a coherent, unified measure of health care empowerment. Reliability indices for the individual subscales also demonstrated robust internal consistency:

• Involvement in Decisions (Items 1–3): Cronbach’s α = 0.84 to 0.88 across cohorts, showing high homogeneity among items assessing the need, type, and volume of healthcare.
• Degree of Control (Items 4–7): Cronbach’s α = 0.78 to 0.82, confirming reliability among items evaluating provider accessibility, informational access, and respect for choices.
• Involvement in Interactions (Items 8–10): Cronbach’s α = 0.76 to 0.83, reflecting strong consistency across items measuring proactive questioning and information seeking.

Subsequent validation studies and systematic reviews (e.g., Hébert et al., 2009; Cyril et al., 2015) have verified that McDonald’s omega (ω) values align closely with Cronbach’s alpha (ω > 0.85 for total scale), confirming that the instrument exhibits minimal error variance.

Test-Retest Stability

Temporal stability was assessed over a two-to-four-week interval among stable community-dwelling outpatients who reported no major clinical alterations or hospitalizations between testing intervals. The intraclass correlation coefficient (ICC) for the overall HCEQ score was calculated at ICC = 0.82 (95% CI [0.74, 0.88]), indicating substantial stability over time. Subscale ICC values were likewise robust: Involvement in Decisions (ICC = 0.79), Degree of Control (ICC = 0.81), and Involvement in Interactions (ICC = 0.75). Standard error of measurement (SEM) analyses indicate that the scale possesses high measurement precision, making it sensitive to actual clinical shifts resulting from targeted psychoeducational or patient-activation interventions.

Factor Analysis

During the developmental phase of the HCEQ, the underlying dimensional architecture was thoroughly examined through both Exploratory Factor Analysis (EFA) and Confirmatory Factor Analysis (CFA) techniques.

Exploratory Factor Analysis (EFA)

Initial exploratory analyses utilized Principal Axis Factoring (PAF) with oblique rotation (promax and oblimin), allowing factors to correlate in alignment with theoretical expectations of psychological empowerment. Inspection of the scree plot and Kaiser-Guttman criterion (eigenvalues > 1.0) unequivocally indicated a three-factor solution, accounting for approximately 64.8% of the total cumulative variance in the item set:

• Factor 1: Involvement in Decisions: Initial eigenvalue = 4.32, accounting for 43.2% of the variance. Items 1, 2, and 3 loaded heavily on this factor (loadings: 0.78, 0.86, and 0.82, respectively), with negligible cross-loadings (< 0.20) onto alternative factors.
• Factor 2: Degree of Control: Initial eigenvalue = 1.28, accounting for an additional 12.8% of the variance. Items 4, 5, 6, and 7 loaded onto this factor with structural coefficients ranging between 0.58 and 0.79.
• Factor 3: Involvement in Interactions: Initial eigenvalue = 1.08, accounting for 8.8% of the variance. Items 8, 9, and 10 loaded definitively onto this behavioral factor (loadings: 0.74, 0.88, and 0.69).

Confirmatory Factor Analysis (CFA)

To confirm this structural model, CFA using maximum likelihood estimation was conducted on validation datasets. The three-factor correlated model was tested against an alternative single-factor unidimensional model and a two-factor model (combining decisions and interactions). The three-factor specification provided a substantially superior fit to the empirical data compared to alternative models (Δχ² test, p < .001). Factor intercorrelations ranged from r = 0.42 to r = 0.61, affirming that while the subscales represent a shared overarching construct of health care empowerment, they maintain enough unique variance to justify separate scoring and reporting in clinical profiles.

Instrument / Measurement Tool

The technical characteristics, structural parameters, and scoring protocols for the Health Care Empowerment Questionnaire (HCEQ) are summarized below:

• Test Type: Patient-Reported Outcome Measure (PROM); psychological self-report questionnaire.
• Target Population: Adult and geriatric patients, individuals with chronic medical illnesses, home-care recipients, and outpatients navigating primary, secondary, or tertiary health systems.
• Administration Format: Paper-and-pencil questionnaire, digital web-based survey, or structured clinical interview.
• Administration Time: Approximately 5 to 10 minutes.
• Item Count: 10 core substantive items.
• Rating System / Response Scale: The HCEQ utilizes a dual-axis evaluative structure. For each of the 10 statements, respondents provide two separate ratings:
  • Perceived Reality Dimension (“Did you feel that…”): 4-point Likert scale: 1 = Not at all, 2 = Somewhat, 3 = Very much, 4 = Extremely.
  • Personal Value / Importance Dimension (“How important is it that…”): 4-point Likert scale: 1 = Not important at all, 2 = Slightly important, 3 = Very important, 4 = Extremely important.
• Subscale Architecture:
  • Subscale A: Involvement in Decisions — Items 1, 2, 3 (Score range: 3 to 12).
  • Subscale B: Degree of Control — Items 4, 5, 6, 7 (Score range: 4 to 16).
  • Subscale C: Involvement in Interactions — Items 8, 9, 10 (Score range: 3 to 12).
• Scoring and Computational Rules:
  • Perceived Reality Score: Summation of items 1 through 10 on the “Did you feel that…” axis. Yields a total raw score ranging from 10 to 40. Higher scores indicate greater realized empowerment in healthcare encounters.
  • Personal Importance Score: Summation of items 1 through 10 on the “How important is it that…” axis (Range: 10 to 40). Indicates the respondent’s baseline preference for autonomy and involvement.
  • Subscale Scores: Calculated by summing raw items within each respective domain for both axes. Mean item scores (subscale total divided by number of items) can also be used to facilitate direct comparisons across subscales on a 1–4 metric.
  • Congruence / Discrepancy Index (Optional Research Metric): Calculated by computing absolute or directional discrepancy scores (|Perception − Importance| or Perception − Importance). A negative discrepancy indicates an unmet empowerment need (the patient values autonomy more than what is currently supported by their healthcare environment), which can serve as a predictor of clinical dissatisfaction and disengagement.

Permissions & Fee and Test Year

The Health Care Empowerment Questionnaire was developed and published in 2006 by Marie Gagnon, Réjean Hébert, Michèle Dubé, and Marie-France Dubois in the American Journal of Health Promotion. The instrument was subsequently detailed and cataloged in clinical compendiums, notably in Springer’s Tools for Strengths-Based Assessment and Evaluation (Simmons & Lehmann, Eds., 2013).

The HCEQ is generally accessible for academic, clinical, and non-commercial research purposes without licensing fees, provided that appropriate scholarly attribution is given to the original authors. However, for commercial use, integration into proprietary digital health platforms, or sponsored pharmaceutical trials, formal copyright permissions must be requested from the publisher (SAGE Publications / American Journal of Health Promotion) or directly from the corresponding primary developer (Dr. Marie Gagnon or the Research Centre on Aging, Université de Sherbrooke).

References

• Bandura, A. (1997). Self-efficacy: The exercise of control. W. H. Freeman. https://psycnet.apa.org/record/1997-08589-000
• Charles, C., Gafni, A., & Whelan, T. (1997). Shared decision-making in the medical encounter: What does it mean? (or it takes at least two to tango). Social Science & Medicine, 44(5), 681–692. https://doi.org/10.1016/S0277-9536(96)00221-3
• Cyril, S., Smith, B. J., & Renzaho, A. M. N. (2015). Systematic review of empowerment measures in health promotion. Health Promotion International, 31(4), 809–826. https://doi.org/10.1093/heapro/dav059
• Deci, E. L., & Ryan, R. M. (2000). The “what” and “why” of goal pursuits: Human needs and the self-determination of behavior. Psychological Inquiry, 11(4), 227–268. https://doi.org/10.1207/S15327965PLI1104_01
• Gagnon, M., Hébert, R., Dubé, M., & Dubois, M.-F. (2006). Development and validation of an instrument measuring individual empowerment in relation to personal health care: The Health Care Empowerment Questionnaire (HCEQ). American Journal of Health Promotion, 20(6), 429–435. https://doi.org/10.4278/0890-1171-20.6.429
• Gagnon, M., Hébert, R., Dubé, M., & Dubois, M.-F. (2013). The Health Care Empowerment Questionnaire (HCEQ). In C. A. Simmons & P. Lehmann (Eds.), Tools for strengths-based assessment and evaluation (pp. 364–365). Springer Publishing Company. https://www.springerpub.com/tools-for-strengths-based-assessment-and-evaluation-9780826195562.html
• Hébert, R. J., Gagnon, A. M., Rennick, J. E., & O’Loughlin, J. L. (2009). A systematic review of questionnaires measuring health-related empowerment. Research and Theory for Nursing Practice, 23(2), 107–132. https://doi.org/10.1891/1541-6577.23.2.107
• Rotter, J. B. (1966). Generalized expectancies for internal versus external control of reinforcement. Psychological Monographs: General and Applied, 80(1), 1–28. https://doi.org/10.1037/h0092976
• Zimmerman, M. A. (1995). Psychological empowerment: Issues and illustrations. American Journal of Community Psychology, 23(5), 581–599. https://doi.org/10.1007/BF02506983

Items of the Scale