Understanding and Measuring Critical Consciousness about Social Determinants of Health and Health Inequalities in the United States

Background: It has been estimated that between 2003 and 2006, health inequalities cost the United States approximately $230 billion in direct medical care expenditures and more than 1 trillion in indirect costs. Research has shown that social determinants of health such as stigma, poverty, and lack of access to care explain health inequalities. From a critical consciousness theory perspective, educating people about marginalizing processes that lead to inequalities and mobilizing them to advocate for the rights of marginalized groups is an effective strategy to promote change. However, this remains hard to test empirically since measuring critical consciousness is challenging. This study used community-based participatory research (CBPR) principles and critical consciousness theory to develop and test the psychometrics of the Health Inequalities Knowledge Scale (HIKS), a scale designed to measure knowledge about social determinants of health and health inequalities.

Methods: HIKS’ items were developed by members of the Newark Community Collaborative Board, a group of service providers, consumers, researchers, and stakeholders working in the field of HIV prevention and substance use disorder in Newark, NJ. After initial development, the HIKS underwent clarity testing and expert validation to refine the theoretical framework and items prior to reliability testing. This process reduced the HIKS’ items from 94 to 37. Items are rated in a Likert scale ranging from 0 = disagree completely to 6 = agree completely. Higher scores indicate higher knowledge about health inequalities. The 37 items were tested for reliability with survey data collected online from 502 individuals representing the spectrum of critical consciousness. An exploratory factor analysis (EFA) was conducted using principal axis factoring because the data violated assumptions of normality. Eigen values and scree plots were used to identify the number of components. Knowledge items meeting the <.4 threshold were retained, while others were removed from the analysis. Cronbach’s Alpha was then calculated and multiple regression tested the scale’s criterion-related validity based on demographic variables.  

Results: The final HIKS included 12 items loaded into a single factor. The scale was found to be reliable with a Cronbach’s Alpha of .914. Normative data showed scores ranging from 28 to 54. The sample had fairly high scores with a mean of 43.2 and standard deviation of 6.77, indicating respondents had a fairly high level of knowledge about health inequalities.  The scale’s criterion-related validity was confirmed with multiple regression analysis showing significant differences based on education level, civic engagement, and political views. Specifically, those reporting higher education levels, higher civic engagement (e.g., reporting to vote, engage in community service, political movements) and less conservative political views had significantly higher HIKS scores. 

Implications: Findings show that the HIKS is a reliable and valid scale to measure knowledge about health inequalities. Future research can use the HIKS along with measures of civic and community engagement to test the applicability of using critical consciousness theory to help understand and combat health inequalities.