Development and Validation of a Brief Healthcare Insecurity Scale in a Sample of U.S. Adults Living with and without HIV

BACKGROUND: Healthcare insecurity is pervasive in the U.S. and abroad, with implications for health, particularly among people living with chronic conditions. Yet, a common definition is lacking and current measures are limited. METHODS: We developed and validated an eight-item healthcare insecurity scale (HCIS) using cross-sectional data collected in 2021-2022 from individuals living with and without HIV in the U.S. (n=2,513). Psychometric properties were assessed through confirmatory factor analysis and item response theory models, and measurement invariance was tested. Criterion and convergent validity were evaluated by examining associations between HCIS scores and health insurance status, socioeconomic factors, perceived stress, and self-reported physical, mental, and general health, adjusting for income and demographics. RESULTS: The unidimensional scale demonstrated good local fit and sufficient global fit. Each item was strongly correlated with the latent trait of healthcare insecurity (standardized factor loadings ranging from 0.69 to 0.90). The scale showed strong measurement invariance across groups defined by HIV serostatus and gender. Mean (SD) HCIS scores were 1.2 (2.5). Higher scores among those with no health insurance demonstrated criterion validity. Higher scores among those with lower income, unemployment, or disability, as well as strong positive associations between HCIS scores and perceived stress and self-reported health supported convergent validity. CONCLUSIONS: The HCIS is a psychometrically sound tool for comprehensively assessing healthcare insecurity in people living with or vulnerable to HIV, even in a sample highly linked to care. The brevity and scope of HCIS support its applicability in research on healthcare insecurity beyond access to health insurance.