Definitions and measurement of health literacy in health and medicine research: a systematic review

Health literacy friendly organizations - A scoping review about promoting health literacy in a surgical setting

OBJECTIVE

This review aims to describe interventions that promote health literacy in a surgical setting and identify knowledge gaps for future research.

METHODS

A scoping review with a systematic search was performed in Medline, CINAHL, Scopus, and Web of Science between January 1, 2012, and January 23, 2024. All screening was conducted using the Covidence software. In total, the search yielded 6 281 articles.

RESULTS

Eighteen articles were included in the results. Studies were heterogeneous regarding the type of health literacy measured, type of surgery, and type of intervention. Most interventions were educational to improve knowledge, decision making or health literacy through digital media, group sessions or consent forms. Most interventions had a positive impact on health literacy.

CONCLUSIONS

Patients with limited health literacy may benefit from a variety of interventions. However, research in this area is sparse. Further research is needed into interventions that may be beneficial for patients.

PRACTICE IMPLICATIONS

Measure, evaluate and implement health literacy-friendly options to ensure people can make safe and sound decisions for their care. Researchers need to consider the type of health literacy investigated and the type of instrument used in the research.

Empowerment of individuals in Iranian health systems: a qualitative study using the Z-cognitive map approach

The empowerment of people is considered as one of the most effective approaches in national healthcare systems. Identifying the effective criteria for this empowerment approach can be useful for planning enhancements. Therefore, studying and researching different aspects of people empowerment, and identifying the various relationships among related factors are of great importance. In this study - after identifying and extracting the effective factors in empowering individuals/insured persons, and interviewing health insurance and healthcare experts through content analysis - a causal model examining variables and their impact intensity through cognitive mapping is designed and drawn up. In modeling the concept of empowerment, to cover the ambiguity of expert comments, a combination of the Z-number approach with cognitive mapping has been used. Results demonstrate how various factors relate to insured empowerment. According to the results of empowerment strategies, the insurance participation strategy with the highest central index was determined as the most effective strategy, and the appropriate component for individuals gained the highest score in the centrality index. The results of this article help a lot to policy making in medical insurance.

Exploring patient-reported barriers to participating in proton therapy clinical trials

Introduction

Clinical trials lead the progress in healthcare. To ensure reliable research conclusions, it is essential to enroll diverse patient groups. Identifying and understanding patient-reported barriers to clinical trials may help enhance recruitment among diverse patient groups.The clinical potential of proton therapy (PT) to reduce late effects is being investigated in clinical trials worldwide. Thus, for some patients, PT is only accessible by participating in clinical trials.Individuals with smoking-related head and neck cancer (HNC) are sometimes socioeconomically deprived, leading to barriers to trial participation. This study aims to identify barriers to their participation in a randomised controlled trial (RCT) involving PT.

Method

Interviews were conducted with 14 HNC patients declining participation in an RCT involving PT. The interviews were transcribed and systematically analysed using an inductive approach identifying categories and themes.

Results

The identified barriers to RCT-participation are: (1) existential distress, which influenced participants' mental and cognitive capacities, (2) insufficient RCT-related knowledge arising from information overload during clinical consultations, (3) the wish for safety and familiarity during the treatment trajectory, particularly for participants needing accommodation during  radiotherapy, and (4) the motivation for study participation was impacted by uncertainty due to randomisation and clinical equipoise. Existential distress is identified as an overarching theme because it influences and amplifies the other three themes.

Conclusion

Existential distress is a central theme that influences and amplifies other participation barriers in PT RCTs. It affects participants' comprehension of trial information, their preference for familiar environments, and their motivation to participate in clinical trials.

Patients' experience of a novel interdisciplinary nurse-led self-management intervention (INSELMA)-a qualitative evaluation

BACKGROUND

Despite continuous improvements in anti-rheumatic pharmacological treatment, people with chronic inflammatory arthritis still report substantial disease impact. Based on the framework for complex interventions, we thus developed INSELMA, a novel nurse-coordinated multidisciplinary self-management intervention for patients with rheumatoid arthritis, psoriatic arthritis or axial spondyloarthritis. Based on individual biopsychosocial assessments, a rheumatology nurse facilitated goal setting and coordinated interdisciplinary support. The aim of this study was to explore the patients' experience of participating in the six-months INSELMA intervention.

METHODS

Individual semi-structured interviews were conducted with 15 of the participants after their final follow-up. Thematic analysis was applied.

RESULTS

The analysis derived four overall themes. (1) A new opportunity at the right time. The participants' disease impacted all areas of daily life. Participation in INSELMA was experienced as an opportunity to improve symptoms and together reduce long-held challenges they had fought alone, until now. (2) The importance of person-centred goals. The participants found it meaningful to work with their individual goals, which encompassed physical, psychological, and social factors. Having time between consultations to work with goals at home was important. (3) Empathy, partnership and a little nudging from health professionals are essential. The empathic nurses' continuous support and coaching helped participants become aware of their own resources. The participants highlighted having access to support from a physiotherapist and occupational therapist with rheumatology experience as important. (4) I got more than I could have hoped for. Most of the participants experienced decreased symptom load and improvement in physical strength, mobility, sleep, and mood as well as increased energy, knowledge, and self-management ability. The participants expressed new hope for the future with an improved ability to manage their symptoms and work towards new goals.

CONCLUSION

The participants found the INSELMA intervention meaningful and feasible. They experienced decreased disease impact and increased activity levels, facilitated by empathy and self-management support from health professionals.

Development of a patient-reported outcome measure of digital health literacy for chronic patients: results of a French international online Delphi study

BACKGROUND

A psychometrically robust patient-reported outcome measure (PROM) to assess digital health literacy for chronic patients is needed in the context of digital health. We defined measurement constructs for a new PROM in previous studies using a systematic review, a qualitative description of constructs from patients, health professionals and an item pool identification process. This study aimed to evaluate the content validity of a digital health literacy PROM for chronic patients using an e-Delphi technique.

METHODS

An international three-round online Delphi (e-Delphi) study was conducted among a francophone expert panel gathering academics, clinicians and patient partners. These experts rated the relevance, improvability, and self-ratability of each construct (n = 5) and items (n = 14) of the preliminary version of the PROM on a 5-point Likert scale. Consensus attainment was defined as strong if ≥ 70% panelists agree or strongly agree. A qualitative analysis of comments was carried out to describe personal coping strategies in healthcare expressed by the panel. Qualitative results were presented using a conceptually clustered matrix.

RESULTS

Thirty-four experts completed the study (with 10% attrition at the second round and 5% at the third round). The panel included mostly nurses working in clinical practice and academics from nursing science, medicine, public health background and patient partners. Five items were excluded, and one question was added during the consensus attainment process. Qualitative comments describing the panel view of coping strategies in healthcare were analysed. Results showed two important themes that underpin most of personal coping strategies related to using information and communications technologies: 1) questionable patient capacity to assess digital health literacy, 2) digital devices as a factor influencing patient and care.

CONCLUSION

Consensus was reached on the relevance, improvability, and self-ratability of 5 constructs and 11 items for a digital health literacy PROM. Evaluation of e-health programs requires validated measurement of digital health literacy including the empowerment construct. This new PROM appears as a relevant tool, but requires further validation.

The Brief Health Literacy Scale for Adults: Adaptation and Validation of the Health Literacy for School-Aged Children Questionnaire

The Health Literacy for School-Aged Children (HLSAC) is a brief, generic instrument measuring health literacy among school-aged children. Given its brevity and broad conceptualization of health literacy, the HLSAC is a potentially valuable measuring instrument among adults as well. This validation study aimed to adapt the HLSAC questionnaire to an adult population through assessment of content validity and subsequently determine the structural validity of the adapted instrument, the Brief Health Literacy scale for Adults (B-HLA). The content validity of the HLSAC was assessed through interviews with respondents and experts, and the structural validity of the adapted instrument (B-HLA) was evaluated using Rasch analysis. The content validity assessment (n = 25) gave rise to adjustments in the wording of five items. The B-HLA demonstrated an overall misfit to the Rasch model (n = 290). Items 6 and 8 had the poorest individual fits. We found no signs of local dependency or differential item functioning concerning sex, age, education, and native language. The B-HLA demonstrated unidimensionality and ability to discriminate across health literacy levels (PSI = 0.80). Discarding items 6 or 8 resulted in an overall model fit and individual fit of all items. In conclusion, the B-HLA appears to be a valid and reliable instrument for assessing health literacy among adults.

eHealth literacy among hospital health care providers: a systematic review

BACKGROUND

eHealth literacy is a key concept in the implementation of eHealth resources. However, most eHealth literacy definitions and frameworks are designed from the perceptive of the individual receiving eHealth care, which do not include health care providers' eHealth literacy or acceptance of delivering eHealth resources.

AIMS

To identify existing research on eHealth literacy domains and measurements and identify eHealth literacy scores and associated factors among hospital health care providers.

METHODS

This systematic review was reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 checklist. A systematic literature search was conducted in MEDLINE, Cinahl, Embase, Scopus, PEDro, AMED and Web of Science. Quantitative studies assessing eHealth literacy with original research, targeting hospital health care providers were included. Three eHealth literacy domains based on the eHealth literacy framework were defined a priori; (1) Individual eHealth literacy, (2) Interaction with the eHealth system, and (3) Access to the system. Pairs of authors independently assessed eligibility, appraised methodological quality and extracted data.

RESULTS

Fourteen publications, of which twelve publications were conducted in non-Western countries, were included. In total, 3,666 health care providers within eleven different professions were included, with nurses being the largest group. Nine of the included studies used the eHealth literacy scale (eHEALS) to measure eHealth literacy, representing the domain of individual eHealth literacy. A minority of the studies covered domains such as interaction with the eHealth system and access to the system. The mean eHEALS score in the studies ranged from 27.8 to 31.7 (8-40), indicating a higher eHealth literacy. One study reported desirable eHealth literacy based on the Digital Health Literacy Instrument. Another study reported a relatively high score on the Staff eHealth literacy questionnaire. eHealth literacy was associated with socio-demographic factors, experience of technology, health behaviour and work-related factors.

CONCLUSIONS

Health care providers have good individual eHealth literacy. However, more research is needed on the eHealth literacy domains dependent on interaction with the eHealth system and access to the system. Furthermore, most studies were conducted in Eastern and Central-Africa, and more research is thus needed in a Western context.

TRIAL REGISTRATION

PROSPERO International Prospective Register of Systematic Reviews (CRD42022363039).

Research priorities for the primordial prevention of acute rheumatic fever and rheumatic heart disease by modifying the social determinants of health

The social determinants of health (SDH), such as access to income, education, housing and healthcare, strongly shape the occurrence of acute rheumatic fever (ARF) and rheumatic heart disease (RHD) at the household, community and national levels. The SDH are systemic factors that privilege some more than others and result in poverty and inequitable access to resources to support health and well-being. Primordial prevention is the modification of SDH to improve health and reduce the risk of disease acquisition and the subsequent progression to RHD. Modifying these determinants using primordial prevention strategies can reduce the risk of exposure to Group A Streptococcus, a causative agent of throat and skin infections, thereby lowering the risk of initiating ARF and its subsequent progression to RHD.This report summarises the findings of the Primordial Prevention Working Group-SDH, which was convened in November 2021 by the National Heart, Lung, and Blood Institute to assess how SDH influence the risk of developing RHD. Working group members identified a series of knowledge gaps and proposed research priorities, while recognising that community engagement and partnerships with those with lived experience will be integral to the success of these activities. Specifically, members emphasised the need for: (1) global analysis of disease incidence, prevalence and SDH characteristics concurrently to inform policy and interventions, (2) global assessment of legacy primordial prevention programmes to help inform the co-design of interventions alongside affected communities, (3) research to develop, implement and evaluate scalable primordial prevention interventions in diverse settings and (4) research to improve access to and equity of services across the RHD continuum. Addressing SDH, through the implementation of primordial prevention strategies, could have broader implications, not only improving RHD-related health outcomes but also impacting other neglected diseases in low-resource settings.

Health literacy strengths and challenges of people in New South Wales prisons: a cross-sectional survey using the Health Literacy Questionnaire (HLQ)

BACKGROUND

Health literacy is an important factor for enabling people to manage their health and live long fulfilling lives. People in prison are frequently from marginalised communities, often out of reach of conventional community based health organisations, and have poorer health outcomes. It is essential to understanding the health literacy profiles of people in prison, and its contribution to the well-established health inequities and outcomes of this population. This study aimed to use a multi-dimensional health literacy measurement tool to describe the strengths and challenges of adults incarcerated in NSW prisons.

METHODS

A cross-sectional survey was conducted for people in prison across 14 publicly operated metropolitan prisons. Data were collected from 471 participants using the Health Literacy Questionnaire (HLQ). Participant characteristics and health conditions were also collected. Data were analysed using descriptive statistics. Effect sizes (ES) for standardised differences in means were used to describe the magnitude of difference between participant characteristic groups.

RESULTS

Participants' median age was 38.0 (range 19 - 91) years. Males comprised 81% of the sample, 21% identified as Aboriginal and/or Torres Strait Islander, and 53% reported a health problem. People in prison had lower scores for all nine HLQ scales when compared to the general Australian population. Small to medium ES were seen for mean differences between most demographic groups. Compared to males, females had lower scores for several of the HLQ scales including 'having sufficient information to manage health' (ES 0.30 [95% Confidence Interval (CI) 0.07, 0.53]), 'ability to actively engage with health care professionals' (ES 0.30 [95% CI 0.06, 0.53]), 'navigating the healthcare system' (ES 0.30 [95% CI 0.06, 0.53]), and, 'ability to find good health information' (ES 0.33 [95% CI 0.10, 0.57]). Differing health literacy scale scores with small to medium ES were found when comparing participants by legal status. Mainly small ES were seen when comparing other participant characteristic groups.

CONCLUSIONS

This study provides insights into the health literacy strengths and challenges for people in NSW prisons. These findings highlight the important role health literacy could have in addressing health disparities in this vulnerable population and can inform prison health services.

Testing a single item screener to support family doctors in identifying patients with limited health literacy: convergent validity of the SILS and the HLS-EU-Q16

BACKGROUND

Low health literacy (HL) is associated with reduced disease self-management skills, worse health outcomes, an increased number of hospitalizations, more frequent use of the emergency room and less utilization of preventive services. To support patients with low HL it is crucial to identify affected patients. HL is a multidimensional construct, which covers different skills and abilities to make informed health decisions. Validated brief screening tools to assess health-literacy-related skills or abilities in primary care settings are currently not available in German. This study aimed to validate a single item screener developed in the US for the German primary care setting.

METHODS

Our study used cross-sectional data from a survey among mainly chronically ill patients (n = 346) conducted in family practices in the state of North Rhine-Westphalia. We explored the convergent validity between a single item literacy screener (SILS) and the HLS-EU-Q16. The SILS measures functional HL by asking patients about their need for help when reading information materials. The HLS-EU-Q16 is a multidimensional HL measure frequently used for research purposes in Germany. Associations between the two instruments were examined using Spearman's correlations and regression analyses. The diagnostic performance of the SILS relative to the HLS-EU-Q16 was assessed using receiver operator curves (ROC).

RESULTS

The SILS had a statistically significant correlation with the HLS-EU-Q16 (Spearman ρ: 0.35) and explained 26% of its total variance. Stratified analyses of the convergent validity between both instruments by age, sex, migration background, education level and chronic disease status showed moderate statistically significant correlations in all subgroups (range: 0.223 to 0.428). With an area under the curve of 0.66, the receiver operator curve indicated a satisfactory diagnostic performance of the SILS relative to the HLS-EU-Q16.

CONCLUSIONS

The SILS provided an acceptable initial assessment of HL limitations among a heterogeneous population of mainly chronically ill patients in a primary care setting. With only one item, the SILS can be a short and effective tool for routine use in primary care and specialized care settings. Future research should test the SILS in other populations and pilot applications of the SILS in routine care.

Health literacy and musculoskeletal disorders in adolescents: a scoping review

OBJECTIVES

Health literacy (HL) related to musculoskeletal disorders (MSDs) in adolescents is a field with limited previous evidence. This study aimed to review and synthesise studies on MSDs and HL as well as various dimensions of HL in adolescents.

DESIGN

Scoping review in accordance with Arksey and O'Malleys framework and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews.

SEARCH STRATEGY

The search strategy was performed in the following databases in November 2021 (initial search) and December 2022 (updated search); Medline, EMBASE, PsychINFO, Cochrane, CINAHL, ERIC, Web of Science and Google Scholar. Eligible studies involving MSDs and HL or either of the HL dimensions related to finding, understanding, appraising or applying health information in adolescents were considered. Any dimension of HL studied, the outcome measure(s) used to assess HL and the type of MSD examined were charted, reviewed and synthesised. A directed content analysis was used for the subjective interpretation of text data.

RESULTS

A total of 16 841 studies were identified and 33 were eligible for inclusion. Ten articles presented HL with a definition or description in the theoretical background. The remaining 23 studies involved finding, understanding, appraising or applying health information, without using the term 'health literacy'. Most of the studies addressed how adolescents understand (n=32), and apply (n=23) health information, while few studies focused on how they find (n=11) and appraise (n=7) musculoskeletal health information.

CONCLUSION

Few studies have addressed HL and MSDs in adolescents explicitly, while most studies have considered dimensions of HL. Our findings suggest that there is important work to be done to align conceptual understandings with the measurement of HL in adolescents and that further research should be carried out to explore how HL is distributed among adolescents with MSDs and how adolescents living with MSDs report their HL.

Questioning 'Informed Choice' in Medical Screening: The Role of Neoliberal Rhetoric, Culture, and Social Context

Participation in medical screening programs is presented as a voluntary decision that should be based on an informed choice. An informed choice is often emphasized to rely on three assumptions: (1) the decision-maker has available information about the benefits and harms, (2) the decision-maker can understand and interpret this information, and (3) the decision-maker can relate this information to personal values and preferences. In this article, we empirically challenge the concept of informed choice in the context of medical screening. We use document analysis to analyze and build upon findings and interpretations from previously published articles on participation in screening. We find that citizens do not receive neutral or balanced information about benefits and harms, yet are exposed to manipulative framing effects. The citizens have high expectations about the benefits of screening, and therefore experience cognitive strains when informed about the harm. We demonstrate that decisions about screening participation are informed by neoliberal arguments of personal responsibility and cultural healthism, and thus cannot be regarded as decisions based on individual values and preferences independently of context. We argue that the concept of informed choice serves as a power technology for people to govern themselves and can be considered an implicit verification of biopower.

Arabic-speaking male immigrants' perceptions of preventive initiatives: An interview study

BACKGROUND

Arabic-speaking men are a sparsely investigated population in health promotion and disease prevention. This may hamper their ability to achieve the highest obtainable health due to less accessibility and acceptability of preventive measures.

AIM

We explored Arabic-speaking (Palestinian, Iraqi and Somali) male immigrants' perceptions of preventive initiatives in general and such initiatives for cardiovascular diseases (CVD) in particular to understand how to address inequalities in engagement in prevention.

METHODS

This qualitative study employed content analysis of semistructured interviews with 60-66-year-old Arabic-speaking men living in Denmark. Supplementary, structured data, for example, health data, were collected. From June to August 2020, 10 men were interviewed.

FINDINGS

Preventive initiatives were found ethically and culturally acceptable alongside personally and socially relevant; they were perceived as humanitarian and caring for the participants' health, respecting of their self-determination and enabling their empowerment. Thus, the participants entreated that their fellow countrymen be assisted in achieving the prerequisite coping capabilities to address inequality in access, perceived acceptance and relevance. This led us to define one main category 'Preventive initiatives - Caring and humanitarian aid empower us' with the underlying subcategories: 'We are both hampered and strengthened by our basic assumptions' and 'We need help to achieve coping capabilities enabling us to engage in preventive initiatives'.

CONCLUSION

Prevention was perceived as acceptable and relevant. Even so, Arabic-speaking men may be a hard-to-reach group due to their basic assumptions and impaired capabilities for engaging in prevention. Addressing inequality in accessibility, acceptability and relevance in regard to prevention may be promoted through a person-centred approach embracing invitees' preferences, needs and values; and by strengthening invitees' health literacy through efforts at the structural, health professional and individual levels.

PUBLIC CONTRIBUTION

This study was based on interviews. The interviewees were recruited as public representatives to assist us in building an understanding of Arabic-speaking male immigrants' perceptions of preventive initiatives in general and preventive initiatives for CVD in particular.

Effectiveness of health literacy interventions on anxious and depressive symptomatology in primary health care: A systematic review and meta-analysis

Background

Affective disorders are a debilitating and very prevalent problem throughout the world. Often these are associated with the onset of comorbidities or a consequence of chronic diseases. Anxiety and depression are associated with poor social and personal relationships, compromised health. We aimed to synthesize evidence from studies measuring the impact of a health literacy (HL) intervention on the improvement of affective disorders.

Methods

For this systematic review and meta-analysis, we searched PubMed/MEDLINE, Embase, Web of Science, Ibecs, Cuiden, Scielo, Science Direct and Dialnet for exclusively randomized controlled trial studies (RCTs) published between 1 Jan 2011, and 31 May 2022. The search terms employed were "health literacy," "health knowledge," "anxiety," "anxiety disorder," "depression," "depressive disorder," and "adult." The risk of bias assessment was performed using the Cochrane Collaboration Revised Risk of Bias tool (RoB2). We conducted random-effects meta-analyses and explored heterogeneity using meta-regression and a stratified survey.

Results

Of 2,863 citations found through the initial screening, 350 records were screened by the title and abstract for their themes and relevance. Finally, nine studies complied with the inclusion criteria for the meta-analysis. 66.66% of studies (n = 6) were rated as having a low risk of bias and 33.33% (n = 3) were judged to raise some concerns. The health literacy interventions were associated with -1.378 reduction in depression and anxiety questionnaires scores [95% CI (-1.850, -0.906)]. Low mood disorder scores are associated with better mental health and wellbeing.

Conclusion

Our findings demonstrate that an HL intervention in relation to the symptoms associated with affective disorders improves the emotional state of patients in PHC, with a moderately positive effect in reducing depression and anxiety.

Health Literacy and Smoking Habits Among a Sample of Jordanian University Students

Limited health literacy is a significant predictor of engaging in unhealthy behaviors. However, the literature regarding the association between health literacy and smoking in university students is very limited. Thus, this study was conducted to examine the association between university students' health literacy and smoking habits. A cross-sectional design was used. A sample of university students (N = 327) was recruited to conduct this study. Data collection was performed using a demographics questionnaire and the health literacy questionnaire. AMOS was used to conduct data analysis using structural equation modeling analysis with maximum likelihood estimation. Different versions of the structural model were compared and evaluated based on specific fit indices criteria. The results showed that 30% of the participants were current smokers. Smoking cigarettes was the most common type of smoking in this study, and 23.1% of the participants were current users of two or more types of smoking (e.g., cigarettes and hookah). The structural model with three latent variables (health literacy, smoking status and type, and smoking frequency and duration) was the one that best fit the data; the model fit indices were X² = 305.84, df = 102, p < .001; RMSEA = .068; CFI = .95; CMIN/df = 2.51; TLI = .929; and AIC = 355.75. A single standard deviation increase of health literacy causes .38 decrease in smoking status and type and .13 decrease of smoking frequency and duration. The results showed that health literacy is negatively associated with smoking in a sample of Jordanian university students.

Effects of Health Literacy Promotion Programs for Preventing Opisthorchiasis and Cholangiocarcinoma: a Systematic Review and Meta-analysis

Cholangiocarcinoma (CCA), caused mainly by Opisthorchis viverrini (OV) infection, is a public health issue. Health literacy can play a significant role in preventing OV and CCA and adopting preventive behaviors. Therefore, this study aimed to evaluate, summarize, and synthesize the current evidence on health literacy programs for preventing OV and CCA.A systematic literature search, with Thai and English languages, was performed using electronic databases through PubMed, Google Scholar, ThaiJo, ThaiLis, and Embase to identify studies examining health literacy programs to prevent OV and CCA. We followed PRISMA 2020 guidelines. In addition, we used the RevMan software to perform a meta-analysis to analyze effect sizes using a fixed-effects model and measures of heterogeneity using Cochran's Q and I². This meta-analysis included seven studies that met the criteria. The results showed that the people who received a program had an increased health literacy overall and in each aspect with a statistically significant (p < 0.001). So, health literacy programs can assist people in understanding their health and gaining access to health information and services. Additionally, the effect of programs (communication abilities, self-management, media and information literacy, and decision-making in practice) can help prevent OV and CCA. As a result, multi-disciplinary healthcare teams are crucial to developing preventive programs to prevent OV and CCA. Further studies need to be done and applied to these programs to modify behavior to avoid other diseases.

Development and validation of a comprehensive health literacy tool for adults in Hong Kong

Introduction

Health literacy (HL) refers to an individual's ability to process and use health information to make health-related decisions. However, previous HL scales did not fully cover all aspects of this concept. This study aimed to develop a comprehensive Hong Kong HL scale (HLS-HK) and evaluate its psychometric properties among Chinese adults.

Methods

A scale of 31-item covering Nutbeam's framework, namely functional and interactive HL (FHL and IHL), and critical HL (CHL) within three subdomains: critical appraisal of information, understanding of social determinants of health, and actions to address social determinants of health, was developed based on previous literature review and Delphi survey. Cognitive interviews were performed to examine all items' face validity in terms of three aspects: comprehensiveness, clarity, and acceptability. A cross-sectional survey was conducted to investigate the scale's psychometric properties, including its internal consistency reliability, factorial structure validity, convergent validity, and predictive validity.

Results

Nine interviewees participated in the cognitive interviews in October 2021. Based on the input from respondents, two items were deleted, two items were combined, and several items' wording was revised. The other items were clear and readable. Finally, 28 items remained. A total of 433 adults completed the questionnaire survey between December 2021 and February 2022. After excluding one item with low inter-item correlations, the scale's internal consistency reliability was acceptable, with a Cronbach's alpha of 0.89. Exploratory factor analysis produced a five-factor model, as shown in the original theoretical framework. These factors accounted for 53% of the total variance. Confirmatory factor analysis confirmed that the fit indices for this model were acceptable (comparative fit index = 0.91, root mean square error of approximation = 0.06, and root mean square residual = 0.06). The scale is also significantly correlated with theoretically selected variables, including education and self-rated health.

Conclusion

The HLS-HK is a valid and reliable tool for evaluating HL. Compared with existing tools, this scale extended the operationalization of FHL, IHL, and CHL and fully operationalized the CHL via three subdomains. It can be used to understand the difficulties and barriers that people may encounter when they use health-related information and services.

Developing the HLS19-YP12 for measuring health literacy in young people: a latent trait analysis using Rasch modelling and confirmatory factor analysis

BACKGROUND

Accurate and precise measures of health literacy (HL) is supportive for health policy making, tailoring health service design, and ensuring equitable access to health services. According to research, valid and reliable unidimensional HL measurement instruments explicitly targeted at young people (YP) are scarce. Thus, this study aims at assessing the psychometric properties of existing unidimensional instruments and developing an HL instrument suitable for YP aged 16-25 years.

METHODS

Applying the HLS₁₉-Q47 in computer-assisted telephone interviews, we collected data in a representative sample comprising 890 YP aged 16-25 years in Norway. Applying the partial credit parameterization of the unidimensional Rasch model for polytomous data (PCM) and confirmatory factor analysis (CFA) with categorical variables, we evaluated the psychometric properties of the short versions of the HLS₁₉-Q47; HLS₁₉-Q12, HLS₁₉-SF12, and HLS₁₉-Q12-NO. A new 12-item short version for measuring HL in YP, HLS₁₉-YP12, is suggested.

RESULTS

The HLS₁₉-Q12 did not display sufficient fit to the PCM, and the HLS₁₉-SF12 was not sufficiently unidimensional. Relative to the PCM, some items in the HLS₁₉-Q12, the HLS₁₉-SF12, and the HLS₁₉-Q12-NO discriminated poorly between participants at high and at low locations on the underlying latent trait. We observed disordered response categories for some items in the HLS₁₉-Q12 and the HLS₁₉-SF12. A few items in the HLS₁₉-Q12, the HLS₁₉-SF12, and the HLS₁₉-Q12-NO displayed either uniform or non-uniform differential item functioning. Applying one-factorial CFA, none of the aforementioned short versions achieved exact fit in terms of non-significant model chi-square statistic, or approximate fit in terms of SRMR ≤ .080 and all entries ≤ .10 that were observed in the respective residual matrix. The newly suggested parsimonious 12-item scale, HLS₁₉-YP12, displayed sufficiently fit to the PCM and achieved approximate fit using one-factorial CFA.

CONCLUSIONS

Compared to other parsimonious 12-item short versions of HLS₁₉-Q47, the HLS₁₉-YP12 has superior psychometric properties and unconditionally proved its unidimensionality. The HLS₁₉-YP12 offers an efficient and much-needed screening tool for use among YP, which is likely a useful application in processes towards the development and evaluation of health policy and public health work, as well as for use in clinical settings.

Development and psychometric analysis of a new tool to assess food literacy in diabetic patients

Background

One of the factors affecting self-care in diabetic patients is food literacy, which helps said patients in following a healthy diet. Thus, it is crucial to analyze food literacy in diabetic patients through suitable and reliable instruments. 

Objective

The current study aimed to design a questionnaire for food literacy assessment in diabetic patients and analyze its psychometric features.

Method

The present study was a cross-sectional descriptive analysis carried out in 2021. Firstly, the concepts of food literacy in diabetic patients were identified and the questionnaire was deigned based on them. Secondly, its face and content validities and its reliability were analyzed. Finally, the construct validity was analyzed by exploratory factor analysis. The study was carried out on 300 diabetic participants chosen at random via stratified cluster sampling from Health service centers. The exploratory factor analysis was carried out by extracting the main factors and using varimax rotation with eigenvalue values more than 1.

Results

A five-pronged structure accounted for 52.745% of food literacy variance. This included the ability to read food facts, practical ability to group foods, the ability to identify the caloric content of different foods, the ability to understand the effect of food on health, and the ability to prepare a healthy meal. Items with an impact score below 1.5 were discarded. Additionally, items with CVR scores below 0.62 and CVI scores below 0.79 were deleted too. The Kaiser-Meyer-Okin measurement was 0.836 (p < 0.001). Alpha Cronbach Scale dimension was 0.610–0.951.

Conclusion

The results of this study showed that the exploratory dimensions of the current study were consistent with health literacy measurements, such as functional, interactive, and critical food literacy. This scale has acceptable reliability and validity. Health professionals can use this scale to analyze and improve food literacy in diabetic patients. This is a new instrument and thus far no questionnaire has been made to evaluate food literacy in diabetic patients.

Developing a Health Literacy Scale for adults in Hong Kong: A modified e-Delphi study with healthcare consumers and providers

INTRODUCTION

Health literacy (HL) refers to individuals' abilities to process and use health information to promote health. This study aimed to develop the first HL measurement tool for the Chinese Hong Kong population.

METHODS

A two-phase methodology was adopted. In Phase I, evidence synthesis with a deductive method was conducted to formulate the item list from the literature. In Phase II, a modified e-Delphi survey was conducted among stakeholders (i.e., healthcare providers and healthcare consumers) to confirm the content validity of the item list. The stakeholders were invited to rate the relevance of each draft item on a 4-point scale and provide suggestions for revisions, removal or adding new items.

RESULTS

In Phase I, a total of 34 items covering functional, interactive and critical HL were generated. In Phase II, to obtain a balanced view from experts and laypeople, healthcare professionals (n = 12) and consumers (n = 12) were invited to participate in the Delphi panel. The response rates of the three rounds were 100%. After the third round, the consensus was reached for 31 items, and no further comments for adding or revising items were received. All items exhibited excellent content validity (item content validity index: 0.79-1.00; K*: 0.74-1.00).

CONCLUSIONS

A Health Literacy Scale for Hong Kong was developed. Compared with existing HL scales, the scale fully operationalized the skills involved in functional, interactive and critical HL. The Delphi study shows evidence supporting the high content validity of all items in the scale. In future studies, these items should undergo rigorous testing to examine their psychometric properties in our target population groups. By illuminating the details in the development process, this paper provides a deeper understanding of the scale's scope and limitations for others who are interested in using this tool.

PATIENT OR PUBLIC CONTRIBUTION

Public as healthcare consumers, in addition to healthcare providers, were involved in developing a new HL scale for this study. The input from the public contributed to examining the scale's content validity by judging whether all items reflected the skills that they need to find and use health-related information in their daily life.

[Quality assurance follow-up survey of the ELISA cohort study on the prevalence of COVID-19: The view of study participants - What is well received?]

INTRODUCTION

With the outbreak of the Corona pandemic, the LübEcker longitudinal study on infections with SARS-CoV-2 (ELISA study) was conducted in the Lübeck area to provide information on the prevalence, unreported cases and symptoms of COVID-19. The aim of the present study is to evaluate defined structure and process indictors of the study conduct of the ELISA study by subjects.

METHODS

After defining and operationalizing participant-oriented quality indicators, 3,710 participants were surveyed online via LimeSurvey. Indicators defined were access to the study, time requirements, reporting of findings, ratings of the study apps used, communication, study center, tolerability of sample collection, and willingness to re-participate. In addition, comments on push and pull factors of study participation could be made. The evaluation was both quantitative and qualitative.

RESULTS

45% of the follow-up respondents (n=1,684) answered the questions on the defined structural and process indicators. In the quantitative part of the survey, tolerability of venous blood sampling was rated as significantly better than that of nasopharyngeal smears. 91% of the follow-up respondents welcomed the offer to view their findings in the personal results portal. Overall, the indicators were mostly rated positively. According to the qualitative data, the study participants found the win-win situation of the test opportunity to contribute to research, the local relevance of the study, the small incentives, and the low-threshold nature of the study registration to be positive aspects of the study. According to the quantitative data, participants suggested improving the usability of the digital applications in terms of more user-friendly identification solutions, reminder functions, announcements of software updates and avoidance of double entries.

DISCUSSION

The defined structure and process indicators appear to be suitable for assessing the quality of study implementation from the subjects' point of view and indicate a good quality of study implementation under pandemic conditions. The lowest participation rate (75%) was measured at the fifth test time of strongly declining COVID-19 infections during the summer holidays in Schleswig-Holstein. Obviously, the benefit and meaningfulness of further study participation as well as competing factors were weighted differently by the subjects at this point. The follow-up survey suggests a variety of options for motivating participants to maintain a high level of participation. Possible limitations are that a non-response bias cannot be excluded for the follow-up survey and that no suitable standardised questionnaire was available.

CONCLUSION

The present study provides recommendations for the planning of future cohort studies. It makes sense to continuously evaluate the motives for participation or non-participation and to explicitly consider them in the course of the study. Therefore, the definition of general quality indicators for the practical implementation of studies seems desirable. Positive experiences of the participants in connection with study participation are important, such as good time management, short response times, technical support offers and additional services such as a study homepage with frequently asked questions (FAQs), timely individual notifications of results and transparent, generally understandable information about study results during the study. Digital solutions are well received, but can still be improved for specific studies.

Actions Speak Louder Than Words: Health Behaviours and the Literacy of Future Healthcare Professionals

Our everyday behaviours in life can positively and negatively impact our health, thus cumulatively shaping our lifestyles as more or less healthy. These behaviours are often determined by our knowledge, literacy, motivations and socioeconomic backgrounds. The authors aimed to assess health behaviours and explore variables that may affect persons studying to become future healthcare professionals in Poland. This study was conducted with a group of 275 undergraduate students attending the Poznan University of Medical Sciences representing six different majors of study. We used self-reported, cross-sectional survey conducted through the use of a questionnaire that consisted of one standardised scale (Juczyński’s Health Behaviour Inventory) as well as a self-developed health literacy measure. The students showed average to high levels of health-promoting behaviours (mean HBI = 82.04 ± 11.26). Medium to strong associations were found between these behaviours and high scores on the health literacy scale (p = 0.001, r = 0.45 between total scores of the two scales). Dietetics students and female respondents scored significantly better on both scales, which suggests that their self-reported behaviours and health literacy were higher than those of other participants. Exhibiting health-protective behaviours and high health literacy is likely to result in the better individual health of our respondents, but, more importantly, will also influence their future professions. As members of the healthcare workforce they will be responsible for the health of the population and it is crucial for them not only to provide care, education, and guidance, but also to act as role-models for their patients and society.

Exploring the Relationships between Children's Oral Health and Parents' Oral Health Knowledge, Literacy, Behaviours and Adherence to Recommendations: A Cross-Sectional Survey

Although preventable, early childhood caries (ECC) is a burdening condition in all WHO regions, with Poland being one of the most affected countries in Europe. Effective home-based prevention of ECC is available and recommended by several expert bodies. Therefore, we wanted to determine how well parents were following selected oral health recommendations in preschool children. Additionally, we wanted to determine which socioeconomic factors influenced such practices the most, and how parents' oral health literacy and behaviours affected the oral hygiene and oral health status of their children. A cross-sectional survey involving 2338 parents and caregivers of children from 167 kindergartens was performed. Children's oral hygiene and oral health status were found to be associated with parents' education and economic status. They were also strongly influenced by parental health literacy and behaviours. With respect to recommendations for preschoolers, the lowest adherence was found in the use of fluoride toothpaste and its age-appropriate amount, supervision of toothbrushing, and refraining from eating after last toothbrushing. The improvement in these areas could be achieved thanks to the involvement of health professionals such as gynaecologists, midwives, and primary care personnel in efforts aimed at increasing parents' oral health knowledge and literacy.

Actions Speak Louder Than Words: Health Behaviours and the Literacy of Future Healthcare Professionals

Our everyday behaviours in life can positively and negatively impact our health, thus cumulatively shaping our lifestyles as more or less healthy. These behaviours are often determined by our knowledge, literacy, motivations and socioeconomic backgrounds. The authors aimed to assess health behaviours and explore variables that may affect persons studying to become future healthcare professionals in Poland. This study was conducted with a group of 275 undergraduate students attending the Poznan University of Medical Sciences representing six different majors of study. We used self-reported, cross-sectional survey conducted through the use of a questionnaire that consisted of one standardised scale (Juczyński’s Health Behaviour Inventory) as well as a self-developed health literacy measure. The students showed average to high levels of health-promoting behaviours (mean HBI = 82.04 ± 11.26). Medium to strong associations were found between these behaviours and high scores on the health literacy scale (p = 0.001, r = 0.45 between total scores of the two scales). Dietetics students and female respondents scored significantly better on both scales, which suggests that their self-reported behaviours and health literacy were higher than those of other participants. Exhibiting health-protective behaviours and high health literacy is likely to result in the better individual health of our respondents, but, more importantly, will also influence their future professions. As members of the healthcare workforce they will be responsible for the health of the population and it is crucial for them not only to provide care, education, and guidance, but also to act as role-models for their patients and society.

Health literacy measurement: embracing diversity in a strengths-based approach to promote health and equity, and avoid epistemic injustice

Definitions of health literacy have evolved from notions of health-related literacy to a multidimensional concept that incorporates the importance of social and cultural knowledge, practices and contexts. This evolution is evident in the development of instruments that seek to measure health literacy in different ways. Health literacy measurement is important for global health because diverse stakeholders, including the WHO, use these data to inform health practice and policy, and to understand sources of inequity. In this Practice paper, we explore the potential for negative consequences, bias and epistemic injustice to occur when health literacy instruments are used across settings without due regard for the lived experiences of people in various contexts from whom data are collected. A health literacy measurement approach that is emic-sensitive, strengths based and solution oriented is needed to minimise biased data interpretation and use and to avoid epistemic injustice.