Assessment of the Chinese Resident Health Literacy Scale in a population-based sample in South China

A study on the effect of school and family environments and self-efficacy on health literacy of college students

Background

Health literacy is an important means to improve health outcomes and reduce health disparities. It plays an important role in promoting multiple health-related behaviors of individuals. Numerous studies have demonstrated a number of sociodemographic and school characteristics, and family related factors were related to health literacy among college students. However, these characteristics and factors were relatively unchangeable. Research on the relationship between factors, that can be intervened, and health literacy remains scarce. This study aims to explore the association between personal and changeable environmental factors, and the level of health literacy in college students.

Methods

A cross-sectional study, which used a stratified random sampling method, was conducted at a university in Wuhan (N = 447). The survey questionnaire included sociodemographic characteristics, the School Environment Questionnaire, the Family Environment Questionnaire, the General Self-Efficacy Scale Questionnaire, and the Health Literacy Questionnaire. We used Spearman correlation tests, and Student's tests or analyses of variance to describe the relationship among continuous variables. In addition, we employed linear regression analysis to test the mediating effect based on the bias-corrected nonparametric percentile Bootstrap method.

Results

Factors related to socioeconomic status, such as living costs (p = 0.011), residential area (p = 0.003), annual household income (p = 0.001), and parents' education level (fathers: p = 0.001; mothers: p = 0.01) and occupation type (fathers: p < 0.001; mothers: p = 0.044), had close correlations with health literacy. School and family environments and self-efficacy had a positive impact on college students' health literacy (β = 0.235, p < 0.001; β = 0.323, p < 0.001; β = 0.489, p < 0.001). Self-efficacy had a mediating effect on the relationship between school and family environments, as well as health literacy. The total, direct, and indirect effects of the school environment on health literacy were 0.235, 0.157, and 0.078, respectively. The total, direct, and indirect effects of the family environment on health literacy were 0.323, 0.189, and 0.134, respectively.

Conclusion

This study confirms that improving school and family environments could directly or indirectly increase college students' health literacy through promoting their self-efficacy. Socioeconomic status has a significant impact on their health literacy. Moreover, other factors that affect students' health literacy and relationships among self-efficacy, surrounding environments, and health literacy may need to be explored in the future.

The association between health literacy and e-cigarette use: evidence from Zhejiang, China

Objectives

The worldwide popularity of electronic cigarettes (ECIG) is becoming a public health concern. Compared to conventional cigarettes (CIG), the harm caused by ECIG is more insidious. Studies have shown that lower health literacy (HL) is associated with CIG use; however, the relationship between HL and ECIG use remains controversial. Because ECIG emerged more recently than CIG, there are fewer relevant studies, and the sample populations and evaluation methods of HL in existing studies differ. This study conducted a large-sample survey to examine the relationship between HL and ECIG use.

Methods

As part of the 2022 China Health Literacy Survey, a total of 60,998 valid questionnaires were collected from September to November in 2022 using a stratified multistage probability proportional to the population size sampling frame. Chi-square tests and multinomial logistic regression was used to analyze the relationship between HL and ECIG use. Some demographic variables were included as covariates in the analysis.

Results

The study showed that the average HL score and the HL level of Zhejiang residents in 2022 were 42.8 and 30.8%, respectively. The prevalence of CIG and ECIG was 19.7 and 1.0%, respectively; 19% of participants exclusively used CIG, while only 0.3% of participants used ECIG exclusively; dual users accounted for 0.6%. After adjusting for covariates, adequate HL was associated with lower odds of ECIG-exclusive use (odds ratio [OR] = 0.452, p < 0.001), CIG-exclusive use (OR = 0.833, p < 0.001), and dual use (OR = 0.632, p < 0.001). Young age, male sex, unmarried status, high-income status, and absence of chronic disease were also associated with ECIG use.

Conclusion

HL was a protective factor against both patterns of ECIG use, especially ECIG-exclusive use. Health policymakers and public health practitioners should consider HL as a potential measure for ECIG control.

The influence of health literacy and knowledge about smoking hazards on the intention to quit smoking and its intensity: an empirical study based on the data of China's health literacy investigation

OBJECTIVE

This study explored the relationship between smokers' health literacy, knowledge of smoking hazards, and their intention to quit.

METHODS

Based on data from the 2019 Health Literacy and Tobacco Use Surveillance among residents of a city in Zhejiang Province, 1120 male smokers were screened. Differential tests were used to analyze whether smokers with varying levels of health literacy and knowledge about smoking hazards differed in their intention to quit smoking and the intensity of their intention. A multi-factor logistic regression model was constructed to explore the extent of these differences.

RESULTS

Only 24.8% of smokers had higher health literacy. Among smokers, those with an intention to quit had a higher health literacy level compared to those without such intention (32.7% vs. 17.0%, p < 0.001). Health literacy levels did not differ significantly between groups with different intensity of intention to quit (34.2% vs. 31.9% vs. 30.1%, p = 0.435). About 48.7% of the smokers a higher level of knowledge about smoking hazards. It was more prevalent in the intent to quit group compared to the no intent to quit group (54.0% vs. 43.4%, p < 0.001), and the low intent to quit group had lower knowledge compared to the moderate and high intent to quit groups (49.1% vs. 56.6% vs. 63.4%, p = 0.011). After adjusting for other influences, smokers with lower health literacy were less likely to have intention to quit (OR = 0.659, p = 0.016). And the association between knowledge about smoking hazards and whether smokers have the intention to quit is no longer significant, but it significantly affects the intensity of the intention to quit among smokers who already have the intention (OR = 0.623, p = 0.005).

CONCLUSION

General health literacy may play a role in facilitating smokers' progression from the stage of no intent to quit to one of intent to quit, but a more specific understanding of the harms of smoking may be needed to increase the strength of intent to quit.

Assessing pharmacogenomic literacy in China through validation of the Chinese version of the Minnesota Assessment of Pharmacogenomic Literacy

Pharmacogenomics (PGx) implementation into clinical care is rapidly increasing in China. However, the extent to which the public understands PGx testing and important knowledge domains requiring patient education or counseling remains unclear. To address this, we created and validated the Chinese version of the Minnesota Assessment of Pharmacogenomic Literacy (MAPL-CTM ). The MAPL-C was developed by translating the English MAPL to Chinese following cross-cultural translation guidelines. An online survey validated the MAPL-C and assessed Chinese individuals' PGx literacy. Validation analyses were performed and associations of PGx literacy with participants' characteristics were quantified. Of 959 high-quality responses, the majority of respondents were Han Chinese (96.3%), men (54.5%), aged 18-29 years (70.9%), residing in China (97.3%), and had received college or higher education (95.0%). Out of 15 starting items developed to query specific predefined knowledge domains, two uninformative items were excluded, resulting in a 13-item MAPL-C. Chinese participants' MAPL-C performance was best explained by a three-factor model, encompassing PGx concepts and function, testing limitations, and privacy. Higher MAPL-C performance was associated with younger age, higher education, and previous genetic testing experience. Correct response rates for questions related to testing limitations were lower than those in other domains. The creation and validation of the MAPL-C fills a gap in determining PGx knowledge among Chinese speakers, quantifying PGx literacy within a Chinese cohort, and identifying response patterns and knowledge gaps. The MAPL-C can be useful in clinical practice to guide patient counseling, assess PGx education interventions, and quantify PGx knowledge in relation to outcomes in research studies involving Chinese participants.

Media exposure, trustworthiness of sources and the health information literacy knowledge gap: a study in China

Health information literacy (HIL), as an essential part of the wellbeing of citizens, is a crucial indicator used to measure a country's primary public health level. The present study collected 1051 samples in southern China to examine the factors predicting HIL. The results showed that males, those less educated, and older adults had lower HIL. Television exposure, unofficial Internet exposure, trust in government and trust in doctors and medical institutions were positively associated with HIL. In contrast, newspapers, radio exposure and trust in web celebrities were negatively associated with HIL. Official Internet media exposure helps to bridge the HIL knowledge gap generated by differences in education level, while trust in celebrities-especially web celebrities-could widen the HIL knowledge gap. This study extends the knowledge gap theory in health communication in the Chinese context and provides pathways for future health interventions.

Association of length of service and job category with occupational health literacy of port employees in Shenzhen, China

BACKGROUND

Health literacy (HL) is associated with health outcomes, but little is known about the occupational HL (OHL) for port employees and its link to the length of service and job category.

METHOD

A cross-sectional survey was conducted on 3492 port employees from the Occupational Health Survey for Port Employees project, and a special questionnaire was utilized to measure the OHL status. Binary and ordinal logistic regressions were used to estimate the association.

RESULT

Among the participants, 72.90% had sufficient OHL with a mean score (standard deviation) of 53.10 (7.26). Binary logistic regression results indicated that the association between length of service (33-40 years group Adjusted OR = 1.11; 41-49 years group Adjusted OR = 1.14; ≥50 years group Adjusted OR = 1.19) and job category (longshoremen Adjusted OR = 0.90; driver Adjusted OR = 0.91) with OHL were statistically significant. Ordinal logistic regression results indicated that, for OHL, Adjusted OR was increased in different lengths of service level (33-40 years group, Adjusted OR = 1.50; 41-49 years group, Adjusted OR = 1.75; ≥50 years group, Adjusted OR = 2.19), and the Adjusted OR of skilled workers was 1.60.

CONCLUSION

Most port participants had sufficient OHL, and the length of service and job category could affect OHL. The effect of the length of service may be more obvious; the length of service can promote the improvement of OHL continuously.

Revised Chinese resident health literacy scale for the older adults in China: simplified version and initial validity testing

Objective

This study aimed to develop a short version of the Chinese Resident Health Literacy Scale focused on older adults in China, and further assess the reliability and validity of this short version.

Methods

The data was from a cross-sectional community-based older adults health survey conducted in 2020. The total of 5,829 older adults were randomly divided into two parts using for the simplification and assessment of the scale, respectively. Item Response Theory (IRT) and Differential Item Functioning (DIF) were used for item analysis and scale simplification. Cronbach's alpha and McDonald's omega were used to assess the reliability and three factors Confirmatory Factor Analysis (CFA) was used to assess the validity, which were compared to the original version. Moreover, Multi-group Confirmatory Factor Analysis (MCFA) was used to test the model invariance of the short version across groups of gender, age groups, level of education, and cognitive status.

Results

The simplified version consisted of 27 items taken from 50 original items, of them 11 items from the dimension of knowledge and attitudes, 9 items from the dimension of behavior and lifestyle, and 7 items from the dimension of health-related skills. The overall Cronbach's alpha and McDonald's omega were both 0.87 (95%CI: 0.86-0.88). The goodness-of-fits of CFA in simplified version were still acceptable in CFI, TLI, GFI, and RMSEA, even improved in CFI, TLI, and GFI compared to those of original version. Also, the model was stable and invariant in MCFA across gender, cognitive status, and educational level groups.

Conclusion

In this study, we formed a simplified instrument for measuring health literacy focused on older adults in China. This short version might be more suitable for the priority recommendation in extended tracking of the dynamic changes on the levels of health literacy in the whole life cycle in public health settings. Further research might be to identify the cut-off values to distinguish the older adults with different levels of health literacy.

Influence of health literacy on health outcomes of different social strata-- an empirical study based on the data of China's health literacy investigation

BACKGROUND

Health literacy has always been considered as an important factor to promote people's health, but does it have a significant effect on health across all social strata and especially lower social strata? This study aims to analyze the influences of health literacy on health outcomes of different social strata, and then infer whether improving health literacy can reduce health disparities among different social strata.

METHODS

Utilizing health literacy monitoring data from a city in Zhejiang Province in 2020, the samples are divided into three social strata according to the socioeconomic status score: low, middle and high social stratum, to compare whether there are significant differences in health outcomes between population with lower and higher health literacy among different social strata. In the strata with significant differences, control the confounding factors to further verify the influence of health literacy on health outcomes.

RESULTS

In low and middle social strata, there are significant differences between population with lower and higher health literacy, when considering the two types of health outcomes (chronic diseases and self-rated health), but in high social stratum, this difference is not significant. After controlling the relevant variables, the influence of health literacy on the prevalence of chronic diseases is statistically significant only in low social stratum, and the health literacy is negatively correlated with the prevalence of chronic diseases(OR = 0.722, P = 0.022). In addition, there are statistical significances for positive impact of health literacy on self-rated health in both low and middle social strata (OR = 1.285, P = 0.047; OR = 1.401, P = 0.023).

CONCLUSION

Compared with high social stratum, the influence of health literacy on health outcomes of low social stratum (chronic diseases) or both middle and low social strata (self-rated health) is more significant, and both are to improve the health outcomes. This finding suggests that improving residents' health literacy may be an effective way to alleviate the health disparities among different social strata.

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.

Investigation of health literacy status and related influencing factors in military health providers of Chinese People's liberation Army, a cross-sectional study

OBJECTIVE

The aim of this study was to investigate health literacy and analyze its influencing factors in military health providers of the Chinese People's Liberation Army (PLA Army).

METHODS

From November to December 2018, cluster sampling was used to select 1512 military health providers from the Army Medical University. Health literacy was measured by using the Chinese Citizen Health Literacy Questionnaire (HLQ) (2015 edition). Influencing factors that may affect health literacy were assessed using the chi-square test and multivariate logistic regression models.

RESULTS

The knowledge rate of health literacy was relatively low (21.6%). The knowledge rate of health-related skills (HRS, 18.7%) was the lowest of the three aspects of health literacy, and the knowledge rate of chronic diseases (CD, 19.6%) was the lowest of the six dimensions of health literacy. Participants who were older, were female, were of Han ethnicity, were the only child in their families, came from urban areas, never used tobacco, and had higher household income were likely to have higher health literacy.

CONCLUSION

The health literacy levels of military health providers of the PLA Army are relatively low. Further research and health education are necessary to improve health literacy.

The development and validation of Chinese Health Literacy Scale (CHLS) for older people

OBJECTIVES

We tried to develop a more concise health literacy scale for Chinese older adults.

METHODS

A draft scale based on the Health Literacy Questionnaire (HLQ) was developed, and revised by experts. We conducted a pilot study to test the readability and establish a standard inquiry method within 10 residents. We tested the validity and internal consistency using a field test with 3,739 participants.

RESULTS

Overall standardized Cronbach's α of Chinese Health Literacy Scale (CHLS) was 0.86 and that of each dimension ranged from 0.69 to 0.81. Nearly all dimensions had satisfactory factor loadings (0.33-0.98). The correlation coefficient between the score of each item and its dimension ranged from 0.59 to 0.92.

CONCLUSIONS

The performance of CHLS was almost the same as the HLQ but more concise. It might play a role in reflecting the health literacy of older adults in China and further promoting their health.

Health literacy and fatigue, anxiety, depression, and somatic symptoms in patients with differentiated thyroid carcinoma from West China: A cross-sectional study

Background and Aims

Differentiated thyroid carcinoma (DTC) patients are associated with excellent prognosis but impaired health-related quality of life (HRQOL) by initial and subsequent therapy. Health literacy plays a pivotal role in public health and medical settings, but data on its relationship with DTC patients' HRQOL are insufficient and equivocal. This study was designed to explore the relationship between health literacy and HRQOL in patients with DTC from West China areas.

Methods

A cross-sectional study with a descriptive correlational design was conducted. 126 patients with DTC were recruited between 2020 and 2021. Levels of health literacy and HRQOL (including fatigue level, anxiety/depression status, and somatoform symptoms) were assessed by questionnaires. Pearson product-moment correlation and Stepwise multiple regression were used to examined the adjusted association of health literacy with HRQOL.

Results

Health literacy and receiving DTC-related education together explained 16.2% of the variance in fatigue level. Patients who had higher health literacy, received more DTC-related education were currently employed and less fatigue. Health literacy, fatigue level and DTC-related education together explained 31.0% of the variance in anxiety and depression of DTC patients. Patients who had higher health literacy, received more DTC-related education and less fatigue level were less anxious and depressive. Age explained 8.3% of the variance in DTC patients' somatoform symptoms. Older patients complained more somatoform symptoms.

Conclusion

Health literacy was positively associated with HRQOL in DTC patients regarding to fatigue level and anxiety/depression status across the entire sample. Interventions to improve HRQOL should take the patients' health literacy into account.

Do Health Information Sources Influence Health Literacy among Older Adults: A Cross-Sectional Study in the Urban Areas of Western China

BACKGROUND

Previous studies have found that the dissemination pattern and delivery mechanism of information can provide crucial resources and empowerment for individuals to the promotion of health literacy. The present study investigates how health information sources are associated with health literacy among older adults in west China, and tries to explain the mechanisms underlying the link between health information sources and health literacy in the Chinese context.

METHODS

The cross-sectional study employed a representative sample of 812 urban citizens aged 60 and older in 2017 in Western China.

RESULTS

We found that health information sources including healthcare practitioners (B = 4.577, p < 0.001), neighbors (B = 2.545, p < 0.05), newspapers (B = 4.280, p < 0.001), and television (B = 4.638, p < 0.001) were positively associated with health literacy. Additionally, age (B = -1.781, p < 0.001) was negatively associated with health literacy, and the socio-economic status factors including minority (B = -10.005, p < 0.001), financial strain status of perceived very difficult (B = -10.537, p < 0.001), primary school (B = 11.461, p < 0.001), junior high school (B = 18.016, p < 0.001), polytechnic school or senior high school (B = 21.905, p < 0.001), college and above (B = 23.433, p < 0.001) were significantly linked to health literacy, and suffering from chronic diseases (B = 3.430, p < 0.01) was also positively related to health literacy.

CONCLUSIONS

Health information sources including healthcare practitioners, neighbors, newspapers, and television have a strong influence on health literacy, which implies that the four main types of sources are the important patterns of health information dissemination in the reinforcement of health literacy. In addition, the present findings also indicate age, minority and disease differences in health literacy and confirm the influence of enabling factors including educational attainment and financial strain on health literacy. Based on these findings and their implications, specific evidence is presented for the reinforcement of health literacy in interpersonal and mass communication, and in the educational and financial settings in the Chinese context. The present results also suggest that the age-specific, minority-specific and disease-specific measures should be taken to promote health literacy among older adults.

Does health literacy promote COVID-19 awareness? Evidence from Zhejiang, China

Background

Health literacy (HL) is considered a crucial determinant of disease prevention and control. However, the role of HL in the Coronavirus Disease 2019 (COVID-19) pandemic has not been studied using provincial representative data among Chinese residents. This study aimed to assess the association between HL and COVID-19 awareness among Zhejiang residents based on the 2020 China Health Literacy Survey (CHLS).

Methods

The study was conducted among 5,596 residents aged 15-69 in Zhejiang using multistage, stratified, and probability proportional to size sampling. COVID-19 awareness and HL were assessed using the "Chinese Citizen Health Literacy Questionnaire (2020)" in Zhejiang. The covariates were divided into predisposing factors, enabling factors, and need factors according to Anderson's model. Data were analyzed by the chi-square test and logistic regression.

Results

The study showed that HL and COVID-19 awareness levels of residents were 24.84% and 8.06%, respectively, in Zhejiang in 2020. After adjusting for covariates, residents with adequate HL were more likely to have better COVID-19 awareness (odds ratio [OR] = 5.22, 95% CI = 4.13-6.59, p < 0.001). Three dimensions of HL (knowledge and attitudes, behavior and lifestyle, and health-related skills) were associated with COVID-19 awareness. Additionally, COVID-19 awareness was associated with age, occupation, family size, annual household income, and chronic conditions.

Conclusion

COVID-19 awareness is significantly associated with HL, suggesting that promoting HL is an important component of health education, disease prevention, and health promotion in response to the COVID-19 pandemic and even possible public health emergencies in the future.

The relationship between dyslipidemia and inflammation among adults in east coast China: A cross-sectional study

Objective

Dyslipidemia is one of the major public health problems in China. It is characterized by multisystem dysregulation and inflammation, and oxidant/antioxidant balance has been suggested as an important factor for its initiation and progression. The objective of this study was to determine the relationship between prevalence of dyslipidemia and measured changes in the levels of proinflammatory cytokines (IL-6, TNF-a, and MCP-1), thiobarbituric acid-reactant substances (TBARS), and serum total antioxidant capacity (TAC) in serum samples.

Study design

A cross-sectional survey with a purposive sampling of 2,631 enrolled participants (age 18–85 years) was performed using the adult population of long-term residents of the municipality of east coast China in Fujian province between the years 2017 and 2019. Information on general health status, dyslipidemia prevalence, and selected mediators of inflammation was collected through a two-stage probability sampling design according to socioeconomic level, sex, and age.

Methods

The lipid profile was conducted by measuring the levels of total cholesterol (TC), high-density lipoprotein cholesterol (HDL-C), low-density lipoprotein cholesterol (LDL-C), and triglycerides (TG) with an autoanalyzer. Dyslipidemia was defined according to National Cholesterol Education Program Adult Treatment Panel III diagnostic criteria, and patients with it were identified by means of a computerized database. Serum parameters including IL-6/TNF-a/MCP-1, TBARS, and TAC were measured in three consecutive years. Familial history, education level, risk factors, etc. were determined. The association between dyslipidemia and serum parameters was explored using multivariable logistic regression models. Sociodemographic, age, and risk factors were also investigated among all participants.

Results

The mean prevalence of various dyslipidemia in the population at baseline (2017) was as follows: dyslipidemias, 28.50%; hypercholesterolemia, 26.33%; high LDL-C, 26.10%; low HDL-C, 24.44%; and hypertriglyceridemia, 27.77%. A significant effect of aging was found among all male and female participants. The mean levels of serum Il-6/TNF-a/MCP-1 were significantly higher in all the types of dyslipidemia among male participants. Female participants with all types of dyslipidemia but low HDL-C showed an elevation of IL-6 and MCP-1 levels, and those with dyslipidemias and hypercholesterolemia presented higher levels of TNF-a compared to the normal participants. The oxidative stress marker TBARS increased among all types of dyslipidemia except hypertriglyceridemia. All participants with different types of dyslipidemia had a lower total antioxidant capacity. Correlation analysis showed that cytokines and TBARS were positively associated with age, obesity, and diabetes mellitus, but not sex, sedentary leisure lifestyle, hypertension, and CVD/CHD history. The activity of TAC was negatively associated with the above parameters.

Conclusions

The correlation between the prevalence of dyslipidemia and the modification of inflammation status was statistically significant. The levels of proinflammatory cytokines, oxidative stress, and antioxidant capacity in serum may reflect the severity of the lipid abnormalities. These promising results further warrant a thorough medical screening in enhanced anti-inflammatory and reduced oxidative stress to better diagnose and comprehensively treat dyslipidemia at an early stage.

Measuring health literacy: A systematic review and bibliometric analysis of instruments from 1993 to 2021

BACKGROUND

It has been about 30 years since the first health literacy instrument was developed. This study aimed to review all existing instruments to summarize the current knowledge on the development of existing measurement instruments and their possible translation and validation in other languages different from the original languages.

METHODS

The review was conducted using PubMed, Web of Science, Scopus, and Google Scholar on all published papers on health literacy instrument development and psychometric properties in English biomedical journals from 1993 to the end of 2021.

RESULTS

The findings were summarized and synthesized on several headings, including general instruments, condition specific health literacy instruments (disease & content), population- specific instruments, and electronic health. Overall, 4848 citations were retrieved. After removing duplicates (n = 2336) and non-related papers (n = 2175), 361 studies (162 papers introducing an instrument and 199 papers reporting translation and psychometric properties of an original instrument) were selected for the final review. The original instruments included 39 general health literacy instruments, 90 condition specific (disease or content) health literacy instruments, 22 population- specific instruments, and 11 electronic health literacy instruments. Almost all papers reported reliability and validity, and the findings indicated that most existing health literacy instruments benefit from some relatively good psychometric properties.

CONCLUSION

This review highlighted that there were more than enough instruments for measuring health literacy. In addition, we found that a number of instruments did not report psychometric properties sufficiently. However, evidence suggest that well developed instruments and those reported adequate measures of validation could be helpful if appropriately selected based on objectives of a given study. Perhaps an authorized institution such as World Health Organization should take responsibility and provide a clear guideline for measuring health literacy as appropriate.

The Influence of Alcohol Consumption on Tobacco Use among Urban Older Adults: Evidence from Western China in 2017

Background: Tobacco use is a global public health concern due to its association with a myriad of health hazards and costs. Previous studies have found that the disinhibiting influence of alcohol consumption may lead to an increase in tobacco use. In this study, we investigated why alcohol consumption is associated with tobacco use among older adults in Western China, and we attempted to explain the mechanisms that underlie the link between alcohol consumption and tobacco use. Methods: In this cross-sectional study, we employed a representative sample of 812 urban individuals aged 60 and older in 2017 in Western China. Results: We found that alcohol consumption (OR = 2.816, 95%CI: 1.770–4.479) was positively associated with tobacco use. Additionally, other factors, including gender (OR = 0.023, 95%CI: 0.009–0.060), age (OR = 0.758, 95%CI: 0.634–0.906), health literacy (OR = 0.977, 95%CI: 0.959–0.995) and functional impairment (OR = 0.871, 95%CI: 0.767–0.988) were also strongly related to tobacco use. Conclusions: Consistent with the results of existing studies, our findings demonstrated the disinhibiting influence of alcohol consumption on tobacco use, which confirmed the theoretical mechanisms that underlie the alcohol–tobacco link and implied the co-occurrence and co-use of alcohol and tobacco, which are used as “social lubricants” in the Chinese context. The importance of other factors related to tobacco use were also discussed. As the tobacco epidemic is combatted, joint interventions tailored to concurrent control over alcohol and tobacco need to be performed, and corresponding male-specific and age-specific health education and the reinforcement of health literacy must be considered as important priorities.

Association of Health Literacy With Medication Adherence Mediated by Cognitive Function Among the Community-Based Elders With Chronic Disease in Beijing of China

Background

Although health literacy was considered to play a crucial role in non-communicable chronic disease (NCD) prevention and control, the relationship of health literacy and medication adherence has rarely given attention among older adult Chinese population in previous studies, especially considered that they might be with cognitive impairment.

Purpose

This study aimed to investigate the association between health literacy and medication adherence and mediation by cognitive ability among community-based older adults with chronic disease in Beijing of China.

Methods

The older adults aged 60 years old or over were recruited in a cross-sectional survey conducted in Beijing of China by using multistage, stratified sampling method. Of those, the participants with chronic disease and need to take long-term medicine were included in our study. The information about sociodemographic characteristics, health literacy, cognition ability, and medication adherence was collected by the questionnaire. The univariate and multiple logistic regression analysis were used to measure the association of health literacy and adherence medication, and mediate effect by cognitive ability.

Results

The total of 4,166 older adult populations (average age: 70.61 ± 7.38 years) was included in this study, 1,395 participants (33.49%) were non-adherence, 1,983 participants (47.60%) had two chronic conditions or more, and 1,459 participants (35.02%) screened as cognitive impairment. The health literacy was negatively associated with medication adherence. The lower total scores of health literacy were found with a high risk of non-adherence [p < 0.01, adjusted odds ratio (OR) = 0.988 per one point increase, 95% CI: 0.982–0.993] controlling other covariates. However, their association tended to be weakened or even disappeared among the older adults with cognitive impairment compared with the populations with normal cognitive.

Conclusion

Improving health literacy might be a public health strategy to increase the medication adherence of older adults, but need to first identify the potential target population based on their cognitive ability.

The economic costs of limited health literacy in China: evidence from China's National Health Literacy Surveillance data

Background

Limited health literacy is a public health challenge contributing to the rising health care costs. We assess the economic costs of limited health literacy in China using data from the National Health Literacy Surveillance survey.

Methods

Our data includes a sample of 6316 residents aged 15–69 years old living in Ningbo, China, in 2019. We use box plots to examine the distribution of out-of-pocket health expenditure by the level of health literacy. We then use the estimates from a two-part model to assess the contribution of limited health literacy to individual medical spending and the aggregate health expenditure at different levels of health literacy for the adult population in Ningbo.

Results

Medical costs of limited health literacy are about 10% (177 CNY or about 25 USD) of the annual medical expense of a resident aged 15–69 living in Ningbo. The medical cost of limited health literacy is greater among the rural, female, and older groups than others. If the proportion of people with adequate health literacy increases from 22 to 30% (the target level by 2030), the aggregate out-of-pocket health expenditure in Ningbo will decrease by 100 million CNY (14 million USD), or 0.88% of the 2019 Ningbo government expenditure on health care.

Conclusions

This paper highlights the direct and indirect economic costs associated with limited health literacy. The results should help policymakers evaluate the cost-effectiveness of relevant programs that aim to improve residents’ health literacy.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-07795-9.

Nutrition Literacy Measurement Tool With Multiple Features for Chinese Adults

BACKGROUND

Nutrition literacy is an emerging term which is increasingly used in policy and research. Progression is limited by the lack of an accepted method to measure nutrition literacy in Chinese adult, even research in this area is growing.

OBJECTIVE

The objective of this study is to develop a valid instrument to assess nutrition literacy in Chinese adults.

METHODS

The process involved 2 steps: constructed nutrition literacy conceptual framework, and developed potential items of scale based on literature review; and conducted 2 rounds of Delphi consultation to select items of the preliminary questionnaire.

RESULTS

In Delphi survey, the content validity index for each domain, level, and dimension of nutrition literacy was 1.0, coefficient of variation was less than 0.10, and Kendall's coefficient of concordance was greater than 0.83. All of the 2 domains, 3 levels, and 6 dimensions initially formulated by our research team were reserved in the conceptual framework of nutrition literacy. Furthermore, a 43-item nutrition literacy measurement scale was established. Each item kept in the final scale reaches a high degree of concentration and a high degree of coordination, with the mean of importance ranging from 4.38 to 5.00.

CONCLUSIONS

A nutrition literacy measurement scale with multiple features was established for Chinese adults, providing an operationalized tool to assess comprehensively nutrition literacy for research and practice in the field of nutrition, diet, and health.

Development and validation of the Cancer Knowledge Scale for the general population: An item response theory approach

OBJECTIVE

To develop and validate a new measure of cancer knowledge for members of the general population who have never been diagnosed with cancer.

METHODS

Initially, 20 items were generated to measure cancer knowledge. After expert refinement and cognitive interviews, 11 items remained and were completed by 1,076 adults with no history of cancer. Responses were assessed using an item response theory (IRT) approach and differential item functioning.

RESULTS

Items were analyzed using a two-parameter logistic IRT model. Two items with tetrachoric correlation coefficients>0.8 and one item with a discrimination parameter>2.0 were excluded. The final eight items demonstrated a good range of discrimination (1.13 to 1.86) and difficulty (-1.11 to 0.85). No meaningful differential item functioning by participant attributes was detected for these eight items.

CONCLUSION

The Cancer Knowledge Scale appears to be a reliable and valid measure for the general population.

PRACTICE IMPLICATIONS

The eight-item scale could be used to assess the effects of psychoeducational programs, including those on cancer knowledge, for members of the general population with no cancer history.

Development and Evaluation of the Quality of Life Scale for Children With Visual Impairments in China

BACKGROUND

Visual impairments related to non-correctable vision loss, including blindness and low vision, have been consistently shown to lower a person's health-related quality of life. This study assessed the reliability, validity, and discrimination of the Quality of Life Scale for Children with Visual Impairments (QOLS-CVI) in China.

METHODS

The Pediatric Quality of Life Inventory™ 4.0 and World Health Organization Quality of Life-Disability Scale for physical disability were selected to define conceptual frameworks and item libraries based on relevant existing studies. According to two rounds of expert consultations and group discussions, some items were modified, and the draft scale was developed. Two item selection processes based on classical test theory and item response theory were used to conduct a preliminary survey and a formal survey in special schools in Shanxi and Hebei Provinces. Finally, the reliability and validity of the quality of life scale for visually impaired children in China were verified.

RESULTS

The final QOLS-CVI consisted of 38 items, 10 subdomains, and 6 domains. Reliability was verified by Cronbach's alpha coefficient, split-half reliability, and test-retest reliability (Cronbach's alpha for the full scale, 0.841; split-half reliability, 0.629; and test-retest reliability, 0.888). The validity results showed that the multidimensional scale met expectations: exploratory factor analysis and confirmatory factor analysis indicated good fitting models for children with visual impairments.

CONCLUSIONS

The QOLS-CVI was determined to be reliable and valid and to have strong feasibility and effectiveness. This scale can be used as an evaluation tool to study the QOL and social-participation ability of children with visual impairments.

Socioeconomic Determinants of Melanoma-Related Health Literacy and Attitudes Among College Students in China: A Population-Based Cross-Sectional Study

Objectives: To investigate the association of gender, ethnicity, living region, and socioeconomic status (SES) with health literacy and attitudes toward nevi and melanoma in Chinese adolescents and to examine whether health literacy mediates the association of SES with attitudes. Study Design: A multicenter cross-sectional study was conducted among newly enrolled college students. First-year students were recruited from five universities in different regions of China in 2018 using the cluster sampling method. The observers were blinded to the participants. Methods: Health literacy and attitudes were measured using a previously validated tool (Nevus and Melanoma Health Literacy and attitudes Test). SES was measured by annual family income and parental highest educational level. Nonparametric test was used to examine the association of participants' characteristics with health literacy and attitudes. Two-level generalized linear model with logarithm link function and Gamma distribution was used individually for SES. The mediation effect model was used to examine the mediation effect of health literacy. Results: A total of 21,086 questionnaires were completed by college students with a mean age of 18.0 ± 0.8 years. The mean scores of health literacy and attitudes were 9.83 ± 7.46 (maximum score: 28) and 16.98 ± 2.92 (maximum score: 20), respectively. Female, Han nationality, annual family income, and parental educational levels were positively associated with health literacy and attitudes. Regional differences showed different effects on health literacy and attitudes. A mediation model showed that literacy mediated the association of SES with attitudes toward nevi and melanoma. Health literacy mediated ~30-50% of the association of SES with attitudes. Conclusions: Melanoma-related health literacy among Chinese college students is generally insufficient and needs to be improved. Targeted and personalized health education for improving health literacy related to nevi and melanoma may improve the general population's attitudes and further promote health-related behavior to prevent and identify early-stage melanoma.

The Community Health Supporting Environments and Residents' Health and Well-Being: The Role of Health Literacy

We evaluate the impacts that health supporting environments have on residents' health and well-being. Using a stratified multi-stage sampling method, we select a sample of 12,360 permanent adult residents aged 15-69, and collect information on their health literacy level, as well as their demographic background and health. This individual level data is then merged with the administrative health supporting environment data. More than two thirds of residents self-reported having good/excellent health, and the percent of adults living in communities with healthy parks, healthy trails, and healthy huts in their community is 23 percent, 43 percent, and 25 percent, respectively. Controlling for a series of confounding factors at the community and individual levels, we find that healthy parks and healthy trails are positively correlated with self-reported health, which increases the probability of self-reporting good health by 2.0 percentage points (p < 0.10) and 6.0 percentage points (p < 0.01), respectively. Access to healthy huts is negatively associated with self-reported health, decreasing the probability of self-reporting good health by 5.0 percentage points (p < 0.01). Health literacy plays a role in moderating the effect of health parks, and a positive effect is more likely to be observed among adults with lower health literacy. Health supporting environments may play a role in reducing the likelihood of undiagnosed diseases and changing residents' lifestyles, which promotes the health and well-being of residents, especially among those with inadequate health literacy.

A decision aid to facilitate informed choices among cataract patients: A randomized controlled trial

OBJECTIVE

To assess the effect of a patient decision aid on the quality of decision-making for patients with age-related cataracts.

METHODS

773 patients with cataracts aged 50-80 years were randomly assigned to receive either the intervention decision aid (including standard information, quantitative information on the possible outcomes of cataract surgery and a value clarification exercise) or the control booklet (including standard information). The primary outcome was informed choice (defined as adequate knowledge and congruency between attitudes and surgical intentions), which was assessed at 2 weeks after intervention via a telephone interview.

RESULTS

The decision aid increased the proportion of participants making an informed choice, from 5.68 % in the control group to 27.7 % in the intervention group (P < 0.001). Compared with controls, more participants in the intervention group had adequate overall knowledge about cataract surgery (36.8 % vs. 8.79 % in controls; P < 0.001), and fewer participants intended to undergo surgery (22.5 % vs. 34.1 % in controls; P < 0.001).

CONCLUSION

Use of the patient decision aid may increase the proportion of patients making informed choices. Importantly, it might also reduce the acceptance of operations.

PRACTICE IMPLICATIONS

Patient decision aids represent a simple and low-cost tool to facilitate informed choice among patients with cataracts.

Health literacy and its socio-demographic risk factors in Hebei: A cross-sectional survey

This study aimed to evaluate the prevalence of low health literacy in Hebei Province of China, and to investigate its socio-demographic risk factors.This study was a community-based, cross-sectional questionnaire survey with a multiple-stage randomization design and a sample size of 10,560. Participants' health literacy status was evaluated by a questionnaire based on the 2012 Chinese Resident Health Literacy Scale. Meanwhile, participants' socio-demographic characteristics were also collected by the questionnaire.A total of 9952 participants provided valid questionnaires and were included in the final analyses. The mean health literacy score was 63.1 ± 17.1 points; for its subscales, the mean basic knowledge and concepts score, lifestyle score, health-related skills score were 31.7 ± 9.0, 17.2 ± 4.8, 14.3 ± 4.1, respectively. Meanwhile, low health literacy prevalence was 81.0%; for its subscales, low basic knowledge and concepts prevalence (70.6%) was numerically reduced compared to low lifestyle prevalence (87.4%) and low health-related skills prevalence (86.1%). Further analyses showed that age, male, and rural area were positively associated, but education level and annual household income were negatively associated with low health literacy prevalence. Further multivariate logistic regression analyses showed that higher age, male, lower education level, lower annual household income, and rural area were closely correlated with the risks of low total health literacy or low health literacy in subscales in Hebei Province.The prevalence of low health literacy is 81.0% in Hebei Province. Meanwhile, higher age, male, lower education level, lower annual household income, and rural area closely associate with low health literacy risk.

Health Literacy and Regional Heterogeneities in China: A Population-Based Study

Background: Health literacy is essential to population health, yet few studies have described the geographic variation in health literacy in China. This study aimed to investigate the level of health literacy, its regional heterogeneities, as well as influencing factors of health literacy in 25 provinces or municipalities in China. Methods: The study was conducted among residents aged 15-69 years from 25 provinces or municipalities in China in 2017. Health literacy was measured using the Chinese Health Literacy Scale. MapInfo software was used to map the geographic distribution. Multiple logistic regression was used to adjust for the factors associated with the health literacy level in the overall and regional samples. Results: A total of 3,482 participants were included in the study, comprising 1,792 (51.5%) males and 1,690 (48.5%) females. Notable geographic variation was observed in health literacy levels. The proportion of respondents with adequate health literacy was 22.3% overall, 33.0% in the eastern region, 23.1% in the central region, and 17.6% in the western region. The proportion of adequate health literacy in the different provinces and municipalities ranged from 10.5% (Xinjiang) to 47.0% (Beijing). Being a female [odds ratio (OR) = 1.353; 95% confidence interval (CI): 1.146-1.597], having a high education level [OR ranging from 2.794 (CI: 1.469-5.314) to 9.458 (CI: 5.251-17.036)], having a high economic status [OR ranging from 1.537 (CI: 1.248-1.891) to 1.850 (CI: 1.498-2.284)], having a good self-rated health status [OR ranging from 2.793 (CI: 1.534-5.083) to 3.003 (CI: 1.672-5.395)], and having frequent community health education (OR = 1.588; 95% CI: 1.066-2.365) were independently associated with adequate health literacy. Conclusions: The health literacy level in the 25 provinces or municipalities of China is relatively low compared to the developed countries, and there are heterogeneities among different regions, between urban and rural areas, and among different social groups. Tailored health education and promotion strategies are needed for different subgroups of residents.

Associations Between Health Literacy, eHealth Literacy, and COVID-19-Related Health Behaviors Among Chinese College Students: Cross-sectional Online Study

Background

During the COVID-19 pandemic, the internet has significantly spread information, providing people with knowledge and advice about health protection regarding COVID-19. While a previous study demonstrated that health and eHealth literacy are related to COVID-19 prevention behaviors, few studies have focused on the relationship between health literacy, eHealth literacy, and COVID-19–related health behaviors. The latter includes not only preventative behaviors but also conventional health behaviors.

Objective

The objective of this study was to develop and verify a COVID-19–related health behavior questionnaire, explore its status and structure, and examine the associations between these behaviors and participants’ health literacy and eHealth literacy.

Methods

A snowball sampling method was adopted to recruit participants to complete anonymous cross-sectional questionnaire surveys online that assessed sociodemographic information, self-reported coronavirus knowledge, health literacy, eHealth literacy, and COVID-19–related health behaviors.

Results

Of 1873 college students who were recruited, 781 (41.7%) had adequate health literacy; the mean eHealth literacy score was 30.16 (SD 6.31). The COVID-19–related health behavior questionnaire presented a two-factor structure—COVID-19–specific precautionary behaviors and conventional health behaviors—with satisfactory fit indices and internal consistency (Cronbach α=.79). The mean score of COVID-19–related health behaviors was 53.77 (SD 8.03), and scores differed significantly (P<.05) with respect to residence, college year, academic major, family economic level, self-reported health status, having a family member or friend infected with coronavirus, and health literacy level. Linear regression analysis showed that health literacy and eHealth literacy were positively associated with COVID-19–specific precautionary behaviors (β_{health literacy}=.149, β_{eHealth literacy}=.368; P<.001) and conventional health behaviors (β_{health literacy}=.219, β_{eHealth literacy}=.277; P<.001).

Conclusions

The COVID-19–related health behavior questionnaire was a valid and reliable measure for assessing health behaviors during the pandemic. College students with higher health literacy and eHealth literacy can more actively adopt COVID-19–related health behaviors. Additionally, compared to health literacy, eHealth literacy is more closely related to COVID-19–related health behaviors. Public intervention measures based on health and eHealth literacy are required to promote COVID-19–related health behaviors during the pandemic, which may be helpful to reduce the risk of COVID-19 infection among college students.

How does health literacy affect the utilization of basic public health services in Chinese migrants?

Previous studies have focused on the determinants of basic public health services utilization, such as socioeconomic status and mobility characteristics, rather than on health literacy. Thus, this study aimed to estimate the effect of health literacy on the utilization of basic public health services among Chinese migrants. Based on the 2016 China Migrants Dynamic Survey data (N = 2335), this study used propensity score matching approach to estimate the effect of health literacy on the utilization of basic public health services, including the establishment of health records and receipt of health education, and to explore heterogeneity in this effect based on educational attainment and urban-rural status. The findings show that high levels of health literacy increased the probability of establishing health records and receiving more health education. Also, high levels of health literacy had a positive effect on the utilization of basic public health services among Chinese migrants, especially those with less education or living in urban areas. Policy makers should more carefully consider the actual situation and needs of migrants who are living in urban areas or have less education, constructing more targeted service programs.

The Effect of Socio-Economic Status on Health Information Literacy among Urban Older Adults: Evidence from Western China

The present study aimed to observe the effect of socio-economic status on health information literacy and to identify whether there is a social gradient for health information literacy among urban older adults in Western China. This study employed a cross-sectional research design, and 812 urban participants aged 60 and older were enrolled in Western China. In the current study, only 16.7% of urban older adults reported having adequate health information literacy. Binary logistic regression analysis showed that socio-economic status factors including educational attainment, ethnicity, and financial strain were significantly and tightly associated with health information literacy. Additionally, other factors including suffering from chronic diseases, information-seeking activity, reading magazines and books, and watching television were also significantly linked to health information literacy. Consistent with existing studies, the findings indicate the health information literacy deficit and demonstrate the crucial impact of socio-economic status on health information literacy, which implies a social gradient in health information literacy. The importance of other factors related to health information literacy are discussed as well. The results suggest that reducing the health information literacy deficit and social gradient in health information literacy must be considered as an important priority when developing public health and health education strategies, programs, and actions among urban older adults in Western China.

The relationship between socioeconomic position and health literacy among urban and rural adults in regional China

BACKGROUND

To examine associations of socioeconomic position (SEP), separately indicated by education, monthly family average income (FAI) and occupation, with health literacy (HL) among adults in regional China.

METHODS

A cross-sectional survey was conducted among urban and rural adults (aged 25-69 years) who were randomly selected, using the probability proportionate to size sampling approach, from Nanjing municipality of China during October and December of 2016. HL, the outcome variable, was assessed using the Chinese Resident Health Literacy Scale. SEP, our independent variable, was separately measured with educational attainment, monthly family average income and occupation. Logistic regression models were introduced to examine SEP-HL association with odds ratio (OR) and 95% confidence interval (CI).

RESULTS

Totally, 8698 participants completed the survey. The proportion of participants with unweighted and weighted adequate HL was 18.0% (95%CI = 17.2, 18.8%) and 19.9% (95%CI = 16.6, 23.6%), respectively, in this study. After adjustment for possible confounding factors, each SEP indicator was in significantly positive relation to both unweighted and weight HL level. Participants who obtained 13+ and 10-12 years educational attainment, respectively, had 2.41 (95%CI = 1.60, 3.64) and 1.68 (95%CI = 1.23, 2.29) times odds to record weighted adequate HL compared to their counterparts who were with 0-9 years education. Subjects within upper (OR = 1.92, 95%CI = 1.24, 2.98) and middle FAI tertile (OR = 1.59, 95%CI = 1.19, 2.13), respectively, were more likely to report weighted adequate HL relative to those who were within lower FAI tertile. White collars were more likely to have weighted adequate HL (OR = 1.33, 95%CI = 1.09, 1.61) than blue collars.

CONCLUSIONS

Each of education, FAI and occupation was positively associated with health literacy among urban and rural adults in China. The findings have important implications that different SEP indicators can be used to identify vulnerable residents in population-based health literacy promotion campaigns.

Patient-provider relationships in China: A qualitative study on the perspectives of healthcare students and junior professionals

BACKGROUND

Mistrust and conflicts in patient-provider relationships (PPR) have become prevalent in China. The frequency of verbal and physical violence against healthcare workers has been increasing, but few interventions seem to be effective. Limited prior research has focused on the perspectives of healthcare professionals in training. This paper aimed to understand their viewpoints and conceptualize potentially actionable areas for future policy interventions.

METHODS

We analyzed de-identified training registration data of a convenience sample of 151 healthcare students and 38 junior professionals from 20 provinces in China. One open-ended question in the registration form asked the participant to comment on PPRs in China. We used qualitative thematic coding to analyze the narrative data. All answers were categorized into three overarching frames: patients, providers, and external agencies/regulations. Frequently mentioned themes in each frame were evaluated to generate an overall theoretical framework.

FINDINGS

Although fewer than 25% indicated that current PPRs are "good" or acceptable, 98% of respondents were optimistic about the future improvement of these relationships. The leading factors of PPRs mentioned as patient-relevant were eroding trust in the physician, unrealistic expectations, and ineffective communication. The provider-relevant themes highlighted were poor service quality, ineffective communication, and heavy workload. Leading themes relevant to external agencies or regulations were dysfunctional administration system, negative media reports, and disparity in healthcare resource distribution.

INTERPRETATION

Healthcare professionals in training had a negative view of the current situation but had confidence in future improvement. Patient, provider, and societal factors all contributed to the tension between patients and providers. All aspects of the healthcare sector should be carefully considered when contemplating policy or social interventions to improve the patient-provider relationship.

Development and Assessment of a Brief Tool to Measure Melanoma-Related Health Literacy and Attitude Among Adolescents

The aim of this study is to develop a tool to measure health literacy and attitude towards melanoma and to assess the tool in a group of adolescents through a multicenter cross-sectional survey. The concept, dimensionality, and item pool of the tool were developed by a focus group. The Delphi method was applied to determine the content validity. Newly enrolled students in five universities were invited to an online questionnaire survey. Items were selected according to correlation, factor loading, and item response parameters. Psychometric properties (reliability, construct validity, and measurement invariance) were assessed using McDonald's ω and confirmatory factor analysis (CFA), respectively. A total of 21,086 valid questionnaires were collected. The focus group drafted two subscales and 13 items. Content validity was good for all items (Kappa > 0.7). One item was removed from the tool owing to low factor loading and discrimination parameter. McDonald's ω of the subscales were 0.84 (health literacy) and 0.86 (attitude). Local dependencies were identified in CFA; after modification, the goodness-of-fit was satisfactory (comparative fit index, CFI > 0.98). The tool showed measurement invariance across subgroups of gender, ethnicity, and university (CFI change < 0.01 across models). The brief tool to measure health literacy and attitude towards nevus and melanoma shows good psychometric properties and measurement invariance. It can be used in further investigation.

Exploring health literacy in Wuhan, China: a cross-sectional analysis

Background

In recent years, research on health literacy has become increasingly focused on the health care system and public health. This cross-sectional study aimed to investigate health literacy and analyse the risk factors that affect health literacy in Wuhan, China.

Methods

Multistage stratified random sampling was used to select 5304 urban and rural residents aged 15 to 69 years from 204 monitoring points in 15 districts of Wuhan. Using the Chinese Citizen Health Literacy Questionnaire (HLQ) (2018 edition), a face-to-face survey was conducted from November to December 2018. Risk factors that may affect health literacy were assessed using the Chi-square test and multivariate logistic regression models.

Results

The knowledge rate of health literacy was relatively low (19.3%). The knowledge rate of health-related behaviour and lifestyle (BAL, 17.3%) was the lowest of the three aspects of health literacy, and the knowledge rate of chronic diseases (CD, 19.0%) was the lowest of the six dimensions of health literacy. Respondents who lived in urban areas, had higher education levels, worked as medical staff, had a higher household income and did not suffer from chronic diseases were likely to have higher health literacy.

Conclusions

The health literacy levels of citizens in Wuhan are insufficient and need to improve.

The Urban-Rural Disparity in the Status and Risk Factors of Health Literacy: A Cross-Sectional Survey in Central China

Health literacy is the ability of individuals to access, process, and understand health information to make decisions regarding treatment and their health on the whole; it is critical to maintain and improve public health. However, the health literacy of urban and rural populations in China has been little known. Thus, this study aims to assess the status of health literacy and explore the differences of its possible determinants (e.g., socio-economic factors) among urban and rural populations in Henan, China. A cross-sectional study, 78,646 participants were recruited from a populous province in central China with a multi-stage random sampling design. The Chinese Resident Health Literacy Scale was adopted to measure the health literacy of the respondents. In the participants, the level of health literacy (10.21%) in central China was significantly lower than the national average, and a big gap was identified between urban and rural populations (16.92% vs. 8.09%). A noticeable difference was reported in different aspects and health issues of health literacy between urban and rural populations. The health literacy level was lower in those with lower levels of education, and a significant difference was identified in the level of health literacy among people of different ages and occupations in both urban and rural areas. Note that in rural areas, as long as residents educated, they all had higher odds to exhibit basic health literacy than those uneducated; in rural areas, compared with those aged 15 to 24 years, residents aged 45 to 54 years (OR = 0.846,95% CI (0.730, 0.981)), 55 to 64 years (OR = 0.716,95% CI (0.614, 0.836)) and above 65 years (OR = 0.679, 95% CI (0.567, 0.812)) were 84.6%, 71.6%, and 67.9%, respectively, less likely to exhibit basic health literacy. Considering the lower health literacy among rural residents compared with their urban counterparts, a reorientation of the health policy-making for Chinese rural areas is recommended. This study suggests that urban-rural disparity about health literacy risk factors should be considered when implementing health literacy promotion intervention.

Patient-centred and economic effectiveness of a decision aid for patients with age-related cataract in China: study protocol of a randomised controlled trial

INTRODUCTION

The need for cataract surgery is on the rise due to our ageing population and high demands for greater visual functioning. Although the majority of patients want to participate in a shared decision-making process, no decision aid has been available to improve the quality of decision. The present study aims to determine whether a decision aid increases informed decision about cataract surgery.

METHODS AND ANALYSIS

A parallel randomised controlled trial (772 participants) will be conducted. The decision aid will be implemented among patients with any age-related cataract in Yuexiu District, which is socioeconomically representative of a major metropolitan region in Southern China. Participants will be randomly assigned to receive either a patient decision aid or a traditional booklet, and they will complete three surveys: (1) baseline assessment before the intervention (time point (T)1), 2 weeks (T2) and 1 year (T3) after the intervention. The control group receives a traditional booklet with standard general information developed by the National Eye Institute to help patients understand cataract, whereas the intervention group receives a patient decision aid that includes not only the standard general information, but also the quantitative risk information on the possible outcomes of cataract surgery as well as value clarification exercise. The primary study outcome is the informed decision, the percentage of patients who have adequate knowledge and demonstrate consistency between attitudes and intentions. Secondary outcomes include perceived importance of cataract surgery benefits/harms, decision conflict and confidence, anticipated regret and booklet utilisation and acceptability at 2 weeks, and surgical rates and a cost-utility estimate of the decision aid at 1 year.

ETHICS AND DISSEMINATION

Ethics approval was obtained from the Ethics Committee of Zhongshan Ophthalmic Center (reference number: 2019KYPJ090). Results will be published in peer-reviewed journals and presented at scientific meetings for academic audiences.

TRIAL REGISTRATION NUMBER

NCT03992807.

Health literacy and its effect on chronic disease prevention: evidence from China's data

BACKGROUND

Improving health literacy is an important public health goal in many countries. Although many studies have suggested that low health literacy has adverse effects on an individual's health outcomes, confounding factors are often not accounted. This paper examines the interplay between health literacy and chronic disease prevention.

METHODS

A population-based sample of 8194 participants aged 15-69 years old in Ningbo were used from China's 2017 National Health Literacy Surveillance Data. We use multivariate regression analysis to disentangle the relationship between health literacy and chronic disease prevention.

RESULTS

We find the association between health literacy and the occurrence of the first chronic condition is attenuated after we adjust the results for age and education. This might arise because having one or more chronic conditions is associated with better knowledge about chronic diseases, thus improve their health literacy. More importantly, we find health literacy is associated with a reduction in the likelihood of having a comorbid condition. However, this protective effect is only found among urban residents, suggesting health literacy might be a key factor explaining the rural-urban disparity in health outcomes.

CONCLUSION

Our findings highlight the important role of health literacy in preventing comorbidities instead of preventing the first chronic condition. Moreover, family support could help improve health literacy and result in beneficial effects on health.

Tools to measure health literacy among Chinese speakers: A systematic review

OBJECTIVE

Health literacy measurement can identify healthcare consumers' needs and help inform healthcare service delivery. The objective of this review is to identify and evaluate tools to measure health literacy among Chinese speakers.

METHODS

A systematic literature search was undertaken in nine databases, both English and Chinese, on articles published from the databases' inception to May 2018, addressing health literacy among Chinese speakers.

RESULTS

Ten health literacy instruments in the Chinese language were reported in 17 studies, of which ten were published in English and seven in Chinese. Of the 17 studies, six reported on a new instrument, while the remainder reported on derivative instruments. All, except for one, are self-administered. These studies applied various implicit or explicit conceptual or operational health literacy definitions. The psychometric strength varied across the instruments.

CONCLUSIONS

A number of instruments are available for assessing health literacy among Chinese speakers. Careful selection is recommended, given the variation in components and psychometric properties assessed.

PRACTICE IMPLICATIONS

This review can be used by healthcare providers and researchers to select effective health literacy tools to examine patients' ability to understand and apply health information so that services can be more appropriately tailored to Chinese speaking patients.

Development and preliminary evaluation of a decision aid to support informed choice among patients with age-related cataract

OBJECTIVE

Shared decision making and meaningful patient involvement are key in improving cataract treatment outcomes, but no decision aid has been formally developed and validated for this purpose. Our aims were to develop a patient decision aid to guide patients' decision about when to undergo cataract surgery, and to determine patient's comprehension and booklet's acceptability.

METHODS

The patient decision aid was developed and included evidence-based information about general cataract, its benefits, risks of treatment options, and value clarification exercise. A total of 30 patients with age-related cataract aged between 50 and 80 years were interviewed after using either the patient decision aid (n = 15) or the traditional education booklet (n = 15).

RESULTS

The patients who received the decision aid agreed that the information was new (n = 15, 100%), the length of the aid was "just about right" (n = 13, 87%), the information was clear and easy to understand (n = 13, 87%), the decision aid was helpful in making decision (n = 13, 87%) and would like to recommend this decision aid to others (n = 14, 93%).

CONCLUSIONS

The decision aid was assessed positively by patients with age-related cataract. There is a need for its further verification in the context of primary eye care setting.

Health literacy and its associated demographic factors in 18-65-year-old, literate adults in Bardaskan, Iran

AIMS

Improvement of general health literacy is one of the ways to achieve the desired public health condition. To this end, the first step is to determine the health literacy level and its associated demographic factors in individuals.

SETTINGS AND DESIGN

This study was a cross-sectional, descriptive-analytic survey conducted on 700 adults (age range: 18-65 years) in Bardaskan, Iran. The required samples were selected via random cluster sampling method.

SUBJECTS AND METHODS

The demographic questionnaire was used to collect sociodemographic information. The Health Literacy for Iranian Adults questionnaire was used to determine the level of health literacy in participants.

STATISTICAL ANALYSIS

Data analysis was conducted using SPSS software version 20 through descriptive and inferential statistics. Results were considered statistically significant at P ≤ 0.05.

RESULTS

A total of 700 participants with a mean (standard deviation) age of 31.25 (9.32) years participated in this study. The primary sources of health information were physicians and health staff (50.9%) followed by the Internet (19.7%). The health literacy level of 18.1% of the participants was inadequate, 27.7% was marginal, 39.4% was adequate, and 14.7% was excellent. The mean overall scores of health literacy and its subscales were within the adequate range (66.1-84.0). The relationships of health literacy level with age, education, marital status, occupational status, and history of disease were statistically significant (P < 0.001).

CONCLUSION

It seems necessary to design and implement a variety of educational programs to improve the general health literacy of the citizens of Bardaskan. Educational programs need to focus on groups with higher priority such as elderly people, individuals with lower educational levels, widows/widowers and divorced/separated individuals, unemployed and retired individuals, homemakers, and individuals with a history of disease.

Inequalities in the health survey using validation question to filter insufficient effort responding: reducing overestimated effects or creating selection bias?

BACKGROUND

The presence of insufficient effort responding participants (IERPs) in a survey can produce systematic bias. Validation questions are commonly used to exclude IERPs. Participants were defined as IERPs if responding inconsistently to two matched validation questions, and non-insufficient effort responding participants (non-IERPs) if responding consistently. However, it has not been tested whether validation questions themselves could result in selection bias.

METHODS

This study was a cross-sectional survey conducted in Guangxi, China. Participants' intentions to use antibiotics for their children when they have self-limiting diseases, including sore throat, cold, diarrhea, and fever, were measured. The Chi-square tests were used to compare the socio-economic status (SES) between non-IERPs and IERPs. Logistic regression was adopted to test the association between intentions to misuse antibiotics and groups (non-IERPs, IERPs with high SES, and IERPs with low SES).

RESULTS

Data with 3264 non-IERPs and 1543 IERPs were collected. The results showed IERPs had a lower education level (χ2 = 6.100, p = 0.047) and a higher proportion of rural residence (χ2 = 4.750, p = 0.030) compared with non-IERPs. Rural IERPs reported significantly higher rates of intentions to misuse antibiotics when their children have a sore throat (OR = 1.32; 95% CI = 1.11,1.56; p < 0.01), cold (OR = 1.33; 95%CI = 1.13,1.58; p < 0.01), diarrhea (OR = 1.46; 95%CI = 1.20,1.77; p < 0.001), and fever (OR = 1.22; 95% CI = 1.04,1.43; p < 0.05) compared with non-IERPs. IERPs living in urban areas reported significantly lower rates of intentions to use antibiotics when their children have a sore throat (OR = 0.76; 95%CI = 0.62,0.93; p < 0.01) compared with non-IERPs. IERPs with lower levels of education reported significantly higher rates of intentions to use antibiotics when their children have a sore throat (OR = 1.19; 95%CI = 1.02,1.39; p < 0.05), cold (OR = 1.43; 95% CI = 1.23,1.66; p < 0.001), diarrhea (OR = 1.38; 95%CI = 1.15,1.64; p < 0.01), and fever (OR = 1.25; 95% CI = 1.09,1.44; p < 0.01) compared with non-IERPs. IERPs with higher education levels reported significantly lower rates of intentions to use antibiotics when their children have a sore throat (OR = 0.72; 95% CI = 0.56,0.94; p < 0.05), cold (OR = 0.66; 95% CI = 0.51,0.86; p < 0.01), and fever (OR = 0.74; 95% CI = 0.60,0.92; p < 0.01) compared with non-IERPs. IERPs with low-income reported significantly higher rates of intentions to use antibiotics when their children have a cold (OR = 1.36; 95% CI = 1.13,1.64; p < 0.01) and diarrhea (OR = 1.30; 95% CI = 1.05,1.62; p < 0.05) compared with non-IERPs.

CONCLUSIONS

Using validation questions to exclude IERPs can result in selection bias in which participants with lower socio-economic standing and poor antibiotic use intentions were disproportionately excluded.

Health literacy, depression, and stress among Chinese immigrants in South Korea

OBJECTIVES

This study examined health literacy, depression, and stress in Chinese immigrants living in South Korea, and analyzed factors related to these outcomes.

DESIGN

This is a cross-sectional, descriptive study.

SAMPLE

Participants were 128 adult Chinese immigrants living in the Jung-gu District of Seoul, South Korea. The majority of the participants were women and in their 40s; had a high school diploma; and were employed and married. Most had lived in Korea for 5-10 years.

MEASUREMENTS

Outcome variables were health literacy, depression, and immigrant stress; independent variables were sociodemographic characteristics, language proficiency, health, and behavioral factors. Hierarchical multiple regression models based on the conceptual framework were tested.

RESULTS

The major factor influencing health literacy was perceived economic status (p = 0.021). The factors related to depression were life satisfaction in China (p = 0.032), life satisfaction in Korea (p = 0.040), and stress perception in everyday life (p = 0.001).

CONCLUSIONS

As the number of immigrants rises, there is increasing demand for public-health-center-based health promotion programs for immigrants. It is recommended that local public health practitioners, including public health nurses, closely analyze the characteristics of their community and immigrants, and develop and implement customized programs accordingly.

Low Health Literacy Is Associated With Risk of Developing Type 2 Diabetes in a Nonclinical Population

PURPOSE

The purpose of this study was to examine associations among risk of type 2 diabetes (T2D), health literacy levels, and sociodemographic characteristics in a nonclinical adult population to assist in the development of effective T2D prevention programs.

METHODS

The Health Literacy Questionnaire and Australian Type 2 Diabetes Risk Assessment Tool were included in an online survey. Participants were a random sample of adults residing in each Australian state and territory. Data were analyzed with descriptive statistics and multinomial logistic regression.

RESULTS

A total of 1279 Australian adults participated (52% female; mean ± SD age, 61 ± 12 years). Most were at medium (42.4%) or high (46.9%) risk of developing T2D. The lowest health literacy scores were found for the domains "critical appraisal of health information" and "navigating the health care system." After controlling for covariates, participants at the highest risk of developing T2D were significantly more likely to be unemployed, have ≥1 chronic conditions, or have a mental health condition. Furthermore, they were significantly more likely to develop T2D if they scored low in 1 of the following health literacy domains: critical appraisal of health information, navigating the health care system, actively managing health, social support, and health care provider support.

CONCLUSIONS

Health literacy was associated with increased risk for developing T2D and should therefore be part of diabetes prevention initiatives. Specifically, new health promotion initiatives need to help people develop skills required to critically appraise health information and navigate the health care system. Health practitioners and educators should ensure that health information developed for consumers is uncomplicated and easily understood.

Disaster response knowledge and its social determinants: A cross-sectional study in Beijing, China

Background

The purpose of this study is to identify the social factors that shape the disaster response knowledge of residents in Beijing, China. This study aims to provide evidence supporting the development and promotion of effective strategies for disaster response knowledge, including natural and human-made ones.

Methods

A cross-sectional household survey on disaster response knowledge was conducted in Beijing, 2015. Using the multistage sampling method, data were collected from community residents through a self-administered questionnaire, and analyzed by descriptive methods and logistic regression models.

Results

Among the 847 respondents, 44.2% had advanced disaster response knowledge in general, while only 9.4% knew how to react to human-made disasters, and 61.4% had advanced natural disaster response knowledge. Rural residents and those with higher education had more disaster response knowledge (P<0.05). Economic status did not show significant effects on residents’ disaster response knowledge.

Conclusion

People’s disaster response knowledge in Beijing was low, especially regarding human-made disasters. The findings implicate further health education on disaster preparedness and response should be implemented, also residents who lived in peri-urban and urban areas or with less education should be given more attention.

Modeling individualized coefficient alpha to measure quality of test score data

Individualized coefficient alpha is defined. It is item and subject specific and is used to measure the quality of test score data with heterogenicity among the subjects and items. A regression model is developed based on 3 sets of generalized estimating equations. The first set of generalized estimating equation models the expectation of the responses, the second set models the response's variance, and the third set is proposed to estimate the individualized coefficient alpha, defined and used to measure individualized internal consistency of the responses. We also use different techniques to extend our method to handle missing data. Asymptotic property of the estimators is discussed, based on which inference on the coefficient alpha is derived. Performance of our method is evaluated through simulation study and real data analysis. The real data application is from a health literacy study in Hunan province of China.

Measuring functional, interactive and critical health literacy of Chinese secondary school students: reliable, valid and feasible?

Health literacy is an increasingly important topic in the global context. In mainland China, health literacy measures mainly focus on health knowledge and practices or on the functional domain for adolescents. However, little is known about interactive and critical domains. This study aimed to adopt a skills-based and three-domain (functional, interactive and critical) instrument to measure health literacy in Chinese adolescents and to examine the status and determinants of each domain. Using a systematic review, the eight-item Health Literacy Assessment Tool (HLAT-8) was selected and translated from English to Chinese (c-HLAT-8). Following the translation process, a cross-sectional study was conducted in four secondary schools in Beijing, China. A total of 650 students in Years 7-9 were recruited to complete a self-administered questionnaire that assessed socio-demographics, self-efficacy, social support, school environment, community environment and health literacy. Results showed that the c-HLAT-8 had satisfactory reliability (Cronbach's α = 0.79; intra-class correlation coefficient = 0.72) and strong validity (translation validity index (TVI) ≥0.95; χ²/ df = 3.388, p < 0.001; comparative fit index = 0.975, Tucker and Lewis's index of fit = 0.945, normed fit index = 0.965, root mean error of approximation = 0.061; scores on the c-HLAT-8 were moderately correlated with the Health Literacy Study-Taiwan, but weakly with the Newest Vital Sign). Chinese students had an average score of 26.37 (±5.89) for the c-HLAT-8. When the determinants of each domain of health literacy were examined, social support was the strongest predictor of interactive and critical health literacy. On the contrary, self-efficacy and school environment played more dominant roles in predicting functional health literacy. The c-HLAT-8 was demonstrated to be a reliable, valid and feasible instrument for measuring functional, interactive and critical health literacy among Chinese students. The current findings indicate that increasing self-efficacy, social support and creating supportive environments are important for promoting health literacy in secondary school settings in China.

The Effect of Vaccine Literacy on Parental Trust and Intention to Vaccinate after a Major Vaccine Scandal

Health literacy, and more specifically vaccine literacy, might be an important factor in reducing the negative effects of exposure to misleading reports on vaccination. This study explores the association between vaccine literacy and vaccination-related outcomes after misleading reports on a scandal concerning locally produced childhood vaccines had emerged in 2016 in China. Data for this study came from a cross-sectional survey, which was conducted in April 2016 in Hangzhou, China. Data were collected in kindergartens and community health centers among parents of children up to 6 years of age. Data were analyzed for 1864 participants. Binary logistic regression models showed that, after controlling for socio-demographics and children's age, parents who had better vaccine literacy (<0.05) were more likely to trust and choose domestically produced vaccines, which account for about 95% of the total vaccinations in China. This study provides evidence on a still largely understudied relationship between vaccine literacy and vaccination-related outcomes. Findings might suggest that higher literacy levels could reduce some of the negative effects of being exposed to misleading information on vaccination, eventually leading to less vaccination hesitancy.

Is college education an equalizer for social disparities in health literacy? A case study in Shanghai, China

OBJECTIVES

The aim of the study was to illustrate the immediate effect of the college education process (across college grades) on the strength of association between parental education and college attendees' health literacy.

METHODS

Cross-sectional analysis was conducted based on data from a random sample of students in one university in Shanghai, China (N = 574). Exploratory factor analysis was used to generate factors of different dimensions of health literacy. Ordinary least square regression models were estimated to investigate how college education process alters the family-based disparity in health literacy.

RESULTS

The link between parental education and health-related skills did not vary significantly across grades of participants, but participants in their third (p < 0.05) and fourth year (p < 0.001) revealed a significantly weaker association between health-promoting proactivity and parental education, relative to the first-year counterparts. Also, the impact of parental education on health-related attitudes significantly declined among the fourth-year seniors, compared with first-year students (p < 0.05).

CONCLUSIONS

Higher education experience is an important mechanism to alleviate the socioeconomic gap in health literacy. Such an equalizer effect, nevertheless, is contingent on the particular dimensions of health literacy.

Prevalence and Risk Factors of Low Health Literacy: A Community-Based Study in Shanghai, China

Background: Health literacy is an increasingly important public health concern. However, little is known about the health literacy of general public in China. The aim of this study was to evaluate the prevalence of low health literacy and demographic associations in Shanghai, China. Methods: This study was a community-based cross-sectional health survey utilizing a multi-stage random sampling design. The sample consisted of 1360 individuals aged 15-69 years with the total community-dwelling Chinese as the sample frame. Health literacy was measured by a questionnaire developed on the basis of a national health literacy manual released by the Chinese Ministry of Health. Multiple logistic regression models were used to identify whether common socio-demographic features were associated with health literacy level. Results: The prevalence of low health literacy was 84.49% (95% CI, 82.56% to 86.41%). The prevalence of low health literacy was negatively associated with the level of education, occupation, and annual household income, but was not associated with gender, age, or the presence of non-communicable chronic disease. Conclusions: Simplifying health services, enhancing health education, and promoting interventions to improve health literacy in high-risk populations should be considered as part of the strategies in the making of health policy in China.

Survey of health literacy level and related influencing factors in military college students in Chongqing, China: A cross-sectional analysis

Health literacy (HL) has become an important public health issue and is receiving growing attention. However, the HL levels of military college students in China have never been analyzed. This study aimed to investigate the HL and related associate factors in military college students in Chongqing, China. Data was obtained with the “Chinese Citizen Health Literacy Questionnaire (2012 edition)” from 3183 military college students aged 16–28 years at Chongqing in December 2015. A total score of ≥80 points determined adequate HL, and HL level was defined as the proportion of students who had adequate HL out of the total number of participants. Multiple logistic regression analysis with a stepwise forward likelihood ratio (LR) method was used to determine the effects of sociodemographic characteristics, health-related behaviors, and family-related factors on HL level. The mean score of HL was 68.56, and the HL level of military college students was 21.05%; the overall knowledge rate was 71.33%. The independent factors that were associated with HL level were years in college, educational system, time playing online games, annual household income and father's education level. Senior (odds ratio [OR] = 1.229, 95% confidence interval [CI] 1.018∼1.484), undergraduate (OR = 1.509, 95% CI 1.151∼1.978), time played games more than 5 hours each week (OR = 0.638, 95% CI 0.486∼0.837), annual household incomes more than 50,000 yuan (OR = 1.231, 95% CI 1.027∼1.476) and father's education level (high school: OR = 2.327, 95% CI 1.186∼4.565; university: OR = 2.450, 95% CI 1.244∼4.825), were independently associated with higher HL level. HL levels of military college students in Chongqing need to be improved across the board. Our data suggests that special emphasis should be placed on students in junior and those in the specialist educational system. School departments may also benefit from incorporating health literacy into their curricula and helping students manage the time they spend playing online games.