Development of the health literacy on social determinants of health questionnaire in Japanese adults

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.

Critical health literacy: reflection and action for health

Health literacy research is growing rapidly and broadly; however, conceptual advances in critical health literacy (CHL) seem hampered by a lack of a clear definition. In this paper, we refer to key features of the concept as identified in earlier works, offer a new definition of CHL and briefly discuss its theoretical roots. Reflection and action are suggested as the two constituent components of CHL. Consequences for future research are also discussed.

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.

Understanding and Responding to Health Literacy as a Social Determinant of Health

Evidence of a social gradient in health literacy has been found in all reported national population surveys. Health literacy is a midstream determinant of health but not a panacea for addressing health inequities created by the maldistribution of opportunity and resources. It is possible to optimize the contribution health literacy makes in mediating the causes and effects of established social determinants of health. Existing interventions demonstrate the feasibility of improving health literacy among higher-risk populations, but research remains underdeveloped and effects on health inequity are largely untested. Future health literacy intervention research should focus on (a) improving the quality of health communication that reaches a diversity of populations, especially by improving frontline professional skills and support; (b) enabling people to develop transferable skills in accessing, understanding, analyzing, and applying health information; and (c) ensuring that priority is proportionate to need by reaching and engaging the population groups who are disproportionately affected by low health literacy.

The health literacy of university students in North Cyprus

Health literacy is individuals' motivation and ability to obtain, understand, evaluate and use health information. Health literacy is very important during university education when students have the ability to acquire and accumulate knowledge of the best way. The aim of this study was to determine the health literacy of university students. The sample of this descriptive cross-sectional study was composed of 365 students who were first-time visitors at the health center of a private university in Northern Cyprus between May and July 2017. An introductory information form and the Adult Health Literacy Scale (AHLS) were used as data collection tools. The mean AHLS score of the students was found as 13.91 ± 2.90. Health literacy was found to be lower for male students and students with more years of study. The students with low daily alcohol use had higher AHLS scores. The results of the study suggest that curricula should be revised to raise the health literacy of university students to the highest level. It is important to organize conferences, seminars and scientific activities to improving the health literacy of male students and students with more years of study. Due to the limitations of studies of health literacy in North Cyprus, future studies should be conducted with larger samples and different measurement tools.

Generic Health Literacy Measurements for Adults: A Scoping Review

BACKGROUND

Generic health literacy measurement (GHLM) is an important tool to identify individuals with limited health literacy and can assist the design of tailored interventions for improving public health literacy. However, there is no consensus on measuring generic health literacy. The present study aims to review current GHLM used for adults in the literature.

METHODS

A scoping review was undertaken to map the available measurements designed to assess generic health literacy.

RESULTS

The review identified 19 GHLM for adults. Most of them applied a multidimensional definition of health literacy with a focus on individuals' abilities to access, appraise, understand, and apply health information and services. Nutbeam's conceptual model and Sørensen's integrated model were widely used among the identified measures as the theoretical foundation. While the social determinants of health (SDH) were acknowledged in the two models, it remains unmentioned in many of the identified measures based on the Nutbeam's model and needs further development in the measure based on the Sørensen's model. A total of 39 different domains were assessed in the 19 measurements: prose was identified in 8 measurements and was the most prominent domain; followed by numeracy (n = 7) and interactive (n = 7). SDH related domains such as social support (n = 3), social capital (n = 1) were seldom included in the identified measurements.

CONCLUSIONS

Although current GHLM adopted a multidimensional construct, they mainly focused on individuals' abilities and SDH has not been well-developed in the assessment. Further research is required to advance the measuring of the interaction between SDH and health literacy.

Moving Health Literacy Research and Practice towards a Vision of Equity, Precision and Transparency

Over the past two decades, health literacy research has gained increasing attention in global health initiatives to reduce health disparities. While it is well-documented that health literacy is associated with health outcomes, most findings are generated from cross-sectional data. Along with the increasing importance of health literacy in policy, there is a lack of specificity and transparency about how to improve health literacy in practice. In this study, we are calling for a shift of current research paradigms from judging health literacy levels towards observing how health literacy skills are developed over the life course and practised in the real world. This includes using a life-course approach, integrating the rationale of precision public health, applying open science practice, and promoting actionable knowledge translation strategies. We show how a greater appreciation for these paradigms promises to advance health literacy research and practice towards an equitable, precise, transparent, and actionable vision.

Factors Associated with the Health Literacy on Social Determinants of Health: A Focus on Socioeconomic Position and Work Environment

Though impressive progress has been made in healthcare worldwide, many people still experience disproportionate health burdens and inequities in healthcare services. For establishing sustainable development goals, health literacy on social determinants of health (HL-SDH) has been recognized as a key to creating better social and physical environments. In particular, low levels of health literacy among industrial workers are considered as a major barrier to benefitting from the progress made in healthcare. This study aimed to describe levels of HL-SDH and to examine the relationships among socioeconomic status, working environment, and HL-SDH among workers in Korea. A total of 660 workers from an online panel participated in Korea from 30 May to 7 June 2018. The Korean version of HL-SDH instrument consisted of 33 items and four dimensions: access, understand, appraise, and apply. Descriptive statistics, a t-test, ANOVA, and multiple regression analysis were conducted. The mean score of HL-SDH was 2.48. Perceived mental health status, annual income, and the number of employees per worksite were found to be statistically significant factors related to HL-SDH (F = 3.64, p = <0.001). The HL-SDH score was considerably higher, indicating that nursing interventions to enhance HL-SDH are required for health promotion, especially among workers in poor social and working environments.

Validity and Internal Consistency of the Preschool-FLAT, a New Tool for the Assessment of Food Literacy in Young Children from the Training-To-Health Project

Background: The importance of assessing “food literacy” since youth has been highlighted and, to this purpose, valid and consistent instruments are needed. This study aimed to assess the validity and internal consistency of the preschool-FLAT (Food Literacy Assessment Tool). Methods. 505 children from 21 kindergartens, recruited within the Training-to-Health Project in Palermo (Italy), underwent oral sessions and activities on food-related aspects. Their knowledge/skills were recorded in the preschool-FLAT. The following scale measures were assessed: Content validity; internal consistency (Chronbach’s alpha coefficients); construct validity (Structural Equation Modeling—SEM); discriminant validity (intervention subgroup of 100 children vs. control group of 27 children). Results. Acceptable content validity of a 16-items scale and overall adequate internal consistency were revealed: Content validity index (CVI) 0.94, content validity ratio (CVR) 0.88, Chronbach’s alpha 0.76. The SEM revealed a 4-factor model fitting the data well (comparative fit index 0.939, root mean square error of approximation 0.033). Discriminant validity was good (intervention group scoring higher than control, p < 0.001, unpaired Student’s t-test). Conclusion. The preschool-FLAT revealed good psychometric properties, adequate validity and internal consistency. This is the only instrument in the literature specifically targeted to 3–6 years old children that could be effectively used to assess food literacy.

Determinants and Consequences of Limited Health Literacy in Polish Society

Background: Health literacy (HL) is perceived as one of the most important concepts for modern health promotion activities to be successful. The research undertaken in the context of HL usually focuses on its antecedents and consequences, either for specific groups of patients or society or for the whole population. Objectives: The main aim of this study was to assess the antecedents and consequences of limited health literacy (HL) in a nationally representative sample of the Polish population. Methods: The analysis was carried out on the data obtained from a sample of 1000 Polish citizens through a telephone-based survey undertaken using a short, 16-item questionnaire developed within the European Health Literacy Project (HLS-EU). The total HLS score was calculated according to the guidelines published by the HLS-EU project. Chi2 test and logistic regression models were used for the analysis of the relationships between the variables. Results: The mean HL score (standard deviation) in the study sample was 12.99 (3.11). HL was related to age, marital and vocational status. Limited HL was associated with a lower self-assessment of health (OR, 95% CI: 2.52, 1.54–4.13), the prevalence of obesity and disability (1.71, 1.13–2.57, and 1.92, 1.25–2.94, respectively), less frequent physical activity (0.70, 0.49–0.99), a lower consumption of fruits and vegetables (0.47, 0.34–0.65), and with more frequent hospitalisations (2.02, 1.38–2.95). Conclusions: The assessment of HL using the16-item HLS-EU questionnaire may be a useful tool to enable health behaviours and utilisation of health care resources by society to be predicted.

Psychometric properties of the Korean version of the Health Literacy on Social Determinants of Health Questionnaire (K-HL-SDHQ)

The association between the social determinant of health (SDH) and sustainable development goals, has directed attention toward the influence of SDH. However, there is a lack of evidence regarding the instruments used to assess SDH. Thus, this study was conducted to assess the validity and reliability of the Korean Version of the Health Literacy on Social Determinants of Health Questionnaire (K-HL-SDHQ). A total of 660 workers in Korea participated in an online survey. The K-HL-SDHQ measures four dimensions (Access, Understand, Appraise, and Apply) with 33 items. The HL-SDHQ was translated into Korean using the forward-back translation method. To test the validity and reliability of the Korean translated HL-SDHQ, item analysis for the 33 items was conducted. Internal consistency was examined using Cronbach's α, an exploratory factor analysis, and a confirmatory factor analysis. The scale-level content validity index (S-CVI)/universal agreement of this study was .12 and S-CVI/average was .83 (item-CVI range = .50-1.00). The goodness of fit determined through a confirmatory factor analysis of the four dimensions was acceptable (χ2 (489) = 1475.054, p < .001, RMSEA = .06, CFI = .87, TLI = .85). The K-HL-SDHQ also demonstrated satisfactory internal consistency reliability (Cronbach's α = .92). The findings indicate that the K-HL-SDHQ is a valid and reliable tool that can be used to assess the SDH of workers in Korea. It is suggested that this tool can be applied through repeated research with workers and non-workers for health promotion, and to enhance researchers' understanding of the different levels of the HL-SDHQ.

Challenges and opportunities in building critical health literacy

BACKGROUND

Critical health literacy is the least explored domain of health literacy and is addressed by few projects seeking to build health literacy. Lack of research means there is little evidence upon which to design effective interventions. Yet critical health literacy offers potential for individuals and communities to make important contributions to their own and society's health. This paper reports on an evaluation of a community project designed to develop critical health literacy.

METHOD

The evaluation explored, (a) processes used to build critical health literacy and (b) the impact on the critical health literacy of participants. A mixed methods approach was used combining a pre-and post-intervention assessment of 14 of the 24 participants using the All Aspects of Health Literacy Scale, with participant focus groups and facilitator interviews.

RESULTS

Strategies used to build critical health literacy included informal and participatory learning, supported and independent assessment of the problem, appraising information, familiarisation of health systems and services, and social support. Common to these was learning within the context of participants' lives. Fewer strategies encouraged empowerment and political action. The evaluation showed slight improvements in some critical health literacy competencies: the ability to critically appraise health information and apply it to the context of their own lives and being able to critically question health professionals based on an individual's own research. However, there was no change in participants' ability to understand the determinants of health or involvement in activities for social and political change.

CONCLUSION

Informal, participatory community projects can successfully build many characteristics of critical health literacy. However, the political action element of critical health literacy remains the least well understood and faces particular challenges in its implementation.

Factors associated with health literacy in multimorbid patients in primary care: a cross-sectional study in Switzerland

OBJECTIVE

To identify factors associated with health literacy in multimorbid patients.

DESIGN

A nationwide cross-sectional study in Switzerland. Univariate and multivariate linear regressions were calculated to identify variables associated with health literacy. A multiple imputation approach was used to deal with missing values.

PARTICIPANTS

Multimorbid patients recruited in primary care settings (n=888), above 18 years old and suffering from at least 3 of 75 chronic conditions on a predefined list based on the International Classification of Primary Care 2.

MAIN MEASURES

Health literacy was assessed using the European Health Literacy Survey project questionnaire (HLS-EU 6). This comprises six items scored from 1 to 4 (very difficult=1, fairly difficult=2, fairly easy=3, very easy=4), and the total health literacy score is computed as their mean. As we wished to understand the determinants associated with lower health literacy, the HLS-EU 6 score was the only dependent variable; all other covariates were considered independent.

RESULTS

The mean health literacy score (SD) was 2.9 (0.5). Multivariate analyses found significant associations between low health literacy scores and treatment burden scores (β=-0.004, 95% CI -0.006 to 0.002); marital status, predominantly the divorced group (β=0.136, 95% CI 0.012 to 0.260); dimensions of the EuroQuol 5 Dimension 3 Level (EQ5D3L) quality of life assessment, that is, for moderate problems with mobility (β=-0.086, 95% CI -0.157 to 0.016); and with moderate problems (β=-0.129, 95% CI -0.198 to 0.060) and severe problems with anxiety/depression (β=-0.343, 95% CI -0.500 to 0.186).

CONCLUSIONS

Multimorbid patients with a high treatment burden, altered quality of life by problems with mobility, anxiety or depression, often also have low levels of health literacy. Primary care practitioners should therefore pay particular attention to these patients in their daily practice.

Health Literacy in School

Health literacy is a core element of patient-centered healthcare. Poor health literacy is a silent epidemic across the globe as it affects every aspect of health. Schools bear an important role in increasing health literacy. Improving health literacy in adolescence is supposed to improve the later life as adolescents are used to carry their modified behavior lifelong. Various school-based interventions covering physical and mental health have been studied and found to be effective. International bodies recommend incorporation of health-related tasks into school lessons and considered that teaching the young people will be a good investment for future. Multisectoral collaborations and locally proved effective strategies are the practical challenges. This chapter aims to focus on health literacy, global scenario of health literacy, measurement tools, role of school, interventions, limitations, and challenges of health literacy.