Translation and Validation of a Brief Health Literacy Instrument for School-Age Children in a Danish Context

Revisiting the symptom iceberg based on the Danish symptom cohort - Symptom experiences and healthcare-seeking behaviour in the general Danish population in 2022

Introduction

Healthcare-seeking behaviour may change over time, and some groups are more likely to avoid relevant help seeking, which possibly contributes to social inequity in health. Thus, we developed an expansion of and follow-up to the Danish Symptom Cohort (DaSC) from 2012 and formed the DaSC II, which encompassed a population-based questionnaire study investigating symptoms and healthcare-seeking behaviour. In this paper, we describe the conceptual framework, development and content validity of the questionnaire and a responder analysis of the participants in the DaSC II. We present the symptom iceberg in the Danish general population by estimating the prevalence of symptoms and proportion of contacts to general practitioners (GPs) in 2022. Moreover, we discuss differences in healthcare-seeking behaviour with reference to the 2012 DaSC.

Methods

100,000 randomly selected Danish citizens aged ≥20 years, along with the 44,713 respondents from the 2012 cohort, were invited to participate in a survey. The questionnaire was pilot and field tested prior to distribution. Descriptive statistics were used to estimate symptom prevalence and proportion of GP contacts, and to execute the respondent analysis.

Results

Nine out of ten respondents reported at least one symptom within the preceding four weeks and reported an average of 4.6 symptoms. One in four symptoms were presented to a GP. The highest proportion of GP contacts was found for haematuria (63.3 %) and shortness of breath (51.8 %). For several symptoms, differences between the sexes were found in relation to both prevalence and GP contacts. The proportion of GP contacts was higher in 2022 than in 2012 and was most pronounced for general, frequently experienced symptoms and to a lesser extent for cancer alarm symptoms.

Conclusion

Many symptoms go unreported, which may delay relevant diagnosis; more research on certain symptom categories and population subgroups is needed. Future studies based on the DaSC II form a basis for interventions targeting symptom awareness, healthcare-seeking behaviour and social equity in society and health.

Developing and Evaluating a Data-Driven and Systems Approach to Health Promotion Among Vocational Students: Protocol for the Data Health Study

BACKGROUND

Vocational school students exhibit significant risk behaviors in terms of poor diet, frequent use of nicotine products, inadequate fruit and vegetable intake, low levels of physical activity, and poor mental health. This makes vocational students vulnerable to the development of noncommunicable diseases. Therefore, effective health promotion programs targeting vocational students are required.

OBJECTIVE

The Danish study "Data-driven and Systems Approach to Health Promotion Among Vocational Students" (Data Health) aims to develop, implement, and evaluate a systems approach to support vocational schools, municipalities, and local communities in implementing locally relevant health promotion actions among and for vocational students. This paper describes the Data Health program and how implementation and preliminary effectiveness will be evaluated.

METHODS

The Data Health program offers an iterative 5-step process to develop changes in the systems that shape health behavior and well-being among vocational students. The program will be implemented and evaluated in 8 Danish vocational schools in 4 municipalities. The implementation of the process and actions will be explored using a systems-based evaluation design that assesses contextual differences and the mechanisms through which the program leads to changes in the systems. Preliminary effectiveness at the individual level (students' self-reported health behavior and well-being) and organizational level (school organizational readiness reported by school staff) will be assessed using a quasi-experimental design, and cross-sectional data will be collected at all 8 schools simultaneously 4 times during the 2-year study period.

RESULTS

This study was launched in 2021, and data collection is expected to be completed in June 2024. The first results are expected to be submitted for publication in January 2024.

CONCLUSIONS

We expect that the Data Health study will make significant contributions to complex intervention research by contributing to the paucity of research studies that have used systems approaches in school settings. The study will also provide evidence of successful elements for systems change and effectiveness to determine whether a national scale-up can be recommended.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05308459; https://clinicaltrials.gov/study/NCT05308459.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/52571.

Evaluation of cross-cultural adaptation and validation of the Persian version of the health literacy for school-aged children scale: Methodological study

Background and Aims

Health literacy (HL) is an essential determinant of health in children. Inadequate HL causes problems for individuals and society, such as more hospitalizations, medication errors, poor health, and higher mortality and health care costs. A valid and reliable scale is needed to measure this population's HL. This study evaluated the cross-cultural adaptation and validation of the Persian version of the HL for School-Aged Children (HLSAC) Scale.

Methods

In this methodological research, the HL scale of school-aged children was translated from English to Persian using the Backward-Forward translation protocol. The content validity, face validity, construct validity (Exploratory Factor Analysis [EFA] and Confirmatory factor analysis [CFA]), plus reliability, were evaluated by Internal consistency and stability methods. Two hundred forty samples from south of Tehran were selected by multi-stage sampling method to assess the construct validity. Data analysis was performed using SPSS v24 and Jamovi v2.2.

Results

A qualitative evaluation of face and content validity showed that experts and the target group approved all items on the scale. The results of EFA indicated the existence of one factor, explaining 47.17% of the total variance of the scale. The CFA results showed that the one-factor model of the Persian version of the HL scale for children is almost acceptable. (χ 2/df = 2.94, Root Mean Square Error of Approximation = 0.09, Normed-Fit Index = 0.89, Tucker-Lewis Index = 0.89, Comparative Fit Index = 0.92). Cronbach's alpha coefficient for the whole scale was 0.80, and the Intraclass Correlation Coefficient value for the whole scale was calculated as 0.78 using the single-rating, absolute-agreement, 2-way mixed-effects method.

Conclusion

The study validates the HLSAC Scale, affirming its suitability for assessing HL in Persian-speaking child populations.

The development and cross-national validation of the short health literacy for school-aged children (HLSAC-5) instrument

Health literacy is an asset for and indicator of adolescents' health and wellbeing, and should therefore be monitored and addressed across countries. This study aimed to develop and validate a shorter version of the original 10-item health literacy for school-aged children instrument in a cross-national context, using data from the health behaviour in school-aged children 2017/18 survey. The data were obtained from 25 425 adolescents (aged 13 and 15 years) from seven European countries. Determination was made of the best item combination to form a shorter version of the health literacy instrument. Thereafter, the structural validity, reliability, measurement invariance, and criterion validity of the new 5-item instrument were examined. Confirmatory factor analysis showed a good model fit to the data across countries and in the total sample, confirming the structural validity (CFI = 0.995, TLI = 0.989, SRMR = 0.011, RMSEA = 0.031). The internal consistency of the instrument was at a good level across countries (α = 0.87-0.98), indicating that the instrument provided reliable scores. Configural and metric invariance was established across genders, ages, and countries. Scalar invariance was achieved for age and gender groups, but not between countries. This indicated that the factor structure of the scale was similar, but that there were differences between the countries in health literacy levels. Regarding criterion validity, structural equation modelling showed a positive association between health literacy and self-rated health in all the participating countries. The new instrument was found to be valid and reliable for the purposes of measuring health literacy among adolescents in a cross-national context.

Validation of the brief instrument "Health Literacy for School-Aged Children" (HLSAC) among Norwegian adolescents

Health literacy (HL) has been identified as an important and modifiable determinant of health. To succeed in promoting HL, it is crucial to evaluate interventions addressing HL using validated instruments. However, HL measurement is an under-researched area among adolescents. The Health Literacy for School-Aged Children (HLSAC) scale is developed in Finland to measure the subjective HL levels of school-aged children. The HLSAC has been used and validated across Europe. No validated instrument for measuring HL among Norwegian adolescents has been identified. Therefore, the aim of this study was to assess the psychometric properties of the HLSAC among Norwegian adolescents in upper secondary schools. Cross-sectional data were collected in 2017 from 1 054 adolescents with a response rate of 93.5%. The participants were students aged 16-21 (mean = 17.3) years from four upper secondary schools in an urban area in Mid-Norway. Confirmatory factor analysis (CFA) was utilized to investigate the underlying dimensionality of the data together with composite reliability based on Raykov's reliability coefficient and certain aspects of construct validity. The original ten-item one-dimensional version of the HLSAC revealed a poor fit. A one-dimensional version including six of the original ten items presented the best fit to our data, demonstrating good reliability and construct validity. This validation study suggests a one-dimensional solution of the HLSAC scale including six of the original ten items, i.e., the HLSAC-6 as a statistical valid and reliable measure for HL among adolescents in upper secondary schools. However, the modifications of the instrument indicate the need for further investigation of the HLSAC in this age group, i.e. by conducting cognitive interviews and focus-group discussions on the concept of HL among adolescents. Testing the wording of the HLSAC prior to additional psychometric evaluations of both the original HLSAC and the suggested HLSAC-6 is recommended. Finally, developing more age-appropriate items for the measurement of HL in this age-group is suggested.

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.