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

Abstract

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.

Keywords

Health literacy adolescents schools measurement China

Introduction

Health literacy is a personal resource to be applied in decision-making for healthcare, disease prevention and health promotion (1). Although there are a wide range of definitions (2), health literacy is commonly understood as an individual’s ability to find, understand and use health information to promote and maintain good health. The importance of health literacy to public health has been well documented in the literature (3 –6). That is, people with low health literacy are likely to have worse health-compromising behaviours (6), poorer health status (5) and higher healthcare costs themselves (3). From a health promotion perspective, improving health literacy at an early age is crucial to adolescent health and empowerment at present and in future (7,8). However, compared with adult health literacy, adolescent health literacy is under-researched (9).

Health literacy is a multi-dimensional concept (10). As elaborated by Nutbeam (1), health literacy has three domains: functional, interactive and critical. Functional domain refers to basic skills in reading and writing health information (1). Interactive domain represents advanced skills that allow individuals to extract health information from different forms of communication (1). Critical domain denotes more advanced skills that can be used to critically evaluate health information and take control over health determinants (1). Integrating interactive and critical domains into adolescent health literacy are essential because they are aligned with the rationale of emphasising empowerment in health promotion for adolescents (8). Unlike health literacy research for patients in clinics, health literacy research for adolescents (a relatively healthy population (11)) should be considered from a health promotion perspective (7) rather than a healthcare perspective. Therefore, health literacy for adolescents should include all three domains.

While health literacy is an important topic in the global context (3,4), health literacy in China is relatively new, especially health literacy measurement in adolescents. In mainland China, the concept ‘health literacy’ was first introduced in 2008 through a public bulletin entitled ‘Basic Knowledge and Skills of People’s Health Literacy’ (12). Since then, health literacy research in China has gained attention. However, most studies focus on the adult population (13 –15) rather than adolescents. As shown in the 2008 Chinese National Health Literacy Survey (14), 93.7% of participants aged 15–24 had low health literacy. Given the close relationship between health literacy and health outcomes (5,6,16), there is a high need to invest in adolescent health literacy research, including its measurement. However, most health literacy instruments in mainland China focus on the functional domain (15,16). Furthermore, compared with the skills-based or three-domain health literacy instruments used in Western countries (10), health literacy measures in mainland China mainly focus on health knowledge and practices (14,17,18). This makes health literacy measurement inequivalent and results incomparable between China and other countries.

In addition, there are few studies exploring the specific relationship between the three domains of health literacy and their determinants for adolescents. Currently, most studies focus on exploring the determinants of functional health literacy (6,19) or overall health literacy (5,20). For example, Chang (6) and Ghaddar et al. (19) found that students were likely to have low functional health literacy if they came from ethnic minorities and had low socio-economic status. Although these findings provide insights about improving adolescent health literacy from different perspectives, they are based on functional health literacy assessment only. As argued by Sansom-Daly et al. (21), exploring interactive or critical health literacy is needed to design more effective interventions for adolescents. As for overall health literacy, the literature has provided a general profile of adolescent health literacy and its determinants (5,20); however, it is still unclear about the specific nature and determinants of each domain.

To address the above two research gaps, the present study aims:

(a) to adopt a skills-based and three-domain instrument to measure health literacy in Chinese adolescents;

(b) to examine the status and determinants of each domain of health literacy.

Methods

Part 1: a systematic review

This study was designed in three parts. Part 1 was a systematic review that aimed to identify a suitable skills-based and three-domain health literacy instrument for adolescents. Findings suggested that the eight-item Health Literacy Assessment Tool (HLAT-8) was the most suitable instrument due to its strong validity, three-domain measurement and quick administration (22). Further details of this review are available from the authors.

Part 2: translation process

In Part 2, the HLAT-8 was translated from English to Chinese (c-HLAT-8) following Beaton’s guidelines (23). There were six steps in the translation process: (1) forward translation; (2) synthesis of forward translation; (3) backward translation; (4) translation committee review; (5) expert panel evaluation of the translation validity index (TVI); and (6) pilot test. Further details of the translation process are available in Supplementary File 1.

Part 3: psychometric testing and determinants analysis

Part 3 was a cross-sectional study that aimed to examine the c-HLAT-8’s reliability and validity and to examine the status and determinants of each domain of health literacy.

Participants and settings

Convenience sampling was used to recruit adolescents aged 11–17 from secondary schools in two districts of Beijing. Two secondary schools in each district were selected conveniently based on previous research partnerships with schools and the appropriateness of survey timing. Thereafter, two intact classes in each year (Years 7, 8 and 9) were conveniently chosen. Students were asked to complete a 25-min self-administered questionnaire in class time. This study was approved by the Institutional Review Board of Peking University (Ethics ID: IRB00001052-15024) and The University of Melbourne (Ethics ID: 1442884) and was conducted in November 2015.

Questionnaire

Health literacy assessment: Three health literacy instruments were employed: the c-HLAT-8 (22), the Newest Vital Sign (NVS) (24) and the Health Literacy Study (HLS)-Taiwan (25). The NVS and the HLS-Taiwan were chosen as comparison tools to test convergent validity of the c-HLAT-8. We hypothesised that there would be positive associations between their health literacy scores.

The HLAT-8 is an eight-item health literacy instrument developed by Abel et al. (22) in Switzerland in 2014. The HLAT-8 measures health literacy in three domains: functional, interactive and critical. Respondents are asked to self-assess their ability to access, understand, communicate and evaluate health information in everyday life (22). The total score range is 0–37, with higher scores indicating higher levels of health literacy. The HLAT-8 took approximately 3 min to complete.

The NVS measures an individual’s skills of reading comprehension and numeracy (24). It consists of six questions, with each question scoring one point when the respondent answers correctly. The total score range is 0–6. The NVS has been demonstrated to have strong convergent validity (the correlation coefficient was 0.71 between the NVS and the Gray Silent Reading Test, p < 0.001) for adolescents (26). The administration time for the NVS was about 4 min.

The HLS-Taiwan is a 47-item translated instrument derived from the Health Literacy Survey-European-Questionnaire (HLS-EU-Q) (25). It covers three domains (healthcare, disease prevention and health promotion) and four competencies related to health information (find, understand, appraise and apply) (27). Respondents are asked to rate their perceived difficulty for each item using a four-point Likert scale. The total score range is 0–50. The HLS-Taiwan showed high internal consistency (Cronbach’s α = 0.96) for the entire scale and satisfactory construct validity for each domain (χ²/df ratio = 20.78–26.70; root mean error of approximation (RMSEA) = 0.08–0.09) (25). The HLS-Taiwan was piloted and adapted for use (see Supplementary File 2). The HLS-Taiwan took 8–10 min to complete.

Socio-demographics: Socio-demographics included age, gender (male or female), ethnicity (Han or ethnic minorities), year level (Years 7, 8 or 9), family structure (intact families or other types) and family affluence level (low, medium or high) (28).

Other health literacy influential factors: Personal self-efficacy, social support, school environment and community environment were collected based on Manganello’s health literacy framework (7). Personal self-efficacy was measured by the General Self-Efficacy Scale (GSES) (29). The GSES is a 10-item scale that assesses personal beliefs in the ability to cope with a variety of difficult demands in life. Respondents indicate their level of agreement on a four-point scale (1 = not at all true, 4 = exactly true). The GSES total score range is 10–40.

Social support was assessed using the Multidimensional Scale of Perceived Social Support (MSPSS) (30). The MSPSS is a 12-item scale that measures an individual’s perceived support from family, friends and significant others. Respondents answer each item on a seven-point Likert scale (1 = very strongly disagree, 7 = very strongly agree). The MSPSS total score range is 12–84.

School environment was assessed by the School Environment Scale (SES), which was derived from the Communities That Care Youth Survey (31). The SES consists of 10 items in three domains: opportunities for prosocial involvement, rewards for prosocial involvement and academic performance. Respondents indicate their level of agreement on a four-point Likert scale (1 = strongly disagree, 4 = strongly agree). The SES total score range is 10–40.

Community environment was assessed by the Community Environment Scale (CES), which measured respondents’ subjective feelings about their neighbourhood environment, such as cleanliness and safety (32). The CES consists of nine items in three domains: neighbourhood liveability, neighbourhood facilities and traffic on the street. Respondents answer each item on a five-point scale (1 = strongly disagree, 4 = strongly agree; 0 = do not know). The CES total score range is 0–36.

All the above scales with higher scores indicate better outcomes for tested variables. In the present study, Cronbach’s α was 0.89, 0.93, 0.88 and 0.84, respectively, for the GSES, the MSPSS, the SES and the CES.

Data analysis

All statistical analysis was conducted using SPSS 22.0 (IBM Corp., US, 2013) and AMOS 23.0 (IBM Corp., US, 2015). Descriptive statistics were calculated for participants’ characteristics. Internal consistency was examined by calculating Cronbach’s α. A Cronbach’s α above 0.7 was considered satisfactory (33). Test-retest reliability was evaluated by the intra-class correlation coefficient (ICC). Sufficient test-retest reliability was assumed if the ICC was above 0.7 (33). Content validity was reviewed by the TVI. A TVI was considered good when a maximal level of 80% of item comparisons was rated as 4 (‘equivalent’), and 100% of item comparisons were rated as either 3 or 4 (‘equivalent but needs minor modification’ or ‘equivalent’) (34). Structural validity was tested by confirmative factor analysis (CFA). A CFA model was considered as an adequate model when the comparative fit index (CFI) value exceeded 0.90, the Tucker and Lewis’s index of fit (TLI) value exceeded 0.90, the normed fit index (NFI) value exceeded 0.90 and the RMSEA value was below 0.10 (35). Convergent validity was examined by Spearman correlation between scores of the c-HLAT-8, the NVS and the HLS-Taiwan. Strong convergent validity was considered when correlation coefficient was above 0.7 (33). Individual mean substitution was conducted for non-response items in self-report scales. After psychometric testing, univariate analysis and multiple linear regression analysis were used to examine the determinants of health literacy. All statistical tests were two-sided and a significant level was set at p < 0.05.

Results

Participants’ characteristics

In total, 650 students participated in this study. The average age of participants was 13.42 ± 1.01. The distribution of gender, ethnicity, year level, family structure, family affluence level, self-efficacy, social support, school environment, community environment and health literacy is shown in Table 1.

Table 1.

Participants’ socio-demographics and descriptive statistics of measured scales (n = 650).

Participant characteristic	Frequency (%) or mean ± SD (n)
Gender
Male	357 (54.9)
Female	293 (45.1)
Ethnicity
Han	617 (94.9)
Ethnic minorities	33 (5.1)
Year level
Year 7	232 (35.7)
Year 8	215 (33.1)
Year 9	203 (31.2)
Family structure
Intact families	553 (85.1)
Other types	96 (14.8)
Family affluence level
Low	179 (27.5)
Medium	296 (45.5)
High	169 (26.0)
Age	13.42 ± 1.01 (n = 648)
Self-efficacy	26.85 ± 6.37 (n = 644)
Social support	62.79 ± 15.26 (n = 644)
School environment	30.48 ± 5.59 (n = 644)
Community environment	25.89 ± 6.09 (n = 644)
Health literacy
c-HLAT-8	26.37 ± 5.89 (n = 649)
NVS	3.65 ± 1.64 (n = 633)
HLS-Taiwan	36.80 ± 9.59 (n = 603)

c-HLAT-8: the Chinese version of the Health Literacy Assessment Tool; HLS-Taiwan: Health Literacy Study-Taiwan; NVS: newest vital sign; SD: standard deviation.

Psychometric properties of the c-HLAT-8

Table 2 shows the descriptive result for each item of the c-HLAT-8. A Cronbach’s α of 0.79 showed satisfactory internal consistency for the c-HLAT-8. The item-total correlation ranged from 0.57 to 0.69. Test-retest reliability was evaluated in 39 students to whom the questionnaire was administered twice, two weeks apart. The ICC was 0.72 (95% confidence interval (CI) 0.46–0.85), suggesting sufficient test-retest reliability.

Table 2.

Item definition and descriptive results of the c-HLAT-8 in Chinese secondary students (n = 650).

Item	Question	Mean ± SD (missing item)
c-HLAT1^a	How well do you understand the written information that comes with medication?	3.83 ± 1.04 (0.2%)
c-HLAT2^a	How well do you understand information presented in health pamphlets?	3.55 ± 1.22 (0.6%)
c-HLAT3^b	How often can you help your family members or a friend if they had questions concerning health issues?	3.29 ± 1.33 (0.2%)
c-HLAT4^b	When you come up with questions concerning health issues, how often can you get information and advice from others?	3.14 ± 1.36 (0.3%)
c-HLAT5^a	There is much advice and many suggestions for health in daily life. How well can you choose the advice and suggestions that suit you the most?	3.51 ± 1.13 (0.2%)
c-HLAT6^c	When I have questions on diseases or health problems, I know where I can find information on these issues	3.03 ± 1.03 (0.2%)
c-HLAT7^c	When I am not ill, but want to do something to further improve my health, I know where I can find information on these issues	3.14 ± 0.91 (0.2%)
c-HLAT8^c	When looking for health information on the Internet, I can determine which sources are of high and which are of poor quality	2.88 ± 1.14 (0.3%)

response options were: very bad, bad, moderate, good, very good and I have not read such information/I have not been interested in these issues.

response options were: never, hardly ever, sometimes, often, always and there have never been any questions.

response options were: strongly disagree, disagree, agree, strongly agree and I do not have experiences with these issues.

c-HLAT-8: the Chinese version of the Health Literacy Assessment Tool; SD: standard deviation.

The TVI examination showed that 95% of items of the c-HLAT-8 were rated as score 4, and 100% of all items achieved ratings of score 3 or 4, indicating the c-HLAT-8 had excellent content validity. In terms of structural validity, the original four-factor model showed three fit indices were good (χ²/df = 7.365, p < 0.001; CFI = 0.922, NFI = 0.911, RMSEA = 0.099) while one index was unsatisfactory (TLI = 0.854 < 0.90). To modify the model, the largest modification indices were used to identify possible correlations between errors. The errors between c-HLAT6 and c-HLAT8, and errors between c-HLAT7 and c-HLAT8, were connected. After modifications, the model demonstrated good data fit: χ²/df = 3.388, p < 0.001; CFI = 0.975, TLI = 0.945, NFI = 0.965, RMSEA = 0.061. The assessment of convergent validity showed a moderate correlation between the c-HLAT-8 and the HLS-Taiwan (r = 0.53, p < 0.001). Specifically, correlations were moderate between the c-HLAT-8 and the three domains (healthcare, disease prevention and health promotion) (r = 0.45–0.53, p < 0.01) and the four competencies (find, understand, appraise and apply) (r = 0.44–0.53, p < 0.01) of the HLS-Taiwan. However, there was a weak correlation between the c-HLAT-8 and the NVS (r = 0.18, p < 0.001). Specifically, correlations between the c-HLAT-8 and the NVS varied by sub-domains of the c-HLAT-8: functional domain (r = 0.20, p < 0.01), interactive domain (r = 0.09, p < 0.05) and critical domain (r = 0.13, p < 0.01).

Status and determinants of three-domain health literacy

The relationship between health literacy and participants’ characteristics is shown in Table 3. Students’ family affluence level showed a positive correlation with all health literacy scores, except for critical health literacy (CHL) scores. There was a slight decline in functional health literacy (FHL) scores as year level increased. Interactive health literacy (IHL) scores were significantly lower among students who were not from intact families. After univariate analysis, the associations between all predictors with p < 0.05 and the dependent variable were examined by backward regression. Table 4 shows that self-efficacy and school environment played more dominant roles in predicting FHL, whereas social support was the strongest predictor of IHL and CHL. However, participants’ characteristics were not included in the final model.

Table 3.

The relationship between health literacy measured by the c-HLAT-8 and participants’ characteristics.

Participant characteristic	Overall HL score		FHL score		IHL score		CHL score
Participant characteristic	Mean ± SD	p value	Mean ± SD	p value	Mean ± SD	p value	Mean ± SD	p value
Gender
Male	26.40 ± 6.16	0.881	13.58 ± 3.20	0.667	6.34 ± 2.31	0.218	6.46 ± 1.82	0.264
Female	26.33 ± 5.56	0.881	13.48 ± 2.80	0.667	6.56 ± 2.16	0.218	6.30 ± 1.77	0.264
Ethnicity
Han	26.37 ± 5.89	0.926	13.54 ± 3.04	0.698	6.43 ± 2.23	0.779	6.39 ± 1.81	0.983
Ethnic minorities	26.27 ± 5.96	0.926	13.33 ± 2.73	0.698	6.55 ± 2.50	0.779	6.39 ± 1.66	0.983
Year level^a
Year 7	26.78 ± 5.75	0.117	13.86 ± 2.73^A	0.030	6.49 ± 2.40	0.789	6.42 ± 1.79	0.254
Year 8	26.59 ± 5.41		13.58 ± 2.71^AB		6.46 ± 2.15		6.51 ± 1.72
Year 9	25.67 ± 6.48		13.10 ± 3.57^B		6.35 ± 2.16		6.22 ± 1.89
Family structure
Intact families	26.49 ± 5.79	0.215	13.52 ± 3.02	0.713	6.53 ± 2.20	0.014	6.43 ± 1.76	0.118
Other types	25.68 ± 6.47	0.215	13.64 ± 3.08	0.713	5.92 ± 2.44	0.014	6.12 ± 2.02	0.118
Family affluence level^a
Low	25.30 ± 5.51^A	0.012	13.04 ± 2.90^A	0.030	6.10 ± 2.25^A	0.047	6.16 ± 1.69	0.121
Medium	26.72 ± 5.95^B		13.70 ± 2.98^B		6.54 ± 2.27^B		6.46 ± 1.81
High	26.96 ± 5.82^B		13.80 ± 3.05^B		6.64 ± 2.13^B		6.52 ± 1.85

CHL: critical health literacy; FHL: functional health literacy; HL: health literacy; IHL: interactive health literacy; SD: standard deviation.

post hoc test was calculated using Fisher’s least significant difference method: there was no statistical difference between two groups with the same letter.

Bold values mean p<0.05.

Table 4.

Determinants of students’ health literacy measured by the c-HLAT-8 by each domain.

Independent variable	Dependent variable
	Overall HL			FHL			IHL			CHL
	β	Beta	p value	β	Beta	p value	β	Beta	p value	β	Beta	p value
Constant	10.59	–	<0.001	7.15	–	<0.001	1.56	–	0.001	2.00	–	<0.001
Self-efficacy	0.11	0.12	0.004	0.05	0.11	0.010	–	–	–	0.04	0.13	0.002
Social support	0.08	0.20	<0.001	0.02	0.09	0.048	0.03	0.23	<0.001	0.03	0.22	<0.001
School environment	0.27	0.26	<0.001	0.13	0.24	<0.001	0.09	0.22	<0.001	0.06	0.18	<0.001

β: unstandardised coefficient; Beta: standardised coefficient; CHL: critical health literacy; FHL: functional health literacy; HL: health literacy; IHL: interactive health literacy.

Bold values mean the most influential factor with the largest standardised coefficient.

Discussion

This study evaluated five psychometric properties of the c-HLAT-8 and examined the status and determinants of students’ health literacy. There are four key findings: (1) the c-HLAT-8 has satisfactory internal consistency and test-retest reliability; (2) the c-HLAT-8 captures four dimensions of health literacy; (3) the c-HLAT-8 is moderately associated with the HLS-Taiwan, but weakly with the NVS; and (4) the determinants of students’ health literacy vary by its domains.

Compared with the HLAT-8 in Swiss samples (22), the c-HLAT-8 had a higher coefficient of Cronbach’s α in Chinese secondary students (0.79 for this study vs. 0.64 for the Swiss study). Also, this study examined the test-retest reliability of the c-HLAT-8 (ICC = 0.72), which was not tested in Swiss samples. These findings indicate that the c-HLAT-8 could function as a scale of overall health literacy measurement and the c-HLAT-8 might be useful for repeated administration in practice.

The CFA results showed that the c-HLAT-8 was supportive of the hypothesised four-factor structure, which was consistent with the HLAT-8 in Swiss samples (22). However, there were modifications to the final model with correlations between errors. The error of Item 8 (c-HLAT-8) was correlated with that of Item 6 (c-HLAT-6) and Item 7 (c-HLAT-7), respectively. The reason for these correlations was probably the systematic measurement error in item responses. Items 6–8 had the same response options, which were different from those used for Items 1–5. Therefore, students might apply the same thinking rationale when answering Items 6–8.

Consistently with the a priori expectation, the c-HLAT-8 was moderately associated with the HLS-Taiwan, but weakly with the NVS. This difference can be explained by the different constructs of health literacy measured within these instruments. As shown in the further correlation analysis, the NVS had a stronger correlation with the functional domain. This suggests that the NVS assesses a single element of health literacy (functional domain), whereas the c-HLAT-8 captures a more comprehensive nature of health literacy (three domains). In comparison, the eight items of the c-HLAT-8 have their equivalents with the items of the HLS-Taiwan.

In the determinants analysis, overall health literacy was positively associated with personal self-efficacy, social support and perceptions of school environment. This empirical finding supports the validity of Manganello’s health literacy framework (7), which advocates an ecological perspective on adolescent health literacy. That means health literacy is not just an individual issue; it is an interactive outcome affected by individual characteristics and the broad environment. This suggests that a systems approach should be considered for future health literacy interventions (4). For example, the ‘Health Promoting Schools’ framework can be a useful guide to implementing school-based health literacy programs (36), as it is in keeping with the principle of a systems approach. Parental health literacy can be another important driver, as it strongly affects adolescent health literacy (37). Unexpectedly, we did not find relationships between socio-demographics and health literacy in the final model. The main reason for this may be that our participants were recruited from the same metropolitan city, with similar ethnicities and socio-economic status. Therefore, further evidence is needed from a wider range of socio-demographics.

As for each domain of health literacy, self-efficacy was found to be an independent factor of FHL and CHL, rather than IHL. Self-efficacy and health literacy are intertwined constructs because they use similar measurement items when self-reporting personal skills (9). The possible reason for the non-significant relationship between self-efficacy and IHL was that social support might override self-efficacy. Due to limited cognitive abilities and dependency on parents (38), adolescents are more likely to rely on social support when communicating health information (9). Social support was also found to be the strongest predictor of CHL. This is consistent with a previous systematic review (39) that identified social support as an important contributor to CHL. Therefore, more attention should be paid to social support when improving IHL and CHL for adolescents. Another important finding is that school environment affects all three domains of health literacy. Positive school environment supports school-based health education programs (36), which in turn contribute to health literacy improvement.

Several limitations should be noted. The convenience sampling may limit the generalisability of the findings. Our sample was recruited from secondary schools in a metropolitan city where subjects’ ability to access good education might be higher. Secondly, respondents may overestimate their health literacy using self-report items. As the present study did not focus on the comparison of self-reported and performance-based measures, this overestimation effect needs to be explored in future research. Thirdly, the health literacy instruments used in this study were not specifically developed for adolescents. Finally, the c-HLAT-8’s responsiveness was not examined. This should be assessed in future longitudinal studies.

Conclusion

The present study demonstrates that the c-HLAT-8 is a reliable, valid and feasible instrument for measuring adolescent health literacy in Chinese secondary schools. The c-HLAT-8 could be used as a monitoring tool to measure adolescent health literacy over time in school-based intervention programs. However, to achieve excellent construct validity of the c-HLAT-8, future work should be mindful of opportunities to reduce systematic measurement errors between items. Compared with existing health literacy instruments in China, the c-HLAT-8 is a skills-based, three-domain and short health literacy instrument that can provide new insights about how to promote adolescent health literacy in each domain. The current findings indicate that increasing self-efficacy, social support and creating supportive environments are important for promoting health literacy in secondary schools in China.

Supplemental Material

Supplementary_Files – Supplemental material for Measuring functional, interactive and critical health literacy of Chinese secondary school students: reliable, valid and feasible?

Supplemental material, Supplementary_Files for Measuring functional, interactive and critical health literacy of Chinese secondary school students: reliable, valid and feasible? by Shuaijun Guo, Elise Davis, Xiaoming Yu, Lucio Naccarella, Rebecca Armstrong, Thomas Abel, Geoffrey Browne and Yanqin Shi in Global Health Promotion

Footnotes

Acknowledgements

We are grateful to the directors of the Healthcare Institute of Primary and Secondary School in Xicheng District and Tongzhou District in Beijing, and we thank all the teachers and participants who were involved in the field study.

Declaration of conflicting interests

None declared.

Funding

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

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