Conceptual Model And Measurement Of Chinese Health Literacy

[Purposes]Health literacy is proposed to address the challenges form Non-communicable diseases(NCDs)and has been considered as the most cost-effective approach to achieve people's universal health.Improving people's health literacy has been acted on as a national health policy in order to address health related issues in China.However,regardless health literacy studies and practices kept exploring,some basic but critical questions are still unanswered: what is health literacy & how to systematically measure health literacy? The core aims of current study is to construct the conceptual model of health literacy and develop a use-friendly,reliable and valid measurement[Methods]Systematic review was adopted to collect and screen literature regarding to clarification of the concept of health literacy.The quality of included studies were assessed based on CASP(Qualitative Research Checklist of Critical Appraisal Skills Programme).Basic information,methodology,conceptualizations of health literacy of included studies were extracted.Data-driven thematic analysis was used to synthesize the different conceptualizations and to identify the latent constructs of health literacy.According to Hinkin's guideline of measurement development,measurement construction of health literacy included 5 stages: item generation,content assess,questionnaire administration,factor analysis and internal consistency evaluation.Cognitive interview was used in content assess,exploratory and confirmatory factor analysis were used in factor analysis and Cronbach's alpha was used in internal consistency evaluation,respectively.After the above procedures,measurements of latent constructs of health literacy were developed.Relationship between latent constructs were identified from literature review.Construction of the conceptual model of health literacy included two stages,in which the relationships between latent constructs were added progressively and mediators were identified.Based on TOPSIS(Technique for Order Preference by Similarity to Ideal Solution),the evaluation of different latent constructs of health literacy was synthesized to generate a comprehensive index to represent individual's health literacy level.Finally,twoparameter item response theory was adopted to refine the measurement based on difficulty and discrimination of items and eventually generate a short form health literacy measure.[Results]“What is health literacy”: 3661 records of literature were retrieved based on systematic search in several datasets.A total of 34 studies included in further qualitative synthesis.Among them,most studies focused on health literacy in general population while several concentrated on minors,elderly etc.The methodology of included studies was clustered as theoretical research design and qualitative research design.Most studies did not presented details regarding to methods and only 13 qualitative studies were assessed based on CASP,in which most studies were assessed as low quality.Based on thematical analysis,health literacy was identified as 6 core themes including 27 latent constructs,namely:l Information: information resources,information contents,information characteristics;l Information ability: basic skills,information obtaining skills,information understanding skills,information appraising skills,information communication skills,information decision-making skills,information applying skills;l Other ability: interpersonal skills,self-regulation skills,goal-achieving skills;l Knowledge: disease knowledge,health knowledge,healthcare system knowledge,science knowledge;l Individual characteristics: personal traits,attitudes,willingness & motivation;l Individual resources: information resources,health services resources,healthcare providers,social support and others.“Measuring health literacy”: 176 original items were generated during the item generation stage.Cognitive interview kept 169 items and rephrased their statements.649 questionnaires were distributed and finally 555 eligible responses were collected(response rate = 85.51%).Factor analysis kept 97 items within 5 core themes,generally reproduce the results proposed by systematic review of the concept of health literacy,namely,information ability,other ability,knowledge,individual characteristics and individual resources.The core theme of information was removed due it could not be steadily reflected on a determined latent construct.Information ability measurement included 39 items covering 10 latent constructs;other abilities measurement included 25 items covering 4 latent constructs;knowledge measurement included 20 items covering 4 latent constructs;individual characteristics measurement included 9 items covering 3 latent constructs and individual resources measurement included 6 items covering 1 latent constructs,respectively.“Conceptual model of health literacy”: Principles of construction of conceptual model of health literacy included: 1)information ability is the core of health literacy,knowledge,individual characteristics,individual resources and other abilities influence individual's health literacy through information ability;2)latent constructs within information ability is sequential and hierarchical,in which the lower level ability is the fundamental of higher level ability and there is time-order of information ability.Based on above principles,information ability of health literacy was clustered as four aspects: basic skills,information processing,information appraising and information applying.The data fit the model very well(RMSEA = 0.044,CFI = 0.969,TLI = 966).In addition,knowledge,individual characteristics,individual resources and other abilities could influence information abilities,while some constructs indicated universal positive association with information abilities and some constructs demonstrated negative associations with information abilities,respectively.“Comprehensive and short form of individual health literacy index”: Based on TOPSIS approach,personal health literacy index was developed.The mean of health literacy index of participants is 65.17(standard deviation = 9.08).The index was further validated based on path analysis,in which health literacy index was negative associated with age(?=-0.09,p=0.040)and positive associated with medical background(?=4.63,p<0.001),education level(?=0.10,p=0.019),and additional business health insurance(?=2.004,p=0.017).In addition,after adjusted individual demographic characteristics,health literacy index was universal positively associated with all dimensions of assessment of health-related quality of life.Two-parameter item response theory was adopted to refine the original questionnaire of health literacy.44 items were kept based on difficulty and discrimination of items.The short form health literacy questionnaire measurement was highly associated with the original version(r = 0.954)and showed good external validity based on universal positively association with health-related quality of life.[Conclusions]Chinese health literacy is constituted of 5 core themes covering 22 latent constructs.The core themes and their latent constructs are:l Information ability: basic skills,information obtaining skills,information appraising skills,information expressing skills,rejection skills,decision-making skills,disease information applying skills,health information applying skills,life information applying skills and social action information applying skills;l Other ability: interpersonal skills,self-perception skills,self-regulation skills and goal achieving skills;l Knowledge: disease knowledge,health knowledge,healthcare system knowledge and science knowledge;l Individual characteristics: confidence,attitudes and willingness;l Individual resources: healthcare providers;The conceptual model of health literacy included two parts: the conceptual model of information ability of health literacy and the conceptual model of effects of other aspects(knowledge,individual characteristics,individual resources and other ability)on information ability.The former one indicated the relationship between latent constructs within the information ability of health literacy,while the latter one represented how other aspects could influence health literacy via information ability.In the conceptual model,information ability was constituted of four parts,including basic skills,information processing,information appraising and information applying.There is sequential and hierarchical level in these four parts,in which lower level of information ability serves as the basis of higher level of information ability.Besides information ability,other aspects(knowledge,individual characteristics,individual resources and other ability)influenced one or several aspects of information ability of health literacy.The original form(97-items)and short form(44-items)of health literacy measurement were reliable and valid assessments of individual's health literacy level.These two measurements shared good external validity with personal demographic characteristics and health-related quality of life and could be further used in health literacy policy and practices.[Values and limitations]There is limited theoretical basis in health literacy practices in China and current study fill the gap.The conceptual model proposed in current study was developed by a series rigorous approaches and was deemed to be reliable and valid,in which the roadmap of what is health literacy and the mechanism of the latent constructs were identified,which could help further studies and practices to improve people's health literacy via policy,intervention,program and educations.Developed health literacy measurement,to our knowledge,is the first measurement developed based on theoretical basis and systematically evaluate one's health literacy level in the mainland of China.The further developed short-form and comprehensive health literacy index also increase the usability of the measurement which could be more use-friendly for patients,doctors and general populations.Finally,the synthesized results of all existing literature regarding to conceptualization of health literacy not only have important implications in China,but also other countries,which could be adopted to serve as the theoretical basis of measurement,policies etc.There are several limitations in current studies: there is still limited high-quality study regarding to clarification of the concept of health literacy and the synthesized results of current studies could be further revised if more high-quality studies are included in the future.Though we tried to highlight the roles of healthcare providers and healthcare system and tried to develop measurement regarding to these latent constructs,several of them were not identified in empirical data analysis.Further studies should use more appropriate method to explore how to measure the effect of healthcare providers and healthcare systems on health literacy.Finally,the participants of current studies shared high education level,while the generalization of current conclusion should be careful.