Developing the HLS19-YP12 for measuring health literacy in young people: a latent trait analysis using Rasch modelling and confirmatory factor analysis.

BACKGROUND: Accurate and precise measures of health literacy (HL) is supportive for health policy making, tailoring health service design, and ensuring equitable access to health services. According to research, valid and reliable unidimensional HL measurement instruments explicitly targeted at young people (YP) are scarce. Thus, this study aims at assessing the psychometric properties of existing unidimensional instruments and developing an HL instrument suitable for YP aged 16-25 years. METHODS: Applying the HLS19-Q47 in computer-assisted telephone interviews, we collected data in a representative sample comprising 890 YP aged 16-25 years in Norway. Applying the partial credit parameterization of the unidimensional Rasch model for polytomous data (PCM) and confirmatory factor analysis (CFA) with categorical variables, we evaluated the psychometric properties of the short versions of the HLS19-Q47; HLS19-Q12, HLS19-SF12, and HLS19-Q12-NO. A new 12-item short version for measuring HL in YP, HLS19-YP12, is suggested. RESULTS: The HLS19-Q12 did not display sufficient fit to the PCM, and the HLS19-SF12 was not sufficiently unidimensional. Relative to the PCM, some items in the HLS19-Q12, the HLS19-SF12, and the HLS19-Q12-NO discriminated poorly between participants at high and at low locations on the underlying latent trait. We observed disordered response categories for some items in the HLS19-Q12 and the HLS19-SF12. A few items in the HLS19-Q12, the HLS19-SF12, and the HLS19-Q12-NO displayed either uniform or non-uniform differential item functioning. Applying one-factorial CFA, none of the aforementioned short versions achieved exact fit in terms of non-significant model chi-square statistic, or approximate fit in terms of SRMR ≤ .080 and all entries ≤ .10 that were observed in the respective residual matrix. The newly suggested parsimonious 12-item scale, HLS19-YP12, displayed sufficiently fit to the PCM and achieved approximate fit using one-factorial CFA. CONCLUSIONS: Compared to other parsimonious 12-item short versions of HLS19-Q47, the HLS19-YP12 has superior psychometric properties and unconditionally proved its unidimensionality. The HLS19-YP12 offers an efficient and much-needed screening tool for use among YP, which is likely a useful application in processes towards the development and evaluation of health policy and public health work, as well as for use in clinical settings.

"Nursing students' experiences with concept cartoons as an active learning strategy for developing conceptual understanding in anatomy and physiology: A mixed-method study".

AIM: The aim of this study was to explore bachelor-level nursing students' experiences with concept cartoons as an active learning strategy and formative assessment to develop conceptual understanding in anatomy and physiology (A&P). BACKGROUND: Many first-year nursing students struggle to understand central concepts in A&P. Concept cartoons-cartoon characters proposing scientifically acceptable statements and misconceptions combined with an illustration-might facilitate active learning in lectures, overcome misconceptions and promote deep learning. Voting on the most precise statement using a student response system gives formative information about the students' conceptual understanding. DESIGN: Parallel mixed methods design with an emphasis on a qualitative approach. METHODS: Nine concept cartoons were developed based on former students' written answers to exam items and applied in lectures at three universities/university colleges. Qualitative data of students' experiences were collected in three focus group interviews during November 2019, one focus group at each of the three universities/university colleges (n = 5, 8 and 8). A short questionnaire was also applied (n = 343) to all students at the three universities/university colleges. Qualitative data were analysed using qualitative content analyses, whereas frequency analysis and Chi-square statistics were applied for the quantitative data. The study was approved by the Norwegian Centre for Research Data, ref. 779586. RESULTS: Qualitative data analysis indicated that the use of concept cartoons addresses different learning styles and could promote deep learning and enhance the environment for learning. The concept cartoons were also seen as valuable for examination preparation. Regarding potential improvements, more information about concept cartoons, how they were developed and how they were supposed to be used would be beneficial, and the cartoons could be used in a more time-efficient manner during lectures. Quantitative data indicated that most of the students thought that concept cartoons were useful and inspiring in learning A&P, and they would recommend further use to increase their understanding of central concepts. There were no significant differences across sex, age, or entrance qualifications when it comes to the benefits of using concept cartoons in learning A&P. Compared to students born in Scandinavia, a larger proportion of students born outside Scandinavia found the use of concept cartoons inspiring for their learning in A&P. CONCLUSIONS: The use of concept cartoons was appreciated by the students to develop a conceptual understanding in A&P. Most students recommended future use. REGISTRATION NUMBER: At point of submission put this on title page Tweetable abstract: Concept cartoons are appreciated as an active learning strategy and formative assessment in developing nursing students' conceptual understanding of anatomy and physiology.

HLS19-NAV-Validation of a New Instrument Measuring Navigational Health Literacy in Eight European Countries.

To manoeuvre a complex and fragmented health care system, people need sufficient navigational health literacy (NAV-HL). The objective of this study was to validate the HLS19-NAV measurement scale applied in the European Health Literacy Population Survey 2019-2021 (HLS19). From December 2019 to January 2021, data on NAV-HL was collected in eight European countries. The HLS19-NAV was translated into seven languages and successfully applied in and validated for eight countries, where language and survey method differed. The psychometric properties of the scale were assessed using confirmatory factor analysis (CFA) and Rasch modelling. The tested CFA models sufficiently well described the observed correlation structures. In most countries, the NAV-HL data displayed acceptable fit to the unidimensional Rasch partial credit model (PCM). For some countries, some items showed poor data-model fit when tested against the PCM, and some items displayed differential item functioning for selected person factors. The HLS19-NAV demonstrated high internal consistency. To ensure content validity, the HLS19-NAV was developed based on a conceptual framework. As an estimate of discriminant validity, the Pearson correlations between the NAV-HL and general health literacy (GEN-HL) scales were computed. Concurrent predictive validity was estimated by testing whether the HLS19-NAV, like general HL measures, follows a social gradient and whether it forms a predictor of general health status as a health-related outcome of general HL. In some countries, adjustments at the item level may be beneficial.

Health literacy in former Soviet Union immigrants in the US: A mixed methods study.

BACKGROUND: People with limited health literacy may have trouble finding, understanding, and using health-related information and services and navigating the healthcare system. PURPOSE: The purpose of this study was to assess the health literacy of immigrants from the former Soviet Union (FSU) using the Health Literacy Survey (HLS19-Q12 in Russian) and explore associated socio-demographic factors. METHOD: This mixed methods study recruited adult immigrants through social networks and social media and included data from online survey and follow-up interviews. Variance in health literacy was explained using multiple linear regression. Qualitative data were analyzed through modified Grounded Theory approach. FINDINGS: Survey respondents (n = 318) were primarily female college-educated FSU immigrants aged 20-74 from 14 of the 15 FSU countries and distributed across 33 US states. Forty percent scored at or below predefined cut-offs for inadequate or problematic health literacy levels. Social status, social support, and English proficiency were significant variables in explaining variance in health literacy scores while controlling for age, gender, and education. Interviews (n = 24) identified eight themes: English proficiency, social support, health insurance, experience with health care, complexity of the US healthcare system, relevant health information, health beliefs/practices, and trust. DISCUSSION: There is a need to distribute health-related information in the native language (e.g., Russian), potentially through social media and immigrants' social networks. Health providers should be aware of the prevalence of inadequate and problematic health literacy among FSU immigrants and consider associated social factors.

Explaining variance in health literacy among people with type 2 diabetes: the association between health literacy and health behaviour and empowerment.

BACKGROUND: To reflect the health literacy (HL) skills needed for managing type 2 diabetes (T2DM) in everyday life, HL in people with T2DM should be measured from a broader perspective than basic skills, such as proficiency in reading and writing. The HLS-Q12, based on the European Health Literacy Survey Questionnaire (HLS-EU-Q47), assesses four cognitive domains across three health domains. International studies on people with T2DM show inconsistent results regarding the association between HL and general health and the association between HL and glycaemic control. Moreover, knowledge is needed related to the link between HL and empowerment for those with T2DM. The aims of this study were to examine the association between i) HL and general health and diabetes outcomes, ii) HL and health behaviours and iii) HL and empowerment in people with T2DM. METHODS: During March and April 2015, 388 adults with T2DM responded to a paper-and-pencil self-administered questionnaire. A sequential multiple regression analysis was applied to explore the association between HL, as measured by the HLS-Q12, and health conditions, HbA1c, health behaviours and empowerment. RESULTS: For people with T2DM, higher levels of HL were associated with higher levels of education, better overall health conditions and higher self-perceived empowerment. No empirical evidence strengthening either the link between HL and glycaemic control or the link between HL and health behaviours was found. CONCLUSIONS: The independent variables education level, overall health condition and empowerment explained about one-third of the total observed variance in HL.

Lower secondary school students' scientific literacy and their proficiency in identifying and appraising health claims in news media: a secondary analysis using large-scale survey data.

OBJECTIVES: Scientific literacy is assumed necessary for appraising the reliability of health claims. Using a national science achievement test, we explored whether students located at the lower quartile on the latent trait (scientific literacy) scale were likely to identify a health claim in a fictitious brief news report, and whether students located at or above the upper quartile were likely to additionally request information relevant for appraising that claim. DESIGN: Secondary analysis of cross-sectional survey data. SETTING AND PARTICIPANTS: 2229 Norwegian 10th grade students (50% females) from 97 randomly sampled lower secondary schools who performed the test during April-May 2013. OUTCOME MEASURES: Using Rasch modelling, we linked item difficulty and student proficiency in science to locate the proficiencies associated with different percentiles on the latent trait scale. Estimates of students' proficiency, the difficulty of identifying the claim and the difficulty of making at least one request for information to appraise that claim, were reported in logits. RESULTS: Students who reached the lower quartile (located at -0.5 logits) on the scale were not likely to identify the health claim as their proficiency was below the difficulty estimate of that task (0.0 logits). Students who reached the upper quartile (located at 1.4 logits) were likely to identify the health claim but barely proficient at making one request for information (task difficulty located at 1.5 logits). Even those who performed at or above the 90th percentile typically made only one request for information, predominantly methodological aspects. CONCLUSIONS: When interpreting the skill to request relevant information as expressing students' proficiency in critical appraisal of health claims, we found that only students with very high proficiency in science possessed that skill. There is a need for teachers, healthcare professionals and researchers to collaborate to create learning resources for developing these lifelong learning skills.

Validating the Functional, Communicative, and Critical Health Literacy Scale Using Rasch Modeling and Confirmatory Factor Analysis.

BACKGROUND AND PURPOSE: The functional, communicative, and critical health literacy (FCCHL) scale is widely used for assessing health literacy (HL) in people with chronic diseases, such as type 2 diabetes (T2DM). Despite related subscales, researchers continue to apply a consecutive modeling approach, treating the three subscales as independent. This article studies the psychometric characteristics of the FCCHL by applying multidimensional modeling approaches. METHODS: Rasch modeling and confirmatory factor analyses were applied to responses (paper-and-pencil) from 386 adults with T2DM. RESULTS: Using a six-point rating scale and a three-dimensional Rasch model, this study found that a 12-item version of the FCCHL reduced within-item bias and improved subscale reliability indexes. CONCLUSION: This study suggests a parsimonious 12-item version of the FCCHL. The data fit a three-dimensional Rasch model best.

Observing the World Through Your Own Lenses - The Role of Perceived Adaptability for Epistemological Beliefs About the Development of Scientific Knowledge.

Students are exposed to vast amounts of information and knowledge that is rapidly changing. This exposure requires them to be adaptive, that is, to constantly adjust their thinking, behavior, and even their affect to successfully solve information-rich and knowledge-lean problems. Considering these developments, the purpose of the present study is twofold: First, it is aimed at exploring the link between students' beliefs about their adaptability in an ever-changing world and their beliefs about the changing nature of scientific knowledge, thus linking two educationally relevant belief systems. Second, this study further explores validity issues related to the well-established and commonly used "Epistemological Beliefs about the Development of Scientific Knowledge (EBDE)" scale. Performing structural equation modeling on a large-scale data set of 1,662 Norwegian tenth-grade students, we estimated the correlations among different aspects of adaptability (i.e., cognitive-behavioral and affective-emotional adaptability) and EBDE. Moving beyond these correlations, we tested whether students' perceived adaptability had an impact on the functioning of EBDE items by means of moderated factor analysis. Our analyses revealed that adaptability was associated with sophisticated EBDE in science, and the EB scale functioned differently with respect to different adaptability scores. The results of this study indicate that students perceive the development of scientific knowledge through the lenses of their own adaptability. Furthermore, the differential functioning of the EBDE scale challenges its validity.

Establishing the HLS-Q12 short version of the European Health Literacy Survey Questionnaire: latent trait analyses applying Rasch modelling and confirmatory factor analysis.

BACKGROUND: The European Health Literacy Survey Questionnaire (HLS-EU-Q47) is widely used in assessing health literacy (HL). There has been some controversy whether the comprehensive HLS-EU-Q47 data, reflecting a conceptual model of four cognitive domains across three health domains (i.e. 12 subscales), fit unidimensional Rasch models. Still, the HLS-EU-Q47 raw score is commonly interpreted as a sufficient statistic. Combining Rasch modelling and confirmatory factor analysis, we reduced the 47 item scale to a parsimonious 12 item scale that meets the assumptions and requirements of objective measurement while offering a clinically feasible HL screening tool. This paper aims at (1) evaluating the psychometric properties of the HLS-EU-Q47 and associated short versions in a large Norwegian sample, and (2) establishing a short version (HLS-Q12) with sufficient psychometric properties. METHODS: Using computer-assisted telephone interviews during November 2014, data were collected from 900 randomly sampled individuals aged 16 and over. The data were analysed using the partial credit parameterization of the unidimensional polytomous Rasch model (PRM) and the 'between-item' multidimensional PRM, and by using one-factorial and multi-factorial confirmatory factor analysis (CFA) with categorical variables. RESULTS: Using likelihood-ratio tests to compare data-model fit for nested models, we found that the observed HLS-EU-Q47 data were more likely under a 12-dimensional Rasch model than under a three- or a one-dimensional Rasch model. Several of the 12 theoretically defined subscales suffered from low reliability owing to few items. Excluding poorly discriminating items, items displaying differential item functioning and redundant items violating the assumption of local independency, a parsimonious 12-item HLS-Q12 scale is suggested. The HLS-Q12 displayed acceptable fit to the unidimensional Rasch model and achieved acceptable goodness-of-fit indexes using CFA. CONCLUSIONS: Unlike the HLS-EU-Q47 data, the parsimonious 12-item version (HLS-Q12) meets the assumptions and the requirements of objective measurement while offering clinically feasible screening without applying advanced psychometric methods on site. To avoid invalid measures of HL using the HLS-EU-Q47, we suggest using the HLS-Q12. Valid measures are particularly important in studies aiming to explain the variance in the latent trait HL, and explore the relation between HL and health outcomes with the purpose of informing policy makers.

Assessing adolescents' perceived proficiency in critically evaluating nutrition information.

BACKGROUND: Over the recent past, there has been an increase in nutrition information available to adolescents from various sources, which resulted into confusion and misinterpretation of the dietary advice. Results from international assessment frameworks such as PISA and TIMMS reflect the need for adolescents to critically appraise health information. While a number of scales measuring the critical health literacy of individuals exist; very few of these are devoted to critical nutrition literacy. More so, these scales target individuals with an advanced level of nutrition education, often gaging their proficiency in information appraisal in relation to principles of evidence-based medical research. The purpose of the present study was to examine the psychometric properties of a newly developed critical nutrition literacy scale (CNL-E) measuring adolescents' perceived proficiency in 'critically evaluating nutrition information from various sources'. METHODS: During spring 2015, more than 1600 tenth graders aged 15-16 years from approximately 60 schools in Norway responded to the five-item questionnaire using an electronic survey system. Applying Rasch analysis approach, we examined the psychometric properties of the CNL-E scale employing the RUMM2030 statistical package. To further investigate the dimensionality of the scale and test the underlying structure, we applied multidimensional Rasch modelling using the ConQuest 4 software and confirmatory factor analysis (CFA) using the Lisrel 9.30 software. RESULTS: In our sample, the CNL-E stood out as a valid, reliable and well-targeted scale with good overall fit to the partial credit parameterization of the polytomous unidimensional Rasch model (PCM). All the items were sufficiently statistically independent, had ordered response categories and showed acceptable individual fit to the PCM. No item displayed within-item bias or differential item functioning (DIF). CONCLUSIONS: From the observed CNL-E sum score, it is possible to draw plausible conclusions about how individuals critically evaluate nutrition information. Efforts to improve communication of nutrition information could benefit from applying validated measures such as the CNL-E scale. The CNL-E scale provides insight into how individuals without an advanced level of nutrition education, such as adolescents, determine the validity and reliability of nutrition information from various sources.

Measuring ability to assess claims about treatment effects: the development of the 'Claim Evaluation Tools'.

OBJECTIVES: To describe the development of the Claim Evaluation Tools, a set of flexible items to measure people's ability to assess claims about treatment effects. SETTING: Methodologists and members of the community (including children) in Uganda, Rwanda, Kenya, Norway, the UK and Australia. PARTICIPANTS: In the iterative development of the items, we used purposeful sampling of people with training in research methodology, such as teachers of evidence-based medicine, as well as patients and members of the public from low-income and high-income countries. Development consisted of 4 processes: (1) determining the scope of the Claim Evaluation Tools and development of items; (2) expert item review and feedback (n=63); (3) cognitive interviews with children and adult end-users (n=109); and (4) piloting and administrative tests (n=956). RESULTS: The Claim Evaluation Tools database currently includes a battery of multiple-choice items. Each item begins with a scenario which is intended to be relevant across contexts, and which can be used for children (from age 10  and above), adult members of the public and health professionals. People with expertise in research methods judged the items to have face validity, and end-users judged them relevant and acceptable in their settings. In response to feedback from methodologists and end-users, we simplified some text, explained terms where needed, and redesigned formats and instructions. CONCLUSIONS: The Claim Evaluation Tools database is a flexible resource from which researchers, teachers and others can design measurement instruments to meet their own requirements. These evaluation tools are being managed and made freely available for non-commercial use (on request) through Testing Treatments interactive (testingtreatments.org). TRIAL REGISTRATION NUMBERS: PACTR201606001679337 and PACTR201606001676150; Pre-results.

Measuring ability to assess claims about treatment effects: a latent trait analysis of items from the 'Claim Evaluation Tools' database using Rasch modelling.

BACKGROUND: The Claim Evaluation Tools database contains multiple-choice items for measuring people's ability to apply the key concepts they need to know to be able to assess treatment claims. We assessed items from the database using Rasch analysis to develop an outcome measure to be used in two randomised trials in Uganda. Rasch analysis is a form of psychometric testing relying on Item Response Theory. It is a dynamic way of developing outcome measures that are valid and reliable. OBJECTIVES: To assess the validity, reliability and responsiveness of 88 items addressing 22 key concepts using Rasch analysis. PARTICIPANTS: We administrated four sets of multiple-choice items in English to 1114 people in Uganda and Norway, of which 685 were children and 429 were adults (including 171 health professionals). We scored all items dichotomously. We explored summary and individual fit statistics using the RUMM2030 analysis package. We used SPSS to perform distractor analysis. RESULTS: Most items conformed well to the Rasch model, but some items needed revision. Overall, the four item sets had satisfactory reliability. We did not identify significant response dependence between any pairs of items and, overall, the magnitude of multidimensionality in the data was acceptable. The items had a high level of difficulty. CONCLUSION: Most of the items conformed well to the Rasch model's expectations. Following revision of some items, we concluded that most of the items were suitable for use in an outcome measure for evaluating the ability of children or adults to assess treatment claims.

Validating the European Health Literacy Survey Questionnaire in people with type 2 diabetes: Latent trait analyses applying multidimensional Rasch modelling and confirmatory factor analysis.

AIM: To validate the European Health Literacy Survey Questionnaire (HLS-EU-Q47) in people with type 2 diabetes mellitus. BACKGROUND: The HLS-EU-Q47 latent variable is outlined in a framework with four cognitive domains integrated in three health domains, implying 12 theoretically defined subscales. Valid and reliable health literacy measurers are crucial to effectively adapt health communication and education to individuals and groups of patients. DESIGN: Cross-sectional study applying confirmatory latent trait analyses. METHODS: Using a paper-and-pencil self-administered approach, 388 adults responded in March 2015. The data were analysed using the Rasch methodology and confirmatory factor analysis. RESULTS: Response violation (response dependency) and trait violation (multidimensionality) of local independence were identified. Fitting the "multidimensional random coefficients multinomial logit" model, 1-, 3- and 12-dimensional Rasch models were applied and compared. Poor model fit and differential item functioning were present in some items, and several subscales suffered from poor targeting and low reliability. Despite multidimensional data, we did not observe any unordered response categories. CONCLUSION: Interpreting the domains as distinct but related latent dimensions, the data fit a 12-dimensional Rasch model and a 12-factor confirmatory factor model best. Therefore, the analyses did not support the estimation of one overall "health literacy score." To support the plausibility of claims based on the HLS-EU score(s), we suggest: removing the health care aspect to reduce the magnitude of multidimensionality; rejecting redundant items to avoid response dependency; adding "harder" items and applying a six-point rating scale to improve subscale targeting and reliability; and revising items to improve model fit and avoid bias owing to person factors.

Effects of School-Based Educational Interventions for Enhancing Adolescents Abilities in Critical Appraisal of Health Claims: A Systematic Review.

BACKGROUND AND OBJECTIVE: Adolescents are frequent media users who access health claims from various sources. The plethora of conflicting, pseudo-scientific, and often misleading health claims in popular media makes critical appraisal of health claims an essential ability. Schools play an important role in educating youth to critically appraise health claims. The objective of this systematic review was to evaluate the effects of school-based educational interventions for enhancing adolescents' abilities in critically appraising health claims. METHODS: We searched MEDLINE, Embase, PsycINFO, AMED, Cinahl, Teachers Reference Centre, LISTA, ERIC, Sociological Abstracts, Social Services Abstracts, The Cochrane Library, Science Citation Index Expanded, Social Sciences Citation Index, and sources of grey literature. Studies that evaluated school-based educational interventions to improve adolescents' critical appraisal ability for health claims through advancing the students' knowledge about science were included. Eligible study designs were randomised and non-randomised controlled trials, and interrupted time series. Two authors independently selected studies, extracted data, and assessed risk of bias in included studies. Due to heterogeneity in interventions and inadequate reporting of results, we performed a descriptive synthesis of studies. We used GRADE (Grading of Recommendations, Assessment, Development, and Evaluation) to assess the certainty of the evidence. RESULTS: Eight studies were included: two compared different teaching modalities, while the others compared educational interventions to instruction as usual. Studies mostly reported positive short-term effects on critical appraisal-related knowledge and skills in favour of the educational interventions. However, the certainty of the evidence for all comparisons and outcomes was very low. CONCLUSION: Educational interventions in schools may have beneficial short-term effects on knowledge and skills relevant to the critical appraisal of health claims. The small number of studies, their heterogeneity, and the predominantly high risk of bias inhibit any firm conclusions about their effects. None of the studies evaluated any long-term effects of interventions. Future intervention studies should adhere to high methodological standards, target a wider variety of school-based settings, and include a process evaluation. SYSTEMATIC REVIEW REGISTRATION: PROSPERO no. CRD42015017936.

Measuring Maternal Health Literacy in Adolescents Attending Antenatal Care in Uganda: Exploring the Dimensionality of the Health Literacy Concept Studying a Composite Scale.

BACKGROUND AND PURPOSE: The purpose of this article is to test the requirement of "local independence" in the newly developed "Maternal Health Literacy" (MaHeLi) composite scale measuring health literacy in pregnant adolescents attending antenatal care. METHODS: The 20-item scale was administered to 384 adolescents aged 15-19 years attending antenatal care in Uganda during the period July-December 2013. Rasch analysis was conducted using RUMM2030. RESULTS: Differential item functioning was observed for 3 items. One item had disordered response categories. One subscale brought substantial multidimensionality into the MaHeLi scale. CONCLUSIONS: Results support the use of a 12-item version of the MaHeLi scale. The article shows how Rasch analyses help us to identify violations of local independence in scales.

Measuring maternal health literacy in adolescents attending antenatal care in a developing country - the impact of selected demographic characteristics.

AIMS AND OBJECTIVES: The aim of this paper is to describe how selected demographic characteristics 'explain' the observed variance in the distribution of maternal health literacy estimates in adolescents attending antenatal care in Uganda, as estimated by the 'Maternal health literacy scale'. BACKGROUND: By the age of 20 years, more than 60% of Ugandan females are mothers. In the Busoga region of Uganda, the percentage of pregnant adolescents and adolescent mothers is at its highest (above 30%). DESIGN: Validated questionnaire survey. METHODS: The Maternal health literacy scale was administered to 384 adolescents aged 15-19 years attending antenatal care in Jinja and Iganga districts of the Busoga region during the period of July 2013-December 2013. The Mann-Whitney U test in SPSS21 was used to determine if the two levels of dichotomised person factors, i.e. demographic characteristics, relate to 'significantly' different mean maternal health literacy estimates, not strictly following the normal distribution, as measured by the Maternal health literacy scale. RESULTS: The person factors, age, education level, pregnancy order and prepregnancy awareness about conception, explained approximately 12% of the observed variance in maternal health literacy estimates. CONCLUSIONS: Prepregnancy awareness about conception was the single most contributory factor to the observed variance in estimated maternal health literacy levels. More research on women of childbearing age is warranted to explore the impact of further person factors on the maternal health literacy in pregnant adolescents. RELEVANCE TO CLINICAL PRACTICE: Using the person factors found to show 'significant' impact on maternal health literacy in pregnant adolescents, target-specific interventions aimed at improving maternal health literacy in pregnant adolescents can be formulated. By accounting for these factors in reproductive health policy designs, one might take preventive actions to curb the prevalence of adolescent pregnancies in both developing and developed countries.

Young adolescents' engagement in dietary behaviour - the impact of gender, socio-economic status, self-efficacy and scientific literacy. Methodological aspects of constructing measures in nutrition literacy research using the Rasch model.

OBJECTIVE: The present study validates a revised scale measuring individuals' level of the 'engagement in dietary behaviour' aspect of 'critical nutrition literacy' and describes how background factors affect this aspect of Norwegian tenth-grade students' nutrition literacy. DESIGN: Data were gathered electronically during a field trial of a standardised sample test in science. Test items and questionnaire constructs were distributed evenly across four electronic field-test booklets. Data management and analysis were performed using the RUMM2030 item analysis package and the IBM SPSS Statistics 20 statistical software package. SETTING: Students responded on computers at school. SUBJECTS: Seven hundred and forty tenth-grade students at twenty-seven randomly sampled public schools were enrolled in the field-test study. The engagement in dietary behaviour scale and the self-efficacy in science scale were distributed to 178 of these students. RESULTS: The dietary behaviour scale and the self-efficacy in science scale came out as valid, reliable and well-targeted instruments usable for the construction of measurements. CONCLUSIONS: Girls and students with high self-efficacy reported higher engagement in dietary behaviour than other students. Socio-economic status and scientific literacy - measured as ability in science by applying an achievement test - did not correlate significantly different from zero with students' engagement in dietary behaviour.

Measuring Maternal Health Literacy in Adolescents Attending Antenatal Care in Uganda: Exploring the Dimensionality of the Health Literacy Concept Studying a Composite Scale.

BACKGROUND AND PURPOSE: The purpose of this article is to test the requirement of "local independence" in the newly developed "Maternal Health Literacy" (MaHeLi) composite scale measuring health literacy in pregnant adolescents attending antenatal care. METHODS: The 20-item scale was administered to 384 adolescents aged 15-19 years attending antenatal care in Uganda during the period July-December 2013. Rasch analysis was conducted using RUMM2030. RESULTS: Differential item functioning was observed for 3 items. One item had disordered response categories. One subscale brought substantial multidimensionality into the MaHeLi scale. CONCLUSIONS: Results support the use of a 12-item version of the MaHeLi scale. The article shows how Rasch analyses help us to identify violations of local independence in scales.

Improving measurement in nutrition literacy research using Rasch modelling: examining construct validity of stage-specific 'critical nutrition literacy' scales.

OBJECTIVE: Critical nutrition literacy (CNL), as an increasingly important area in public health nutrition, can be defined as the ability to critically analyse nutrition information, increase awareness and participate in action to address barriers to healthy eating behaviours. Far too little attention has been paid to establishing valid instruments for measuring CNL. The aim of the present study was to assess the appropriateness of utilizing the latent scales of a newly developed instrument assessing nursing students' 'engagement in dietary habits' (the 'engagement' scale) and their level of 'taking a critical stance towards nutrition claims and their sources' (the 'claims' scale). DESIGN: Data were gathered by distributing a nineteen-item paper-and-pencil self-report questionnaire to university colleges offering nursing education. The study had a cross-sectional design using Rasch analysis. Data management and analysis were performed using the software packages RUMM2030 and SPSS version 20. SETTING: School personnel handed out the questionnaires. SUBJECTS: Four hundred and seventy-three students at ten university colleges across Norway responded (52% response rate). RESULTS: Disordered thresholds were rescored, an under-discriminating item was discarded and one item showing uniform differential item functioning was split. The assumption of item locations being differentiated by stages was strengthened. The analyses demonstrated possible dimension violations of local independence in the 'claims' scale data and the 'engagement' scale could have been better targeted. CONCLUSIONS: The study demonstrates the usefulness of Rasch analysis in assessing the psychometric properties of scales developed to measure CNL. Qualitative research designs could further improve our understanding of CNL scales.