Background
Improving child health is core to the Sustainable Development Goals [
1]. In the past decades, the survival rate of children under 5 years old has improved significantly globally. In low- and middle-income countries, however, 250 million children under 5 years old are at risk of not achieving their developmental potential [
2]. Early child development largely depends on the quality of nurturing and care provided to the children in the family. Studies have showed that inappropriate caring practice was adversely associated with child development and health [
3].
Health literacy is a better predictor of health condition than income, employment, education, race or ethnicity [
4]. In China, the 2016 health literacy surveillance reported that only 11.58% Chinese residents had basic health literacy [
5]. Caregivers with lower health literacy had difficulty in comprehending important aspects of pediatric anticipatory guidance, including coping with common family emergencies, weighing risks and benefits of routine vaccinations, and conducting home safety checks [
6]. Children whose parents had low health literacy often had poor health outcomes, such as poor asthma control and poor glycemic control, especially for younger children [
7,
8]. Low health literacy in parents was also associated with a variety of adverse health behaviors, including not practicing breastfeeding [
9], poor performance of administering medicine prescribed [
10], which could have adverse effects on children’s health.
Currently, there are several scales to assess adult health literacy, such as Test of Functional Health Literacy in Adults (TOFHLA) [
8], Rapid Estimate of Adult Literacy in Medicine (REALM) [
11] and Newest Vital Sign (NVS) [
12]. However, other than the Parental Health Literacy Activities Test (PHLAT) [
6], no instrument has been specifically developed for evaluating parental health literacy of caregivers of young children. The PHLAT was designed for parents of children younger than 13 months, and mainly assessing parents’ literacy and numeracy skills in understanding instructions of caring for children [
6].
In 2012, the World Health Organization Regional Office for Europe developed a broader and inclusive definition of health literacy, “people’s knowledge, motivation and competences to access, understand, appraise, and apply health information in order to make judgments and take decisions in everyday life concerning health care, disease prevention and health promotion to maintain or improve quality of life during the life course” [
4,
13]. This suggests that the measurement of health literacy should be multi-dimensional.
Given the limited information on parental health literacy measurements, our study aimed to develop a Chinese Parental Health Literacy Questionnaire (CPHLQ) for caregivers of children 0 to 3 years old.
Results
Results of the validation study of the 39-question CPHLQ using a cross-sectional survey are presented below.
Social and demographic characteristics of participants
In total, 807 caregiver-child pairs participated in the study. There were 551 mothers (68.3%), 178 fathers (22.1%) and 78 grandparents or other caregivers (9.6%). The social and demographic characteristics of the caregivers and their children are shown in Table
3. 64.9% caregivers had college or above education. Among the participants’ children, 52.0% were boys, 67.0% were registered as Shanghai
Hukou; and 70.5% were the only-child. 70.5% participants reported to have a family monthly income of over RMB 4500 (USD 678) (Table
3).
Table 3
Social and demographic characteristics of participants and scores of CPHLQa
Relationship to the child |
Mother | 551 (68.3) | 74.5 (10.98) |
27.901(<0.001)
|
Father | 178 (22.1) | 69.2 (15.1) | |
Grandparents and others | 78 (9.6) | 68.5 (13.4) | |
Caregiver’s education |
Junior school and below | 126 (15.6) | 64.8 (12.5) |
155.903(<0.001)
|
High school | 157 (19.5) | 67.1 (12.8) | |
College | 176 (21.8) | 74.4 (11.6) | |
University or higher | 348 (43.1) | 77.4 (10.2) | |
Child’s age (years) |
≤ 1 | 522 (64.7) | 72.5 (12.6) | 0.417 (0.659) |
1~2 | 191 (23.7) | 72.8 (12.4) | |
2~3 | 94 (11.6) | 73.8 (12.2) | |
Child’s gender |
Female | 387 (48.0) | 73.2 (12.8) | 0.870 (0.384) |
Male | 420 (52.0) | 72.4 (12.2) | |
Child’s Hukou |
Shanghai | 541 (67.0) | 75.0 (11.7) |
7.362(<0.001)
|
Other provinces | 267 (33.0) | 68.3 (12.5) | |
Only-child or not |
Yes | 569 (70.5) | 73.6 (11.8) |
2.882 (0.004)
|
No | 238 (29.5) | 70.7 (13.8) | |
Family monthly income per capita (in RMB) |
<4500 | 179 (22.1) | 69.7 (14.4) |
27.154(<0.001)
|
4500~7500 | 220 (27.3) | 73.1 (12.6) | |
7500~12,500 | 183 (22.7) | 75.1 (10.1) | |
≥ 12,500 | 156 (19.3) | 75.1 (10.8) | |
I don’t know | 69 (8.6) | 68.2 (13.9) | |
Reliability
The overall 39-question CPHLQ had high internal consistency (Cronbach’s α = 0.89), high spilt-half reliability (Spearman-Brown coefficient = 0.92) and high test-retest reliability (Pearson correlation coefficient = 0.82). Regarding the three subscales (health care health literacy, disease prevention health literacy, health promotion health literacy), Cronbach’s α coefficient was 0.72, 0.86 and 0.61, respectively; Spearman-Brown coefficient was 0.75, 0.90 and 0.68, respectively; and test-retest reliability coefficient was 0.69, 0.82 and 0.68, respectively.
Validity
Construct validity
The results showed a relatively good fit of all the four-factor structure within the three domains of parental health literacy (Table
4).
Table 4
Construct Validity of CPHLQ with goodness-of-fit indices
HC-HL | 12 | 0.05 | 0.97 | 0.95 | 0.94 | 2.94 |
DP-HL | 16 | 0.05 | 0.95 | 0.93 | 0.95 | 3.27 |
HP-HL | 11 | 0.07 | 0.96 | 0.93 | 0.89 | 4.87 |
Descriptive statistics for the CPHLQ
The mean CPHLQ score of this sample of caregivers of children under 3 years old was 72.8 ± 12.5, ranged 6.0 to 96.8. No floor or ceiling effects was found. The standardized scores of the three subscales (health care, disease prevention and health promotion) were 72.7 ± 11.5, 76.1 ± 16.7, 67.4 ± 14.6, respectively. Furthermore, the standardized scores of the four competences (accessing, understanding, appraising and applying) were 68.7 ± 13.5, 77.0 ± 18.9, 72.6 ± 12.6, 74.3 ± 13.4, respectively.
As shown in Table
3, mothers had higher CPHLQ total scores than fathers and grandparents or other caregivers (
P<.001). The higher CPHLQ total scores were associated with higher education level (
P<.001) and higher family income (
P<.001). In addition, higher CPHLQ total scores were also associated with caregivers’ children had Shanghai
Hukou (
P<.001) and were the only child (
P = 0.004). Scores of the CPHLQ were not significantly associated with child’s age (
P = 0.659) or gender (
P = 0.384).
Discussion
The 39-question CPHLQ was developed for evaluating parental health literacy among caregivers of children 0 to 3 years old in China. The validation study was carried out among primary caregivers who lived in Shanghai. The range of the CPHLQ score is between 0 and 100, a higher score indicates higher parental health literacy level. Psychometric analysis results indicated that the CPHLQ has good reliability and validity, and it could potentially be a useful instrument for assessing parental health literacy for people who care for children aged under 3 years in the Chinese context.
Nutbeam suggested that the measurement of health literacy would be best achieved where content and context were well defined [
30]. This study was based on the conceptual framework of health literacy [
13], which integrated the content of medical services and public health, and emphasized the individual’s comprehensive literacy abilities, including functional, interactive, and critical health literacy. The application of this conceptual framework provides a better clarity for the connotation of health literacy and provides a theoretical basis for the development of instruments for assessing health literacy. The interactive and critical health literacy involve more advanced cognitive and social skills that can be applied to participate, analyze and better control over life events; while the functional health literacy refers to the basic skills in reading and writing [
13]. We found that caregivers scored lower in the competences of accessing, appraising and applying (referring to the interactive and critical health literacy) compared with the competence of understanding (referring to the functional health literacy). This indicates that a comprehensive health literacy intervention is needed to empower caregivers to access, appraise and apply health information. A systematic review showed that a mixed measurement approach can broaden the health literacy concept and enable research to address multiple skills [
31]. In the CPHLQ, we used a 4-point Likert scale to determine the ability of “accessing”, “appraising”, and “applying” health information, and used true/false questions or multiple choice to assess the “understanding” of the health information among caregivers.
The psychometric evaluation of the CPHLQ produced plausible results. The overall 39-question questionnaire was reliable, demonstrated by high internal consistency, spilt-half reliability and test-retest reliability (the coefficients were all over 0.8). For the three subscales, all reliability coefficients were over 0.6 which was considered as acceptable reliability for subscales [
25]. The results of confirmatory factor analysis showed that the construct of the questionnaire fitted well with the theoretical model. Despite the comparative fit index (CFI) was below the recommended criteria of 0.90 in HP-HL, it still represented a tolerable fit [
32,
33]. In addition, we used several methods to ensure the content validity of the questionnaire. We applied the health literacy integration conceptual framework (2012) by Sorenson et al. [
13] to construct the CPHLQ. We ensured that the CPHLQ covered the key content of the physical development of children 0 to 3 years old through literature review and expert consultation. We also followed the content development procedures strictly during the questionnaire development process [
34] which led to the good content validity.
The study found that mothers’ parental health literacy was significantly higher than fathers, grandparents and other caregivers. This could be due to that in the Chinese culture fathers are less involved in caring for children despite the vital role of fathers in child development [
35]. The finding highlighted that in practical terms fathers should not be neglected when carrying out the health education about caring children under 3 years old. In line with other studies, our study found that lower health literacy was significantly associated with lower education level and lower family income [
36,
37]. We also found caregivers whose children had Shanghai
Hukou scored higher than those whose children did not have Shanghai
Hukou. This is consistent with findings from another study that the level of health literacy among Shanghai residents was higher than the average of the country [
38]. This might be partially due to relatively higher education level of Shanghai residents and health care resources, for example health promotion and health information are more accessible among Shanghai registered family [
39]. Another interesting finding was that caregivers of two or more children had lower parental health literacy than caregivers of only one child. This indicated that the caregivers of only one child might pay more attention to parenting and child care.
The development and validation of an appropriate instrument is an essential step for parental health literacy research. To our knowledge, this is the first study of developing and evaluating a parental health literacy questionnaire for caregivers of children under 3 years old in China. Using the CPHLQ in a larger and representative sample to determine cutoff point, and in different settings in China are needed. The instrument could potentially be used in other Chinese population, and adapted for the use in other places of the world. Furthermore, the CPHLQ can help to identify the population in need of parenting and child care related information. Therefore, it will be useful for developing targeted interventions to improve the parental health literacy of caregivers of children 0 to 3 years old and the quality of care.
There are several limitations of this study. Firstly, the parenting health literacy presented in this manuscript only involved the physical development and health of children. Secondly, since the participants in this study were all from Shanghai, one of the most developed areas of China, further studies are needed to test the application of instrument in other regions and settings of China. Thirdly, majority questions are based on self-reporting. There might be response bias, for example some participants might overestimate their parenting ability.
Acknowledgements
The authors were grateful to Shanghai Scientific Association of Better Birth and Better Upbringing and Pudong, Huangpu, Changning, Jiading, Songjiang, Baoshan, Fengxian, Jinshan District centers for Women and Children’s Health of Shanghai, China for their support during data collection. We also thank all the participants for their collaboration.
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