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Our study aimed to report on variables associated with communicative health literacy (COM-HL) in European adults. The HLS 19 survey was conducted in 2019-2021 including nine countries which measured COM-HL by using a validated questionnaire (HLS 19 -COM-P-Q6 with a score ranging from 0 to 100). Linear regression models were used to study variables associated with COM-HL globally (multilevel model with random intercepts and slopes and at country level) and in each country. Additional models studied each of the HLS 19 -COM-P-Q6 items separately. The mean COM-HL score ranged between 62.5 and 76.6 across countries. Among the 18,137 pooled participants, COM-HL was positively associated with age, a higher self-perceived social status, previous training in healthcare, an increasing number of general practitioner visits; and negatively associated with female sex, reported financial difficulties, having a chronic condition and an increasing number of specialist visits. These effects were heterogeneous from one country to another, and from one item to another when analysing the different COM-HL items separately. However, there was a consistent statistically significant association between COM-HL (score and each item) and financial difficulties as well as self-perceived social status in all countries. Interventions to improve communication between patients and physicians should be a high priority to limit communication disparities., Competing Interests: Declarations. Competing interests: The authors declare no competing interests., (© 2024. The Author(s).)

Background: Despite increasing global attention to health literacy and adolescents' digital health information seeking, no unidimensional instruments measuring digital health literacy (DHL) in adolescents have reportedly been validated using Rasch modeling. Moreover, the evidence of adolescents' abilities to navigate the health system (NAV-HL) in light of their DHL proficiency is still scarce. Therefore, our study aims to evaluate the psychometric properties of a DHL instrument (HLS 19 -DIGI scale) in order to investigate DHL in adolescents and young adults aged 16-25 and associations with abilities to navigate the health system., Methods: A population-based cross-sectional survey among 890 Norwegian adolescents was conducted during April-October 2020 using computer-assisted telephone interviewing. Rasch modeling, independent samples t-test, chi-square test, and binary regression models were used to analyze the data., Results: The HLS 19 -DIGI scale was sufficiently unidimensional, whereas no differential item functioning or disordered response categories were observed. However, relatively poor targeting was revealed indicating too many easy items for the target population. Yet, a high proportion (54%) of low DHL proficiency in adolescents was observed, as well as DHL was positively associated with the abilities to navigate the health system., Conclusions: The HLS 19 -DIGI scale is considered a sufficiently unidimensional and valid instrument for measuring DHL in adolescents, which may be a useful tool for health authorities, public health workers, and health service providers. While DHL affects adolescents' abilities to navigate the health system, future research should measure and examine their ability to utilize digital health services, separately., (© 2024. The Author(s).)

Background: A healthy diet is a critical factor in maintaining long-term health. In addition to a health-promoting food environment, the nutrition health literacy (NHL) and food literacy (FL) of the population are important in this context. This paper describes the development and validation of two short instruments to measure the nutrition literacy of the population, used in the Austrian Nutrition Literacy Survey 2021., Methods: An instrument to measure NHL (Nutrition Health Literacy Scale; NHLS) has been adapted and further developed. To measure FL, the Self-perceived Food Literacy Scale by Poelman et al. has been modified and shortened (SPFL-SF). Validation of the instruments was based on data from a web survey conducted in Austria in 2021 with almost 3,000 participants aged 18 years and older. Exploratory and confirmatory factor analyses were performed to assess the factorial validity/dimensionality of the instruments. Additionally, internal consistency was assessed using Cronbach's alpha, ordinal alpha, and McDonald's omega., Results: Both instruments demonstrate excellent data-model fit. The NHLS also shows excellent internal consistency (α = 0.91), while the SPFL-SF displays a sufficient internal consistency for all (α between 0.70 and 0.89) but one sub-dimension (resisting temptation α = 0.61). Furthermore, the distribution of the items indicates that the measures are understandable and suitable, as evidenced by the absence of missing values in the sample. In addition, the items of both instruments differ in their level of difficulty or agreement., Conclusions: The NHLS and SPFL-SF are reliable and valid instruments for measuring NHL and FL in the general adult population. The brief instruments measuring the different aspects of nutrition literacy can be easily used in nutritional or evaluation studies. Further work is required to investigate other aspects of validity., (© 2024. The Author(s).)

Background: For improving health literacy (HL) by national and international public health policy, measuring population HL by a comprehensive instrument is needed. A short instrument, the HLS 19 -Q12 based on the HLS-EU-Q47, was developed, translated, applied, and validated in 17 countries in the WHO European Region., Methods: For factorial validity/dimensionality, Cronbach alphas, confirmatory factor analysis (CFA), Rasch model (RM), and Partial Credit Model (PCM) were used. For discriminant validity, correlation analysis, and for concurrent predictive validity, linear regression analysis were carried out., Results: The Cronbach alpha coefficients are above 0.7. The fit indices for the single-factor CFAs indicate a good model fit. Some items show differential item functioning in certain country data sets. The regression analyses demonstrate an association of the HLS 19 -Q12 score with social determinants and selected consequences of HL. The HLS 19 -Q12 score correlates sufficiently highly (r ≥ 0.897) with the equivalent score for the HLS 19 -Q47 long form., Conclusions: The HLS 19 -Q12, based on a comprehensive understanding of HL, shows acceptable psychometric and validity characteristics for different languages, country contexts, and methods of data collection, and is suitable for measuring HL in general, national, adult populations. There are also indications for further improvement of the instrument.

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 HLS 19 -NAV measurement scale applied in the European Health Literacy Population Survey 2019-2021 (HLS 19 ). From December 2019 to January 2021, data on NAV-HL was collected in eight European countries. The HLS 19 -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 HLS 19 -NAV demonstrated high internal consistency. To ensure content validity, the HLS 19 -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 HLS 19 -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.

Background: Sufficient communicative health literacy (COM-HL) is important for patients actively participating in dialogue with physicians, expressing their needs and desires for treatment, and asking clarifying questions. There is a lack of instruments combining communication and HL proficiency. Hence, the aim was to establish an instrument with sufficient psychometric properties for measuring COM-HL., Methods: The HLS 19 -COM-P instrument was developed based on a conceptual framework integrating HL with central communicative tasks. Data were collected using different data collection modes in nine countries from December 2019 to January 2021 ( n = 18,674). Psychometric properties were assessed using Rasch analysis and confirmatory factor analysis. Cronbach's alpha and Person separation index were considered for reliability., Results: The 11-item version (HLS 19 -COM-P-Q11) and its short version of six items (HLS 19 -COM-P-Q6) fit sufficiently the unidimensional partial credit Rasch model, obtained acceptable goodness-of-fit indices and high reliability. Two items tend to under-discriminate. Few items displayed differential item functioning (DIF) across person factors, and there was no consistent pattern in DIF across countries. All items had ordered response categories., Conclusions: The HLS 19 -COM-P instrument was well accepted in nine countries, in different data collection modes, and could be used to measure COM-HL., Competing Interests: The authors declare no conflict of interest.

Vaccines are among the most important public health achievements of the last century; however, vaccine awareness and uptake still face significant challenges and the COVID-19 pandemic has only exacerbated this phenomenon. Vaccine Literacy (VL) is the ability to find, understand and judge immunisation-related information to make appropriate immunisation decisions. A cross-sectional study on a sample of 3500 participants, representative of the Italian adult population aged 18+ years, was conducted in Italy in 2021. A validated questionnaire, including sections on health literacy (HL), sociodemographic characteristics, risk factors, and lifestyles of respondents, was used. VL was measured by four items (item 19, 22, 26 and 29) of the HL section. While 67.6% of the respondents had a "good" (47.5%) or "sufficient" (20.1%) level of VL, 32.4% had "limited" VL levels. Although the overall VL level was quite high, many participants reported difficulties in dealing with vaccination information, particularly those with a lower educational level, those living in southern and insular regions of Italy, those with greater financial deprivation and those with a migration background. Improving VL in Italy should be a top priority in the political agenda, with special regard to socially and geographically disadvantaged communities.

The COVID-19 pandemic has caused an overabundance of valid and invalid information to spread rapidly via traditional media as well as by internet and digital communication. Health literacy (HL) is the ability to access, understand, appraise, and apply health information, making it fundamental for finding, interpreting, and correctly using COVID-19 information. A cross-sectional study of a sample of 3500 participants representative of the Italian adult population aged 18+ years was conducted in Italy in 2021. A validated HL questionnaire was employed, including sections on coronavirus-related HL, general HL, sociodemographic characteristics, risk factors, and respondents' lifestyle. Of our sample, 49.3% had "excellent" levels of coronavirus-related HL and 50.7% had "sufficient" (20.7%) or "limited" (30.0%) levels. Although the overall HL-COVID level was high, many participants reported difficulties dealing with COVID-19 information; in particular, participants older than 65 years, with a low education level, living in southern regions of Italy, and with high financial deprivation. Targeted public information campaigns and the promotion of HL are required for better navigation of health information environments. The COVID-19 pandemic has highlighted the need to improve HL and to prepare the general population for future emergency and non-emergency situations, confirming that HL can be considered a social vaccine.

There is growing recognition that implementation of low-carbon policies in urban passenger transport has near-term health co-benefits through increased physical activity and improved air quality. Nevertheless, co-benefits and related cost reductions are often not taken into account in decision processes, likely because they are not easy to capture. In an interdisciplinary multi-model approach we address this gap, investigating the co-benefits resulting from increased physical activity and improved air quality due to climate mitigation policies for three urban areas. Additionally we take a (macro-)economic perspective, since that is the ultimate interest of policy-makers. Methodologically, we link a transport modelling tool, a transport emission model, an emission dispersion model, a health model and a macroeconomic Computable General Equilibrium (CGE) model to analyze three climate change mitigation scenarios. We show that higher levels of physical exercise and reduced exposure to pollutants due to mitigation measures substantially decrease morbidity and mortality. Expenditures are mainly born by the public sector but are mostly offset by the emerging co-benefits. Our macroeconomic results indicate a strong positive welfare effect, yet with slightly negative GDP and employment effects. We conclude that considering economic co-benefits of climate change mitigation policies in urban mobility can be put forward as a forceful argument for policy makers to take action.

Background: Given the pressure that educators and policy makers are under to achieve academic standards for students, understanding the relationship of academic success to various aspects of health is important. The international Health Behavior in School-Aged Children (HBSC) questionnaire, being used in 41 countries with different school and grading systems, has contained an item assessing perceived school performance (PSP) since 1986. Whereas the test-retest reliability of this item has been reported previously, we determined its convergent and discriminant validity., Methods: This cross-sectional study used anonymous self-report data from Austrian (N = 266), Norwegian (N = 240), and Canadian (N = 9,717) samples. Students were between 10 and 17 years old. PSP responses were compared to the self-reported average school grades in 6 subjects (Austria) or 8 subjects (Norway), respectively, or to a general, 5-category-based appraisal of most recent school grades (Canada)., Results: Correlations between PSP and self-reported average school grade scores were between 0.51 and 0.65, representing large effect sizes. Differences between the median school grades in the 4 categories of the PSP item were statistically significant in all 3 samples. The PSP item showed predominantly small associations with some randomly selected HBSC items or scales designed to measure different concepts., Conclusions: The PSP item seems to be a valid and useful question that can distinguish groups of respondents that get good grades at school from those that do not. The meaning of PSP may be context-specific and may have different connotations across student populations from different countries with different school systems., (© 2012, American School Health Association.)

OBJECTIVES: The present study examines the prevalence of headache in early adolescents in 21 European and North-American countries and the role of perceived teacher unfairness in predicting this health complaint across different countries. METHODS: Data were taken from the "Health Behaviour in School-aged Children" study (HBSC), a World Health Organization cross-national survey on health behaviors in 11-, 13- and 15-year-old students. Headache and perceived teacher unfairness were measured through a self-administered questionnaire filled out by 115,212 adolescents. RESULTS: The overall prevalence of frequent headaches (at least once a week) was 28.8%, ranging from 18.9% in Slovenia to 49.4% in Israel. After adjusting for gender, grade, family affluence, school achievement, being bullied and lifestyles (drinking, smoking, eating and physical activity), teacher unfairness showed a significant association with frequent headache in all but two countries (Ukraine and Luxembourg). CONCLUSIONS: Our results show that headache is a common health symptom in European and North-American countries, even though there are substantial differences in its prevalence across countries. The study indicates that perceived teacher unfairness can be a significant predictor of frequent headache during adolescence, and this association is consistent across countries.

The cross-national measurement invariance of the teacher and classmate support scale was assessed in a study of 23202 Grade 8 and 10 students from Austria, Canada, England, Lithuania, Norway, Poland, and Slovenia, participating in the Health Behaviour in School-aged Children (HBSC) 2001/2002 study. A multi-group means and covariance analysis supported configural and metric invariance across countries, but not full scalar equivalence. The composite reliability was adequate and highly consistent across countries. In all seven countries, teacher support showed stronger associations with school satisfaction than did classmate support, with the results being highly consistent across countries. The results indicate that the teacher and classmate support scale may be used in cross-cultural studies that focus on relationships between teacher and classmate support and other constructs. However, the lack of scalar equivalence indicates that direct comparison of the levels support across countries might not be warranted.

Background: This article describes changes in health complaints of Austrian adolescents during a period of 12 years., Methods: The HBSC (Health Behaviour in School-aged Children) symptom checklist assesses how often specific physical and emotional symptoms occurred in the past 6 months. We display data collected in 1994, 1998, 2002 and 2006 for the whole sample (about 4500 students at each time point) as well as separated by age, gender and family affluence., Results: The symptom load in Austrian adolescents decreased in the past 12 years slowly, but continuously. Boys and younger adolescents scored more favourably at all time points. Only in 2006, not at an earlier measurement time point, an impact of family affluence on symptom load could be detected., Conclusions: With the exception of the socioeconomic impact on symptom load in the year 2006, from an Austrian perspective, these results are favourable. The HBSC-data to be collected in 2010 will show if this trend continues to increase.

Background: Medicine use among children and young people is under-researched. Studies that investigated cross-national patterns in adolescents' medicine use practice are rare. This study aims to investigate adolescents' medicine use for corresponding health complaints in Europe and USA., Methods: Nationally representative samples of adolescents from 19 countries and regions in Europe and USA completed an anonymous, standardised questionnaire as part of the Health Behaviour in School-aged Children 2005/2006 survey. The prevalence of health complaints and medicine use were determined. The influence of the frequency of medicine use, age, gender and country of residence, on the likelihood of medicine use was assessed using multilevel multivariate logistic regression, with separate analyses for boys and girls., Results: Both health complaints and medicine use were common among adolescents. Medicine use was strongly associated with the frequency of health complaints. The prevalence of both medicine use and health complaints was higher among girls than boys. Boys and girls with weekly health complaints were both similarly likely to report elevated rates of medicine use., Conclusions: The findings indicated that adolescents who report more frequent recurrent health complaints are also more likely to report more frequent medicine use for their health complaints. Adolescent boys with weekly health complaints have the same risk of medicine use as girls with weekly health complaints. The importance of educating school-aged children to interpret their bodily feelings and complaints and to use medicines appropriately is of high priority., (Copyright © 2011 John Wiley & Sons, Ltd.)

Objectives: To examine the extent to which school climate and school pressure could predict other aspects of adolescents' lives, most particularly their emotional health and bullying. Furthermore, the study sought to investigate if these relationships were consistent across countries., Methods: Participants were 11-, 13-, and 15-year-olds from 26 European countries/regions, Canada, the United States, and Israel. Participants completed surveys focusing on health behaviours and lifestyles, using a contextual framework. Using cluster analytic techniques, three clusters were created varying on school pressure and perceived school climate. These clusters were then examined using variables not used in the clustering., Results: Students in the cluster having the most positive relationships to school outcomes, including academic achievement, truancy, teacher and peer support, also had the most positive emotional health and the lowest incidence of bullying. Similarly, those in the poorest cluster in terms of school also had the poorest outcomes in terms of emotional health and bullying., Conclusions: These relatively small but significant associations suggest that schools may have a small role in supporting children's emotional well-being and ameliorate the presence of bullying.

We tested the reliability of a modified version of the Block 98-item food frequency questionnaire (FFQ) and a short 40-item FFQ derived from the Block form to estimate usual calcium intake. Ninety-eight female volunteers completed both forms three times during a 6-month period; forms were initially completed by participants at a group meeting (T1) and, subsequently, 2 months (T2) and 4 months (T3) later, by mail. Both mean total energy intake in kilocalories and mean calcium intake derived from the long FFQ dropped significantly between T1 and T2. The nutrient density variable, calcium per 1,000 kcal, did not vary significantly between administrations. Pearson correlation coefficients were most uniform for pairwise comparisons of calcium per 1,000 kcal at the three times. Mean calcium intake derived from the short FFQ did not vary significantly between administrations, and Pearson correlation coefficients ranged from .70 to .77 for paired comparisons. When using the long FFQ, the nutrient density variable, calcium per 1,000 kcal, was a more reliable measure of usual calcium intake than was calcium in milligrams. The short FFQ provided reliable estimates of usual calcium intake in milligrams and captured more than 75% of the calcium intake measured by the long FFQ.