ObjectiveImproving health literacy at an early age is crucial to personal health and development. Although health literacy in children and adolescents has gained momentum in the past decade, it remains an under-researched area, particularly health literacy measurement. This study aimed to examine the quality of health literacy instruments used in children and adolescents and to identify the best instrument for field use.DesignSystematic review.SettingA wide range of settings including schools, clinics and communities.ParticipantsChildren and/or adolescents aged 6–24 years.Primary and secondary outcome measuresMeasurement properties (reliability, validity and responsiveness) and other important characteristics (eg, health topics, components or scoring systems) of health literacy instruments.ResultsThere were 29 health literacy instruments identified from the screening process. When measuring health literacy in children and adolescents, researchers mainly focus on the functional domain (basic skills in reading and writing) and consider participant characteristics of developmental change (of cognitive ability), dependency (on parents) and demographic patterns (eg, racial/ethnic backgrounds), less on differential epidemiology (of health and illness). The methodological quality of included studies as assessed via measurement properties varied from poor to excellent. More than half (62.9%) of measurement properties were unknown, due to either poor methodological quality of included studies or a lack of reporting or assessment. The 8-item Health Literacy Assessment Tool (HLAT-8) showed best evidence on construct validity, and the Health Literacy Measure for Adolescents showed best evidence on reliability.ConclusionsMore rigorous and high-quality studies are needed to fill the knowledge gap in measurement properties of health literacy instruments. Although it is challenging to draw a robust conclusion about which instrument is the most reliable and the most valid, this review provides important evidence that supports the use of the HLAT-8 to measure childhood and adolescent health literacy in future school-based research.

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; χ/ 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.

While adolescent health literacy has gained momentum, it is under-researched from a cross-cultural perspective. This study aims to compare health literacy among two cultural groups of secondary students in Beijing and Melbourne. A cross-sectional study was conducted with 770 students from five secondary schools in Beijing and Melbourne. A self-administered questionnaire was designed to collect information on health literacy (the eight-item health literacy assessment tool (HLAT-8), the Newest Vital Sign (NVS) and the 47-item Health Literacy Survey (HLS-47)), its antecedents and health outcomes. Overall, students’ health literacy in Melbourne (n = 120) was higher than that in Beijing (n = 650): 28.25 ± 6.00 versus 26.37 ± 5.89 (HLAT-8); and 4.13 ± 1.73 versus 3.65 ± 1.64 (NVS). The proportion of students with low health literacy varied by instruments, representing 23.7–32.2% in Melbourne and 29.0%–45.5% in Beijing. In both cultural groups, students’ self-efficacy, social support, and perceptions of school environment were associated with their health literacy, which in turn predicted their health behaviours, patient-provider communication and health status. Given the nature of our study design and small samples, a cautious conclusion would be that adolescent health literacy is sensitive to the broad cultural context and might be an interactive outcome influenced by an individual’s health skills and the social environment. Particularly, creating a supportive school environment is critical to develop adolescent health literacy that would eventually contribute to better health outcomes.