Psychometric properties of Turkish version of the adult vaccine literacy scale

Psychometric properties of Turkish version of the adult vaccine literacy scale | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Psychometric properties of Turkish version of the adult vaccine literacy scale Ebru BULUT, Hanifi DÜLGER, Güleser ADA, Hacer YALNIZ DİLCEN This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8555513/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 13 You are reading this latest preprint version Abstract Backround: Vaccine literacy plays a critical role in enabling individuals to access accurate and reliable information about vaccines, understand and evaluate this information, and make informed and rational decisions about vaccination. This study aimed to adapt the Adult Vaccine Literacy Scale (AVLS) into Turkish and examine its psychometric properties and relationship with health literacy. Method The adaptation process of the scale included forward–backward translation, expert review, and pilot testing. Construct validity was examined using exploratory and confirmatory factor analyses, while internal consistency was assessed with Cronbach’s alpha coefficient. Test–retest reliability was evaluated to determine the temporal stability of the scale. Results The three-factor structure of the 14-item scale explained 60.82% of the total variance. Model fit indices indicated a good fit (χ²/df = 1.447, RMSEA = 0.040, CFI = 0.980, GFI = 0.952). The total Cronbach’s alpha was 0.846, with sub-dimension values ranging from 0.686 to 0.881. Results demonstrated that individuals’ vaccination literacy improved as their health literacy levels increased (p < 0.001; r=-0.563). Test–retest analysis demonstrated a strong positive correlation between the two measurements, indicating high temporal stability of the scale (r = 0.830, p < 0.001). Conclusion The Turkish version of the AVLS is a valid and reliable tool. It can be effectively used to assess vaccine literacy among adults in future research and public health studies. Health Literacy Reliability Vaccine Literacy Scale Vaccine Validation Figures Figure 1 Backround The concept of vaccine literacy extends from the broader framework of health literacy, which encompasses not only possessing knowledge about vaccines but also establishing a simplified and efficient system for vaccine communication and delivery, regarded as an essential component of an effective health system [ 1 ]. Vaccine literacy refers to an individual’s ability to access, interpret, and effectively use essential information and services related to vaccination in order to make well-informed immunization decisions [ 2 , 3 ]. Vaccination is the most cost-effective method for fighting against infectious diseases that can be prevented through immunization. The World Health Organization (WHO) reported that many diseases can be prevented by vaccination and that deaths due to these diseases are significantly reduced [ 4 ]. Although some diseases are completely eradicated and some are eliminated with vaccination, vaccine hesitation has continued since the existence of the vaccine has become widespread [ 5 ]. Vaccine literacy constitutes a critical factor in addressing vaccine hesitancy. Aligned with the principles of health literacy, it seeks to empower individuals with the necessary knowledge and skills to make informed decisions and complete the vaccination process [ 6 ]. As in the rest of the world, inconsistent information about the advantages and disadvantages of vaccines has emerged in Türkiye. This information causes people to hesitate about vaccination and make incorrect decisions. A study conducted by Aygün and Tortop (2020) revealed that individuals did not have the opportunity to obtain sufficient information about vaccines and thought that vaccines were useless, could cause diseases or disabilities, and were not religiously appropriate [ 7 ]. This situation may be because individuals cannot obtain sufficient information about the vaccine or cannot interpret the information they have obtained correctly [ 2 ]. In all these cases, individuals' ability to access, understand, evaluate and apply information is associated with only good health literacy. When the literature is examined, there are standard scales that evaluate many types of vaccine-related knowledge, attitudes and behaviors such as vaccines, vaccine opposition, vaccine hesitancy, vaccine ambivalence, vaccine attitudes, attitudes toward vaccines, parental attitudes toward childhood vaccines, COVID-19 vaccine ambivalence, COVID-19 vaccine literacy, COVID-19 vaccine knowledge and attitudes, and attitudes toward the COVID-19 vaccine. These standardized tools make it possible to identify the relevant strengths and weaknesses of the individuals being assessed. In Türkiye, there is no standardized scale that includes general adult vaccine literacy and evaluates the level of knowledge. For this reason, the psychometric properties of a tool measuring adult vaccine literacy will be examined according to Turkish culture. By ensuring its applicability to Turkish society, it will prepare the ground for the content of the training to be given to individuals about vaccines to be applied. A relationship between health literacy and vaccine literacy is also considered to exist. The objective of this study was to assess the psychometric performance of the Turkish adaptation of the Adult Vaccine Literacy Scale [ 8 ] originally developed by Biasio et al. (2020), and to explore its association with health literacy. METHODS Participants and Procedure Individuals aged 18 years and older in Turkey who use social media were included via an online survey. Participants with physical or mental conditions that could impair accurate responses and those with incomplete data collection forms were excluded. Data were collected through self-reporting. Materials Introductory Information Form There are 14 questions that examine sociodemographic characteristics (age, education level, social security, and marital status) according to the literature [ 5 , 8 – 10 ]. Adult Vaccine Literacy Scale (AVLS) : The scale was developed by Biasio et al. (2020) to determine individuals' knowledge about vaccination and their interpretation of this information [ 8 ]. The original AVLS comprises 14 items distributed across three dimensions, namely functional, interactive/communicative, and critical literacy, corresponding to items 1–5, 6–10, and 11–14, respectively. Psychometrically, functional subscale questions are more related to language skills, while interactive/critical questions are related to problem-solving and decision-making skills. The scale consists of items rated on a four-point Likert-type response format, scored from 1 to 4 (1:ever, 2:rarely, 3:sometimes, 4:often).The first five items are negatively worded and are therefore reverse-coded. The original scale's internal consistency coefficient is 0.92 [ 8 ]. In this study, to ensure the reliability and construct validity of the scale, the item-total score correlation was examined as recommended in scale adaptation studies, and no values below 0.30 were observed. The Turkish AVLS, with its three-dimensional structure explaining 30.82% of the variance, showed strong item-level reliability and satisfactory construct validity. The Cronbach's alpha coefficient for the entire scale was 0.846, 0.881 for the functional subscale, 0.814 for the interactive/communicative subscale, and 0.686 for the critical subscale. These findings suggest satisfactory reliability for the overall scale as well as for the functional and interactive/communicative subscales, whereas the reliability of the critical subscale was at a moderate level. Health Literacy Scale (HLS) The Health Literacy Scale, which was adapted into Turkish by Bayık Temel and Aras, was developed by Toçi et al. in 2013. The scale has a cronbach alpha value of 0.92 and has 25 items and four sub-dimensions [ 11 , 12 ]. HLS was found to have Cronbach's α = 0.945, indicating high internal consistency. This demonstrates that HLS is suitable for assessing the convergent validity of AVLS. Translation and cultural adaptation Permission was obtained from the original author of the scale prior to initiating the Turkish translation and cross-cultural adaptation process. A translation and back-translation process was carried out as suggested by Beaton et al. (2000)[ 13 ]. Expert rewiew and a pilot test were conducted to ensure cultural appropriateness and comprehensibility. The following steps were followed in the adaptation: Forward translation: The scale was first translated from English into Turkish by four independent translators who were fluent in both languages. These translations were subsequently reviewed and merged into a single preliminary Turkish version by a bilingual expert, who addressed discrepancies and ensured both linguistic accuracy and conceptual equivalence. Backward translation: The finalized Turkish draft was independently translated back into English by two bilingual translators who were blinded to the original version of the scale. The resulting English versions were carefully reviewed against the original instrument, and discrepancies were resolved to ensure semantic and conceptual equivalence. Expert Review: Ten experts (five public health nursing professors, two midwifery associate professors, and three midwifery assistant professors) evaluated the scale items for content and language validity in terms of linguistic intelligibility and cultural appropriateness. The Lawshe content validity ratio and index were used to determine content validity at the item level [ 14 ]. Participant feedback: The final stage of the adaptation study involved a pilot application. To evaluate the comprehensibility of the Turkish version, a pilot study was conducted with 15 participants (7 men and 8 women) not included in the sample. Each participant completed the form, and interviews were conducted to understand the meaning of each item and the selected response. Feedback from experts and participants was evaluated, and the final version of the AVLS in Turkish was finalized. Data Collection The sample size was calculated based on the requirements of factor analysis. In this regard, methodological studies recommend that the number of participants be between 5 and 20 times the number of scale items [ 15 ]. The analysis was evaluated using data obtained from 281 participants. To examine the temporal stability of the scale, a subset of 30 participants selected at random (16 females and 14 males) completed the questionnaire a second time after a two-week interval, and test–retest reliability was assessed based on these responses. Data Analysis The purpose of the adult vaccination literacy scale is to determine individuals' ability to acquire knowledge about adult vaccination and critically evaluate this knowledge. Based on this conceptual framework, the validation approach was designed to evaluate multiple aspects of validity, including content validity, to determine whether the items adequately reflect the underlying construct; construct validity, to examine the factorial structure of the scale; and convergent validity, to assess its association with the health literacy scale. In addition, reliability was examined through analyses of internal consistency and test–retest reliability in order to evaluate the consistency and temporal stability of the measurements. Statistical analyses were conducted using IBM SPSS Statistics version 24.0 (IBM Corp., Armonk, NY, USA) and AMOS version 24.0. Frequencies and percentages for categorical variables and means and standard deviations for continuous variables are presented. The suitability of the data for factor analysis was assessed using the Kaiser–Meyer–Olkin (KMO) and Bartlett's sphericity testThe procedures applied for validity and reliability assessment included the following analyses Content and language validity Lawshe technique was used for content and language validity. According to this technique, the translated scale was submitted to expert opinion [ 14 ]. Content validity ratio (CVR) and content validity index (CVI) were calculated based on the feedback received from the experts. Construct validty Exploratory Factor Analysis (EFA) and Confirmatory Factor Analysis (CFA) were conducted to examine the factorial structure of the scale. EFA was used to explore how the items clustered into underlying factors, whereas CFA was applied to evaluate the extent to which the three-factor structure proposed in the original AVLS was supported by the data obtained from the Turkish sample. Convergent validity Vaccine literacy is viewed as a specific dimension of health literacy and is strongly associated with individuals’ capacity to comprehend, appraise, and apply health-related information.. Therefore, to assess the convergent validity of the vaccine literacy scale, a correlation analysis was performed with the health literacy scale, which is theoretically related[ 1 , 17 ]. Reliability The reliability of the Turkish AVLS was assessed using internal consistency and test–retest methods. Internal consistency analysis was conducted to examine the extent to which the items of the scale reliably measured the same underlying construct, using Cronbach’s alpha coefficient. Test–retest reliability was evaluated to examine the temporal stability of the scale and to assess whether similar scores were obtained when the same participants completed the scale again after a two-week interval. A threshold of p < 0.05 was set to determine statistical significance across all analyses. RESULTS Socio-Demographics A total of 66.9% of the participants in the research group were female, 61.9% were married, and 24.9% had less income than expenses. In addition, the majority of the participants (50.9%) were undergraduate graduates, 44.38% had sufficient knowledge about vaccines, and 43.74% had the necessary vaccinations. Validity of the Turkish AVLS Content validity : In the calculation “CVR = Nu/(N/2)-1” formula (Nu: number of experts who think that the item is important; N: total number of experts) was used. The CVI reflects the overall adequacy of the scale by summarizing the relevance and clarity of its items. It is obtained by calculating the average of the CVR values across all items included in the scale. According to this evaluation, the CVR values of the scale items in the study were determined to be above 0.80 and the CVR value was 0.97 and the language validity index was 0.77. When the number of experts is 10, the minimum value (content validity criterion) at 0.05 significance level should be CVR = 0.62 [18]. CVR is greater than the CVI, this value is statistically significant. Construct validty The KMO measure for the AVLS was 0.861, indicating a very good level of sampling adequacy. This suggests that the factor analysis results are reliable and appropriate for the dataset. Furthermore, Bartlett’s test of sphericity indicated that the data were appropriate for conducting factor analysis. (X 2 : 1621.053. SD:91. p < 0.000). Exploratory factor analysis To evaluate the suitability for factor analysis, the correlation between expressions was examined. No value less than 0.30 was observed in the correlation matrix between the statements. The item correlation coefficient ranged from 0.696–0.871 in the functional subdimension of the scale, 0.551–0.840 in the interactive/communicative subdimension, 0.577–0.791 in the critical subdimension, and the reliability of the scale was good (Table 1). An item‒total score correlation coefficient of 0.30 and above indicates that the scale has good reliability[19]. Principal Component Analysis was applied to determine the factor structure of the scale. Considering the Kaiser criterion (eigenvalue > 1), it was determined that the scale has a three-factor structure. As a result of EFA, it was found that the total variance explained in the 14-item, three-factor structure of the scale was 60.82%. The fact that the total variance explained was above 50% indicates that the scale items have good representativeness [19]. After varimax rotation in the analysis, it was observed that the variance distribution between the factors was balanced and the items were distributed more clearly across the factors. In EFA, the eigenvalue of factor 1 was 4.82 and the variance explained was 24.73%, factor 2 was found to have an eigenvalue of 2.67 and explained variance of 20.50%, and factor 3 was found to have an eigenvalue of 1.02 and explained variance of 15.58% (Table 1). Table 1. Data on the exploratory factor analysis of the Adult Vaccine Literacy Scale (Please find the table details at the end of the manuscript.) Confirmatory factor analysis CFA was conducted to evaluate the construct validity of the scale. In the literature, it is stated that the number of items should be between 12–30 when the sample size is larger than 250 (16) . Accordingly, the number of samples included in the analysis (n = 281) is sufficient for the 14-item AVLS scale. According to the results of the CFA analysis, the Chi-square/degree of freedom ratio (χ²/df) was found to be 1.447, which is below the threshold of 5, indicating a good model fit. Furthermore; RMSEA = 0.040, CFI = 0.980, GFI = 0.952, AGFI = 0.928, TLI = 0.974 and NFI = 0.939 (Fig. 1). These results show that the three-factor Turkish version of the scale has a strong construct validity. Figure 1 First Level Factorial Structure of the Adult Vaccine Literacy Scale (Please find the figure details at the end of the manuscript.) Convergent validity To assess convergent validity, the relationship between the AVLS total score and the HLS total score, which is theoretically related, was examined. Pearson correlation analysis revealed a positive, moderate, and statistically significant relationship between the two scales (r = 0.563; p ≤ 0.001). This finding supports the convergent validity of the AVLS. Reliability of the Turkish AVLS Internal consistency The internal consistency of the AVLS was evaluated with the cronbach alpha coefficient. A high cronbah alpha value indicates that the inter-item consistency is high and the items measure the same basic construct. In the literature, cronbach alpha is defined as “excellent reliability” if it is between 0.80 and 1.00, “high reliability” if it is between 0.60 and 0.80, and “low reliability” if it is between 0.40 and 0.60. indicates[20, 21]. The cronbach alpha value determined as 0.846 in the scale has a high reliability. In addition, the Cronbach's alpha values of the subdimensions of the scale were determined to vary between 0.686 and 0.881 (Table 1). Test-retest reliability Reliability of the scale over time was assessed using the test–retest method. The scale was reapplied to 30 participants randomly selected from those included in the initial analysis two weeks later. a The relationship between the total scores obtained from the first and second applications was examined using Spearman's rank correlation coefficient. The analysis revealed a positive, high-level, and statistically significant relationship between the two applications (r = 0.830; p < 0.001). This finding indicates that the scale has a high level of reliability over time. Descriptive results The study analyzed the effects of variables such as gender, marital status, education level, economic status, adequacy of vaccine knowledge, and vaccination status on HL and AVL, as well as the relationship between HL and AVL. The participants' average HL score was found to be 104.95 ± 15.54. The average score on the AVL scale was 42.43 ± 7.15. The participants' levels of health literacy and vaccine literacy were high. A statistically significant difference was found between the variables of gender, economic status, education level, sufficient knowledge about vaccines, required vaccines, and average vaccine literacy (p < 0.05) (Table 2). Table 2. Distribution of health literacy and vaccine literacy scale scores according to some socio-demographic characteristics of individuals (Please find the table details at the end of the manuscript.) It was found that female participants, those with a higher income than their expenses, those with a graduate education level, those who thought that sufficient information was given by health professionals about vaccines, those who had sufficient information about vaccines, and those who had the necessary vaccines had a higher vaccine literacy level. In addition, the health literacy levels of female participants, those who thought that sufficient information was given by health professionals about vaccines, those who reported that they had sufficient knowledge about vaccines and those who had the necessary vaccines, were greater (p > 0.05) (Table 2). Table 3. The relationship and correlation coefficients between vaccine literacy and health literacy Table 3 The relationship and correlation coefficients between vaccine literacy and health literacy Vaccine literacy Scale Total Score Functional Interactive Communicative Critical HL Total Score Access to Information Understanding Information Evaluation Functional r p .722** .000 1 Interactive Communicative r p .818** .000 .301** .000 1 Critical r p .705** .000 .159** .008 .594** .000 1 HL Total Score r p .563** .000 .380** .000 .482** .000 408** .000 1 Access to Information r p .452** .000 .298** .000 .405** .000 .317** .000 .791** .000 1 Understanding Information r p .558** .000 .390** .000 .483** .000 .380** .000 .899** .000 .664** .000 1 Evaluation r p .549** .000 .384** .000 .447** .000 .410** .000 .928** .000 .617** .000 .775** .000 1 Perform r p .326** .000 .190** .001 .294** .000 .262** .000 .806** .000 .515** .000 .597** .000 .722** .000 In Table 3. correlation analysis was made between the total scores of adult vaccine literacy and health literacy and the total scores of its sub-dimensions. According to the results of the analysis, a positive relationship was found between vaccine literacy and its sub-dimensions and health literacy, access to information, understanding information, evaluating and applying information (p < 0.001). It was found that as the health literacy level of the individuals increased, the vaccine literacy level also increased (p < 0.001. r=-0.563). Table 4. The Relationship between Vaccine Literacy and Health Literacy Dimensions Table 4 The Relationship between Vaccine Literacy and Health Literacy Dimensions B S.E. β t p 95% C.I.for EXP(B) Lower Upper Health Literacy Access to Information .229 .131 .115 1.745 0.082 − .029 .488 Health Literacy Understanding Information .424 .117 .296 3.622 0.001 .194 .655 Health Literacy Evaluation .473 .110 .385 4.320 0.001 .258 .689 Health Literacy Perform .387 .143 .189 2.700 0.007 .669 .105 Total Health Literacy .229 .023 .563 11.368 0,001 .214 .304 (Please find the table details at the end of the manuscript.) Multiple linear regression analysis was conducted to predict participants’ vaccination literacy levels based on the subdimensions of the HLS, and the results are presented in Table 4. The health literacy level, knowledge comprehension, evaluation and application subdimensions were significant predictors of participants' vaccine literacy level (p < 0.05). When the health literacy score increases by one unit, vaccine literacy increases by 0.229 units (Table 4). DISCUSSION Biasio et al. (2020) developed the AVLS based on health literacy and tested its reliability and validity. AVLS consists of 14 items and three sub-dimensions; functional, interactive/communicative and critical[ 8 ]. The reliability coefficient of the Turkish version of the scale was 0.846. The cronbach alpha values of the sub-dimensions vary between 0.686 and 0.881. Cronbach alpha value reflects the degree of homogeneity and internal consistency of the items in the scale. The higher this value is, the more reliable the scale is[ 20 , 21 ]. In the original version of the scale, the cronbach alpha coefficient is 0.92[ 8 ]. The findings of the study show that the scale has high consistency as in the original version. Furthermore, the first-order factorial structure is in good agreement with the results obtained. CFA, one of the tests commonly used in scale development and adaptation studies, aims to confirm the hypothesized factor structure[ 20 ]. As a result of CFA, goodness of fit (ꭓ 2 (70, n = 281) p < 0.009; ꭓ 2 /sd = 1.447; CMIN:101.301; RMSEA = 0.040; CFI = 0.980; GFI = 0.952) was found in the first order factor structure with 14 items and three sub-dimensions. One of the important criteria for CFA is the RMSEA threshold. The model with RMSEA between 0.03 and 0.08 at 95% confidence interval is considered to have a good fit[ 19 ]. The scale fit is good, with an RMSEA value of 0.040 in this study. The χ2/df, RMSEA, AGFI, CFI, GFI, NFI and TLI values of the scale show acceptable compatibility. Due to the lack of goodness-of-fit results in scale validity and reliability studies in other countries, they could not be discussed. The results of the psychometric analysis revealed that the original structure of the scale with three factors and 14 items was compatible with Turkish culture. Vaccine literacy, which is based on health literacy, is a factor that directly affects individuals' vaccination decisions[ 1 ]. Poor vaccine literacy is known to cause vaccine hesitancy. Improving vaccination literacy helps society understand the value of vaccination, increases confidence in vaccination, and is thought to contribute to the immunization of the entire society with vaccines[ 22 , 23 ]. However, the tools that measure the vaccination literacy level of individuals are insufficient. It is thought that this study, in which AVLS was adapted to the Turkish population and found to be valid and reliable, can be used to evaluate the vaccine literacy of individuals and will make important contributions to the literature. Health literacy is a concept related to how individuals understand, interpret and apply health services and health-related information. The level of health literacy is a determining factor for individuals to make informed and correct decisions about their own health[ 24 , 25 ]. Inadequate health literacy level may lead to many negative consequences: Decrease in healthy lifestyle behaviors of individuals, difficulty in prevention and control of diseases, lack of information or information pollution, inability to use health services effectively, increase in chronic diseases and their complications, less use of preventive health services, dissatisfaction and decrease in quality of life are some of these consequences[ 26 , 27 ]. In this study examining the relationship between vaccine literacy and health literacy in adults, the mean HLS score of the participants was 104.95 ± 15.54. Considering that the highest score that can be obtained from the scale is 125, the score obtained is quite good. The total health literacy score of female participants in the study was 107.31, while that of male participants was 100.17. Similarly, studies using different measurement tools have shown that women's health literacy scores are relatively high[ 28 – 30 ]. On the other hand, some studies have reported that men have higher health literacy levels[ 23 , 31 , 32 ]. However, no significant difference was found between education level and health literacy in the study (p = 0.816). When the literature is reviewed, it is seen that there is a strong link between education level and health outcomes. Low education level causes a decrease in health literacy, difficulties in accessing health services and negative health behaviors[ 33 ]. Several studies in Türkiye have demonstrated that individuals with high levels of education also have high levels of health literacy[ 27 , 28 ]. Similarly, studies conducted in other countries have also shown that there is a significant positive relationship between education level and health literacy[ 10 , 34 , 35 ]. Due to the high educational level of the majority of the participants in this study, the difference between educational level and health literacy level did not create significance in the results. The results of the study showed that as the health literacy level of individuals increased, the level of vaccine literacy also increased (p < 0.001) (r=-0.563). Ertaş and Göde and Ertaş (2021) and the level of vaccine opposition, and that the perception of vaccine opposition decreased as the level of health literacy increased[ 5 ]. Similarly, Wang et al. (2018) found that as the level of health literacy increased, trust in vaccines increased and vaccination intention increased[ 36 ]. On the other hand, Johri et al. (2015) concluded that as the health literacy level of mothers improved, the vaccination rates of their children increased[ 10 ]. Contrary to our study, there are studies that have obtained different findings about the level of health literacy, vaccine literacy and anti-vaccine attitudes[ 37 ]. The possible reason for this difference is thought to be the sharing of materials such as articles and written texts published by scientists with anti-vaccine attitudes, videos and animations containing many anti-vaccine views on television, social media and the internet. CONCLUSION The validity and reliability analyses revealed that the three subdimensions of Adult Vaccine Literacy, with 14 items, are compatible with Turkish culture at an acceptable level. The scale is an important measurement tool that can be used to evaluate the knowledge and attitudes of participants, especially as a result of the vaccine literacy training given to health professionals. In addition, it has been revealed that individuals' health literacy levels develop in parallel with their vaccine literacy skills and that these two constructs support each other. Abbreviations AGFI Adjusted goodness-of-fit index AVLS Adult Vaccine Literacy Scale CFA Confirmatory factor analysis CFI Comparative fit index CVI Content validity index CVR Content validity ratio EFA Exploratory factor analysis GFI Goodness-of-fit index HLS Health Literacy Scale KMO Kaiser‒Meyer‒Olkin NFI Normed Fit Index RMSEA Root mean square error of approximation TLI Tucker–Lewis Index Declarations Acknowledgements We thank all the participants who participated in this study. Author contributions Conceptualization: E.B., H.D., H.Y.D.; Methodology: E.B., H.D., G.A., H.Y.D; Resources, Writing-Original draft preparation: E.B., H.D., G.A.; Data Curation, Writing-Review & Editing:E.B., H.D., G.A., H.Y.D;; Supervision: E.B., H.D., G.A., H.Y.D; Funding This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Data availability The datasets used and/or analyzed during the current study are available from the first author upon reasonable request. Ethical Approval This study was conducted in accordance with the principles of the Declaration of Helsinki. Approval was granted by the Ethics Committee of Bartın University (E-23688910-050.01.04-2200048907). In addition, before starting the study, permission was obtained via e-mail from the authors who developed the original version of the scale to conduct a Turkish validity and reliabilit study. Informed consent was obtained from all individual participants included in the study. Conflict of interests The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper. Clinical trial number: Not applicable References Biasio LR. Vaccine literacy is undervalued. Hum Vaccines Immunotherapeutics. 2019;15:2552–3. https://doi.org/10.1080/21645515.2019.1609850 . Durmuş A, Mahmut Akbolat AM. COVID-19 Aşı Okuryazarlığı Ölçeği’nin Türkçe geçerlilik ve güvenirliliği. Cukurova Med J. 2021;46:732–41. https://doi.org/10.17826/cumj.870432 . Gusar I, Konjevoda S, Babić G, Hnatešen D, Čebohin M, Orlandini R, et al. Pre-Vaccination COVID-19 vaccine literacy in a Croatian adult population: A cross-sectional study. Int J Environ Res Public Health. 2021;18:7073. Vaccines. Jan and immunization. https://www.who.int/health-topics/vaccines-and-immunization . Accessed 16 2025. Göde A, Ertaş H. Sağlık Okuryazarlığı ile Aşı Karşıtlığı Arasındaki İlişkinin İncelenmesi: Üniversite Öğrencileri Üzerinde Bir Araştırma. J Acad Value Stud. 2021;7:1–14. Lorini C, Collini F, Galletti G, Ierardi F, Forni S, Gatteschi C, et al. Vaccine literacy and source of information about vaccination among staff of nursing homes: a cross-sectional survey conducted in Tuscany (Italy). Vaccines. 2022;10:682. Aygun E, Tortop HS. Investigation of Parents’ Vaccine Hesitation Levels and Reasons of Vaccine Refusal/Ebeveynlerin Asi Tereddut Duzeylerinin ve Karsitlik Nedenlerinin Incelenmesi. J Curr Pediatr. 2020;18:300–17. Biasio LR, Giambi C, Fadda G, Lorini C, Bonaccorsi G, D’Ancona F. Validation of an Italian tool to assess vaccine literacy in adulthood vaccination: A pilot study. Annali di igiene Med Preventiva e di Comunità. 2020;32:205–22. Do BN, Nguyen P-A, Pham KM, Nguyen HC, Nguyen MH, Tran CQ, et al. Determinants of health literacy and its associations with health-related behaviors, depression among the older people with and without suspected COVID-19 symptoms: a multi-institutional study. Front Public Health. 2020;8:581746. Johri M, Subramanian SV, Sylvestre M-P, Dudeja S, Chandra D, Koné GK, et al. Association between maternal health literacy and child vaccination in India: a cross-sectional study. J Epidemiol Community Health. 2015;69:849–57. Temel AB, Aras Z. Evaluation of validity and reliability of the Turkish version of health literacy scale. Florence Nightingale J Nurs. 2017;25:85–94. Toçi E, Burazeri G, Sorensen K, Jerliu N, Ramadani N, Roshi E et al. Health literacy and socioeconomic characteristics among older people in transitional Kosovo. 2013. Beaton DE, Bombardier C, Guillemin F, Ferraz MB. Guidelines for the process of cross-cultural adaptation of self-report measures. Spine (Phila Pa 1976). 2000;25:3186–91. https://doi.org/10.1097/00007632-200012150-00014 . Lawshe CH. A quantitative approach to content validity. Personal Psychol. 1975;28(4):563–75. Akin ZC, Gonul BA, Basdas O. Psychometric properties of the Turkish version of the child food rejection scale. J Eat Disord. 2025;13:43. https://doi.org/10.1186/s40337-025-01228-8 . Discovering Statistics. Using IBM SPSS Statistics (PDFDrive). Sørensen K, Van den Broucke S, Fullam J, Doyle G, Pelikan J, Slonska Z, et al. Health literacy and public health: A systematic review and integration of definitions and models. BMC Public Health. 2012;12:80. https://doi.org/10.1186/1471-2458-12-80 . Yurdagül H. Use of content validity indeces in the scale development studies. In: XIV. National Education Sciences Congress.(Congress Book). Denizli. 2005, 28–30, September, 1. 2005. Yaşlıoğlu MM. Factor analysis and validity in social sciences: Application of exploratory and confirmatory factor analyses. Istanbul Univ J School Bus. 2017;46 Special Issue:74–85. Erbil N, Bakır A. Developing inventory of professional attitude at occupation. J Hum Sci. 2009;6:290–302. Tavşancıl. Tutumların Ölçülmesi ve SPSS ile Veri Analizi. 6. baskı. Nobel Akademik Yayıncılık; 2019. Yang L, Zhen S, Li L, Wang Q, Yang G, Cui T, et al. Assessing vaccine literacy and exploring its association with vaccine hesitancy: A validation of the vaccine literacy scale in China. J Affect Disord. 2023;330:275–82. Zhang F, Or PP-L, Chung JW-Y. The effects of health literacy in influenza vaccination competencies among community-dwelling older adults in Hong Kong. BMC Geriatr. 2020;20:103. https://doi.org/10.1186/s12877-020-1504-5 . Deniz SŞ, Özer Ö, Sonğur C. Effect of Health Literacy on Health Perception: An Application in Individuals at Age 65 and Older. Social Work Public Health. 2018;33:85–95. https://doi.org/10.1080/19371918.2017.1409680 . Malik M, Zaidi RZ, Hussain A. Health literacy as a global public health concern: a systematic review. J Pharmacol Clin Res. 2017;4:1–7. Ayaz-Alkaya S, Dülger H. Fear of coronavirus and health literacy levels of older adults during the COVID-19 pandemic. Geriatr Nurs. 2022;43:45–50. Yigitbas C, Genc F. Yaşlılarda sağlık okuryazarlığı: Türkiye Doğu Karadeniz örneğinde nicel bir araştırma. Turkish J Public Health. 2021;19. Abacigil F, Harlak H, Okyay P, Kiraz DE, Gursoy Turan S, Saruhan G, et al. Validity and reliability of the Turkish version of the European Health Literacy Survey Questionnaire. Health Promot Int. 2019;34:658–67. Kuloğlu Y, Uslu K, GELECEĞİN SAĞLIK ÇALIŞANLARINDA SAĞLIK OKURYAZARLIK DÜZEYİNİN, SAĞLIK ALGISI ÜZERİNDEKİ ETKİSİ. DOUJ. 2022;23:255–77. https://doi.org/10.31671/doujournal.955317 . Tuğut N, Yılmaz A, Çelik BY. Hemşirelik öğrencilerinin sağlık okuryazarlığı düzeyleri ile sağlıklı yaşam biçimi davranışlarının belirlenmesi. Instıtute Health Sci J. 2021;6:120–8. Öncü E, Vayısoğlu SK, Güven Y, Aktaş G, Ceyhan H, Karakuş E. The evaluation of hypertensive individuals regarding chronic disease management and its relation to health literacy. Anatol J Family Med. 2018;1:31–2. Štefková G, Čepová E, Kolarčik P, Gecková AM. The level of health literacy of students at medical faculties. Kontakt. 2018;20:e363–9. van der Heide I, Uiters E, Sørensen K, Röthlin F, Pelikan J, Rademakers J, et al. Health literacy in Europe: the development and validation of health literacy prediction models. Eur J Public Health. 2016;26:906–11. Nguyen HC, Nguyen MH, Do BN, Tran CQ, Nguyen TT, Pham KM, et al. People with suspected COVID-19 symptoms were more likely depressed and had lower health-related quality of life: the potential benefit of health literacy. J Clin Med. 2020;9:965. Van Hoa H, Giang HT, Vu PT, Van Tuyen D, Khue PM. Factors Associated with Health Literacy among the Elderly People in Vietnam. Biomed Res Int. 2020;2020:3490635. https://doi.org/10.1155/2020/3490635 . Wang X, Zhou X, Leesa L, Mantwill S. The Effect of Vaccine Literacy on Parental Trust and Intention to Vaccinate after a Major Vaccine Scandal. J Health Communication. 2018;23:413–21. https://doi.org/10.1080/10810730.2018.1455771 . Aharon AA, Nehama H, Rishpon S, Baron-Epel O. Parents with high levels of communicative and critical health literacy are less likely to vaccinate their children. Patient Educ Couns. 2017;100:768–75. Table 1 and 2 Table 1 and 2 are available in the Supplementary Files section. Additional Declarations No competing interests reported. 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Vaccine literacy refers to an individual\u0026rsquo;s ability to access, interpret, and effectively use essential information and services related to vaccination in order to make well-informed immunization decisions [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Vaccination is the most cost-effective method for fighting against infectious diseases that can be prevented through immunization. The World Health Organization (WHO) reported that many diseases can be prevented by vaccination and that deaths due to these diseases are significantly reduced [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Although some diseases are completely eradicated and some are eliminated with vaccination, vaccine hesitation has continued since the existence of the vaccine has become widespread [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eVaccine literacy constitutes a critical factor in addressing vaccine hesitancy. Aligned with the principles of health literacy, it seeks to empower individuals with the necessary knowledge and skills to make informed decisions and complete the vaccination process [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. As in the rest of the world, inconsistent information about the advantages and disadvantages of vaccines has emerged in T\u0026uuml;rkiye. This information causes people to hesitate about vaccination and make incorrect decisions. A study conducted by Ayg\u0026uuml;n and Tortop (2020) revealed that individuals did not have the opportunity to obtain sufficient information about vaccines and thought that vaccines were useless, could cause diseases or disabilities, and were not religiously appropriate [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. This situation may be because individuals cannot obtain sufficient information about the vaccine or cannot interpret the information they have obtained correctly [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. In all these cases, individuals' ability to access, understand, evaluate and apply information is associated with only good health literacy. When the literature is examined, there are standard scales that evaluate many types of vaccine-related knowledge, attitudes and behaviors such as vaccines, vaccine opposition, vaccine hesitancy, vaccine ambivalence, vaccine attitudes, attitudes toward vaccines, parental attitudes toward childhood vaccines, COVID-19 vaccine ambivalence, COVID-19 vaccine literacy, COVID-19 vaccine knowledge and attitudes, and attitudes toward the COVID-19 vaccine. These standardized tools make it possible to identify the relevant strengths and weaknesses of the individuals being assessed.\u003c/p\u003e \u003cp\u003eIn T\u0026uuml;rkiye, there is no standardized scale that includes general adult vaccine literacy and evaluates the level of knowledge. For this reason, the psychometric properties of a tool measuring adult vaccine literacy will be examined according to Turkish culture. By ensuring its applicability to Turkish society, it will prepare the ground for the content of the training to be given to individuals about vaccines to be applied. A relationship between health literacy and vaccine literacy is also considered to exist. The objective of this study was to assess the psychometric performance of the Turkish adaptation of the Adult Vaccine Literacy Scale [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e] originally developed by Biasio et al. (2020), and to explore its association with health literacy.\u003c/p\u003e"},{"header":"METHODS","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eParticipants and Procedure\u003c/h2\u003e \u003cp\u003eIndividuals aged 18 years and older in Turkey who use social media were included via an online survey. Participants with physical or mental conditions that could impair accurate responses and those with incomplete data collection forms were excluded. Data were collected through self-reporting.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eMaterials\u003c/h3\u003e\n\u003cp\u003e \u003cstrong\u003eIntroductory Information Form\u003c/strong\u003e \u003cp\u003eThere are 14 questions that examine sociodemographic characteristics (age, education level, social security, and marital status) according to the literature [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan additionalcitationids=\"CR9\" citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003eAdult Vaccine Literacy Scale (AVLS)\u003c/em\u003e: The scale was developed by Biasio et al. (2020) to determine individuals' knowledge about vaccination and their interpretation of this information [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. The original AVLS comprises 14 items distributed across three dimensions, namely functional, interactive/communicative, and critical literacy, corresponding to items 1\u0026ndash;5, 6\u0026ndash;10, and 11\u0026ndash;14, respectively. Psychometrically, functional subscale questions are more related to language skills, while interactive/critical questions are related to problem-solving and decision-making skills. The scale consists of items rated on a four-point Likert-type response format, scored from 1 to 4 (1:ever, 2:rarely, 3:sometimes, 4:often).The first five items are negatively worded and are therefore reverse-coded. The original scale's internal consistency coefficient is 0.92 [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. In this study, to ensure the reliability and construct validity of the scale, the item-total score correlation was examined as recommended in scale adaptation studies, and no values below 0.30 were observed. The Turkish AVLS, with its three-dimensional structure explaining 30.82% of the variance, showed strong item-level reliability and satisfactory construct validity. The Cronbach's alpha coefficient for the entire scale was 0.846, 0.881 for the functional subscale, 0.814 for the interactive/communicative subscale, and 0.686 for the critical subscale. These findings suggest satisfactory reliability for the overall scale as well as for the functional and interactive/communicative subscales, whereas the reliability of the critical subscale was at a moderate level.\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eHealth Literacy Scale (HLS)\u003c/strong\u003e \u003cp\u003eThe Health Literacy Scale, which was adapted into Turkish by Bayık Temel and Aras, was developed by To\u0026ccedil;i et al. in 2013. The scale has a cronbach alpha value of 0.92 and has 25 items and four sub-dimensions [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. HLS was found to have Cronbach's α\u0026thinsp;=\u0026thinsp;0.945, indicating high internal consistency. This demonstrates that HLS is suitable for assessing the convergent validity of AVLS.\u003c/p\u003e \u003c/p\u003e\n\u003ch3\u003eTranslation and cultural adaptation\u003c/h3\u003e\n\u003cp\u003ePermission was obtained from the original author of the scale prior to initiating the Turkish translation and cross-cultural adaptation process. A translation and back-translation process was carried out as suggested by Beaton et al. (2000)[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Expert rewiew and a pilot test were conducted to ensure cultural appropriateness and comprehensibility. The following steps were followed in the adaptation:\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eForward translation: The scale was first translated from English into Turkish by four independent translators who were fluent in both languages. These translations were subsequently reviewed and merged into a single preliminary Turkish version by a bilingual expert, who addressed discrepancies and ensured both linguistic accuracy and conceptual equivalence.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eBackward translation: The finalized Turkish draft was independently translated back into English by two bilingual translators who were blinded to the original version of the scale. The resulting English versions were carefully reviewed against the original instrument, and discrepancies were resolved to ensure semantic and conceptual equivalence.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eExpert Review: Ten experts (five public health nursing professors, two midwifery associate professors, and three midwifery assistant professors) evaluated the scale items for content and language validity in terms of linguistic intelligibility and cultural appropriateness. The Lawshe content validity ratio and index were used to determine content validity at the item level [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e].\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eParticipant feedback: The final stage of the adaptation study involved a pilot application. To evaluate the comprehensibility of the Turkish version, a pilot study was conducted with 15 participants (7 men and 8 women) not included in the sample. Each participant completed the form, and interviews were conducted to understand the meaning of each item and the selected response.\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003eFeedback from experts and participants was evaluated, and the final version of the AVLS in Turkish was finalized.\u003c/p\u003e\n\u003ch3\u003eData Collection\u003c/h3\u003e\n\u003cp\u003eThe sample size was calculated based on the requirements of factor analysis. In this regard, methodological studies recommend that the number of participants be between 5 and 20 times the number of scale items [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. The analysis was evaluated using data obtained from 281 participants. To examine the temporal stability of the scale, a subset of 30 participants selected at random (16 females and 14 males) completed the questionnaire a second time after a two-week interval, and test\u0026ndash;retest reliability was assessed based on these responses.\u003c/p\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eData Analysis\u003c/h2\u003e \u003cp\u003eThe purpose of the adult vaccination literacy scale is to determine individuals' ability to acquire knowledge about adult vaccination and critically evaluate this knowledge. Based on this conceptual framework, the validation approach was designed to evaluate multiple aspects of validity, including content validity, to determine whether the items adequately reflect the underlying construct; construct validity, to examine the factorial structure of the scale; and convergent validity, to assess its association with the health literacy scale. In addition, reliability was examined through analyses of internal consistency and test\u0026ndash;retest reliability in order to evaluate the consistency and temporal stability of the measurements.\u003c/p\u003e \u003cp\u003eStatistical analyses were conducted using IBM SPSS Statistics version 24.0 (IBM Corp., Armonk, NY, USA) and AMOS version 24.0. Frequencies and percentages for categorical variables and means and standard deviations for continuous variables are presented. The suitability of the data for factor analysis was assessed using the Kaiser\u0026ndash;Meyer\u0026ndash;Olkin (KMO) and Bartlett's sphericity testThe procedures applied for validity and reliability assessment included the following analyses\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eContent and language validity\u003c/strong\u003e \u003cp\u003eLawshe technique was used for content and language validity. According to this technique, the translated scale was submitted to expert opinion [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Content validity ratio (CVR) and content validity index (CVI) were calculated based on the feedback received from the experts.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eConstruct validty\u003c/strong\u003e \u003cp\u003eExploratory Factor Analysis (EFA) and Confirmatory Factor Analysis (CFA) were conducted to examine the factorial structure of the scale. EFA was used to explore how the items clustered into underlying factors, whereas CFA was applied to evaluate the extent to which the three-factor structure proposed in the original AVLS was supported by the data obtained from the Turkish sample.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eConvergent validity\u003c/strong\u003e \u003cp\u003eVaccine literacy is viewed as a specific dimension of health literacy and is strongly associated with individuals\u0026rsquo; capacity to comprehend, appraise, and apply health-related information.. Therefore, to assess the convergent validity of the vaccine literacy scale, a correlation analysis was performed with the health literacy scale, which is theoretically related[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e].\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eReliability\u003c/strong\u003e \u003cp\u003eThe reliability of the Turkish AVLS was assessed using internal consistency and test\u0026ndash;retest methods. Internal consistency analysis was conducted to examine the extent to which the items of the scale reliably measured the same underlying construct, using Cronbach\u0026rsquo;s alpha coefficient. Test\u0026ndash;retest reliability was evaluated to examine the temporal stability of the scale and to assess whether similar scores were obtained when the same participants completed the scale again after a two-week interval. A threshold of p\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was set to determine statistical significance across all analyses.\u003c/p\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"RESULTS","content":"\u003cdiv id=\"Sec9\"\u003e\n \u003ch2\u003eSocio-Demographics\u003c/h2\u003e\n \u003cp\u003eA total of 66.9% of the participants in the research group were female, 61.9% were married, and 24.9% had less income than expenses. In addition, the majority of the participants (50.9%) were undergraduate graduates, 44.38% had sufficient knowledge about vaccines, and 43.74% had the necessary vaccinations.\u003c/p\u003e\n\u003c/div\u003e\n\u003ch3\u003eValidity of the Turkish AVLS\u003c/h3\u003e\n\u003cp\u003e\u003cstrong\u003eContent validity\u003c/strong\u003e: In the calculation “CVR = Nu/(N/2)-1” formula (Nu: number of experts who think that the item is important; N: total number of experts) was used. The CVI reflects the overall adequacy of the scale by summarizing the relevance and clarity of its items. It is obtained by calculating the average of the CVR values across all items included in the scale. According to this evaluation, the CVR values of the scale items in the study were determined to be above 0.80 and the CVR value was 0.97 and the language validity index was 0.77. When the number of experts is 10, the minimum value (content validity criterion) at 0.05 significance level should be CVR = 0.62 [18]. CVR is greater than the CVI, this value is statistically significant.\u003c/p\u003e\n\u003cdiv id=\"Sec11\"\u003e\n \u003ch2\u003eConstruct validty\u003c/h2\u003e\n \u003cp\u003eThe KMO measure for the AVLS was 0.861, indicating a very good level of sampling adequacy. This suggests that the factor analysis results are reliable and appropriate for the dataset. Furthermore, Bartlett’s test of sphericity indicated that the data were appropriate for conducting factor analysis. (X\u003csup\u003e2\u003c/sup\u003e: 1621.053. SD:91. p \u0026lt; 0.000).\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec12\"\u003e\n \u003ch2\u003eExploratory factor analysis\u003c/h2\u003e\n \u003cp\u003eTo evaluate the suitability for factor analysis, the correlation between expressions was examined. No value less than 0.30 was observed in the correlation matrix between the statements. The item correlation coefficient ranged from 0.696–0.871 in the functional subdimension of the scale, 0.551–0.840 in the interactive/communicative subdimension, 0.577–0.791 in the critical subdimension, and the reliability of the scale was good (Table 1). An item‒total score correlation coefficient of 0.30 and above indicates that the scale has good reliability[19]. Principal Component Analysis was applied to determine the factor structure of the scale. Considering the Kaiser criterion (eigenvalue \u0026gt; 1), it was determined that the scale has a three-factor structure. As a result of EFA, it was found that the total variance explained in the 14-item, three-factor structure of the scale was 60.82%. The fact that the total variance explained was above 50% indicates that the scale items have good representativeness [19]. After varimax rotation in the analysis, it was observed that the variance distribution between the factors was balanced and the items were distributed more clearly across the factors. In EFA, the eigenvalue of factor 1 was 4.82 and the variance explained was 24.73%, factor 2 was found to have an eigenvalue of 2.67 and explained variance of 20.50%, and factor 3 was found to have an eigenvalue of 1.02 and explained variance of 15.58% (Table 1).\u003c/p\u003e\n \u003cp\u003eTable 1. \u003cstrong\u003eData on the exploratory factor analysis of the Adult Vaccine Literacy Scale\u003c/strong\u003e\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec13\"\u003e\n \u003ch2\u003e(Please find the table details at the end of the manuscript.)\u003c/h2\u003e\n \u003cdiv id=\"Sec14\"\u003e\n \u003ch2\u003eConfirmatory factor analysis\u003c/h2\u003e\n \u003cp\u003eCFA was conducted to evaluate the construct validity of the scale. In the literature, it is stated that the number of items should be between 12–30 when the sample size is larger than 250\u003csup\u003e(16)\u003c/sup\u003e. Accordingly, the number of samples included in the analysis (n = 281) is sufficient for the 14-item AVLS scale. According to the results of the CFA analysis, the Chi-square/degree of freedom ratio (χ²/df) was found to be 1.447, which is below the threshold of 5, indicating a good model fit. Furthermore; RMSEA = 0.040, CFI = 0.980, GFI = 0.952, AGFI = 0.928, TLI = 0.974 and NFI = 0.939 (Fig. 1). These results show that the three-factor Turkish version of the scale has a strong construct validity.\u003c/p\u003e\n \u003cp\u003eFigure 1 \u003cstrong\u003eFirst Level Factorial Structure of the Adult Vaccine Literacy Scale\u003c/strong\u003e\u003c/p\u003e\n \u003c/div\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec15\"\u003e\n \u003ch2\u003e(Please find the figure details at the end of the manuscript.)\u003c/h2\u003e\n \u003cdiv id=\"Sec16\"\u003e\n \u003ch2\u003eConvergent validity\u003c/h2\u003e\n \u003cp\u003eTo assess convergent validity, the relationship between the AVLS total score and the HLS total score, which is theoretically related, was examined. Pearson correlation analysis revealed a positive, moderate, and statistically significant relationship between the two scales (r = 0.563; p ≤ 0.001). This finding supports the convergent validity of the AVLS.\u003c/p\u003e\n \u003c/div\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec17\"\u003e\n \u003ch2\u003eReliability of the Turkish AVLS\u003c/h2\u003e\n \u003cdiv id=\"Sec18\"\u003e\n \u003ch2\u003eInternal consistency\u003c/h2\u003e\n \u003cp\u003eThe internal consistency of the AVLS was evaluated with the cronbach alpha coefficient. A high cronbah alpha value indicates that the inter-item consistency is high and the items measure the same basic construct. In the literature, cronbach alpha is defined as “excellent reliability” if it is between 0.80 and 1.00, “high reliability” if it is between 0.60 and 0.80, and “low reliability” if it is between 0.40 and 0.60. indicates[20, 21]. The cronbach alpha value determined as 0.846 in the scale has a high reliability. In addition, the Cronbach's alpha values of the subdimensions of the scale were determined to vary between 0.686 and 0.881 (Table\u0026nbsp;1).\u003c/p\u003e\n \u003c/div\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec19\"\u003e\n \u003ch2\u003eTest-retest reliability\u003c/h2\u003e\n \u003cp\u003eReliability of the scale over time was assessed using the test–retest method. The scale was reapplied to 30 participants randomly selected from those included in the initial analysis two weeks later. a The relationship between the total scores obtained from the first and second applications was examined using Spearman's rank correlation coefficient. The analysis revealed a positive, high-level, and statistically significant relationship between the two applications (r = 0.830; p \u0026lt; 0.001). This finding indicates that the scale has a high level of reliability over time.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec20\"\u003e\n \u003ch2\u003eDescriptive results\u003c/h2\u003e\n \u003cp\u003eThe study analyzed the effects of variables such as gender, marital status, education level, economic status, adequacy of vaccine knowledge, and vaccination status on HL and AVL, as well as the relationship between HL and AVL. The participants' average HL score was found to be 104.95 ± 15.54. The average score on the AVL scale was 42.43 ± 7.15. The participants' levels of health literacy and vaccine literacy were high. A statistically significant difference was found between the variables of gender, economic status, education level, sufficient knowledge about vaccines, required vaccines, and average vaccine literacy (p \u0026lt; 0.05) (Table\u0026nbsp;2).\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eTable\u0026nbsp;2. Distribution of health literacy and vaccine literacy scale scores according to some socio-demographic characteristics of individuals\u003c/strong\u003e\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec21\"\u003e\n \u003ch2\u003e(Please find the table details at the end of the manuscript.)\u003c/h2\u003e\n \u003cp\u003eIt was found that female participants, those with a higher income than their expenses, those with a graduate education level, those who thought that sufficient information was given by health professionals about vaccines, those who had sufficient information about vaccines, and those who had the necessary vaccines had a higher vaccine literacy level. In addition, the health literacy levels of female participants, those who thought that sufficient information was given by health professionals about vaccines, those who reported that they had sufficient knowledge about vaccines and those who had the necessary vaccines, were greater (p \u0026gt; 0.05) (Table\u0026nbsp;2).\u003c/p\u003e\n \u003cp\u003eTable 3. \u003cstrong\u003eThe relationship and correlation coefficients between vaccine literacy and health literacy\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n \u003ctable id=\"Tab2\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv\u003eTable 3\u003c/div\u003e\n \u003cdiv\u003e\n \u003cp\u003eThe relationship and correlation coefficients between vaccine literacy and health literacy\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\" colspan=\"2\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eVaccine literacy Scale Total Score\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eFunctional\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eInteractive\u003c/p\u003e\n \u003cp\u003eCommunicative\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eCritical\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eHL\u003c/p\u003e\n \u003cp\u003eTotal Score\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eAccess to Information\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eUnderstanding Information\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eEvaluation\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eFunctional\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003er\u003c/p\u003e\n \u003cp\u003ep\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.722**\u003c/p\u003e\n \u003cp\u003e.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eInteractive\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eCommunicative\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003er\u003c/p\u003e\n \u003cp\u003ep\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.818**\u003c/p\u003e\n \u003cp\u003e.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.301**\u003c/p\u003e\n \u003cp\u003e.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eCritical\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003er\u003c/p\u003e\n \u003cp\u003ep\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.705**\u003c/p\u003e\n \u003cp\u003e.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.159**\u003c/p\u003e\n \u003cp\u003e.008\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.594**\u003c/p\u003e\n \u003cp\u003e.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eHL\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eTotal Score\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003er\u003c/p\u003e\n \u003cp\u003ep\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.563**\u003c/p\u003e\n \u003cp\u003e.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.380**\u003c/p\u003e\n \u003cp\u003e.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.482**\u003c/p\u003e\n \u003cp\u003e.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e408**\u003c/p\u003e\n \u003cp\u003e.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eAccess to Information\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003er\u003c/p\u003e\n \u003cp\u003ep\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.452**\u003c/p\u003e\n \u003cp\u003e.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.298**\u003c/p\u003e\n \u003cp\u003e.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.405**\u003c/p\u003e\n \u003cp\u003e.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.317**\u003c/p\u003e\n \u003cp\u003e.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.791**\u003c/p\u003e\n \u003cp\u003e.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eUnderstanding Information\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003er\u003c/p\u003e\n \u003cp\u003ep\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.558**\u003c/p\u003e\n \u003cp\u003e.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.390**\u003c/p\u003e\n \u003cp\u003e.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.483**\u003c/p\u003e\n \u003cp\u003e.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.380**\u003c/p\u003e\n \u003cp\u003e.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.899**\u003c/p\u003e\n \u003cp\u003e.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.664**\u003c/p\u003e\n \u003cp\u003e.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eEvaluation\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003er\u003c/p\u003e\n \u003cp\u003ep\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.549**\u003c/p\u003e\n \u003cp\u003e.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.384**\u003c/p\u003e\n \u003cp\u003e.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.447**\u003c/p\u003e\n \u003cp\u003e.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.410**\u003c/p\u003e\n \u003cp\u003e.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.928**\u003c/p\u003e\n \u003cp\u003e.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.617**\u003c/p\u003e\n \u003cp\u003e.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.775**\u003c/p\u003e\n \u003cp\u003e.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003ePerform\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003er\u003c/p\u003e\n \u003cp\u003ep\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.326**\u003c/p\u003e\n \u003cp\u003e.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.190**\u003c/p\u003e\n \u003cp\u003e.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.294**\u003c/p\u003e\n \u003cp\u003e.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.262**\u003c/p\u003e\n \u003cp\u003e.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.806**\u003c/p\u003e\n \u003cp\u003e.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.515**\u003c/p\u003e\n \u003cp\u003e.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.597**\u003c/p\u003e\n \u003cp\u003e.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.722**\u003c/p\u003e\n \u003cp\u003e.000\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec22\"\u003e\n \u003cp\u003eIn Table 3. correlation analysis was made between the total scores of adult vaccine literacy and health literacy and the total scores of its sub-dimensions. According to the results of the analysis, a positive relationship was found between vaccine literacy and its sub-dimensions and health literacy, access to information, understanding information, evaluating and applying information (p \u0026lt; 0.001). It was found that as the health literacy level of the individuals increased, the vaccine literacy level also increased (p \u0026lt; 0.001. r=-0.563).\u003c/p\u003e\n \u003cp\u003eTable 4. \u003cstrong\u003eThe Relationship between Vaccine Literacy and Health Literacy Dimensions\u003c/strong\u003e\u003c/p\u003e\n \u003cdiv\u003e\u0026nbsp;\u0026nbsp;\u003ctable id=\"Tab3\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv\u003eTable 4\u003c/div\u003e\n \u003cdiv\u003e\n \u003cp\u003eThe Relationship between Vaccine Literacy and Health Literacy Dimensions\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\" rowspan=\"2\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003eB\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003eS.E.\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003eβ\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003et\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003ep\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e95% C.I.for EXP(B)\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eLower\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eUpper\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eHealth Literacy Access to Information\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.229\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.131\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.115\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.745\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.082\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e− .029\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.488\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eHealth Literacy Understanding Information\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.424\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.117\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.296\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3.622\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.194\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.655\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eHealth Literacy Evaluation\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.473\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.110\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.385\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4.320\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.258\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.689\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eHealth Literacy Perform\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.387\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.143\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.189\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.700\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.007\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.669\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.105\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eTotal Health Literacy\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.229\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.023\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.563\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e11.368\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e0,001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.214\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.304\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003c/div\u003e\n \u003cdiv id=\"Sec23\"\u003e\n \u003ch2\u003e(Please find the table details at the end of the manuscript.)\u003c/h2\u003e\n \u003cp\u003eMultiple linear regression analysis was conducted to predict participants’ vaccination literacy levels based on the subdimensions of the HLS, and the results are presented in Table\u0026nbsp;4. The health literacy level, knowledge comprehension, evaluation and application subdimensions were significant predictors of participants' vaccine literacy level (p \u0026lt; 0.05). When the health literacy score increases by one unit, vaccine literacy increases by 0.229 units (Table\u0026nbsp;4).\u003c/p\u003e\n \u003c/div\u003e\n\u003c/div\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eBiasio et al. (2020) developed the AVLS based on health literacy and tested its reliability and validity. AVLS consists of 14 items and three sub-dimensions; functional, interactive/communicative and critical[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. The reliability coefficient of the Turkish version of the scale was 0.846. The cronbach alpha values of the sub-dimensions vary between 0.686 and 0.881. Cronbach alpha value reflects the degree of homogeneity and internal consistency of the items in the scale. The higher this value is, the more reliable the scale is[\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. In the original version of the scale, the cronbach alpha coefficient is 0.92[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. The findings of the study show that the scale has high consistency as in the original version. Furthermore, the first-order factorial structure is in good agreement with the results obtained. CFA, one of the tests commonly used in scale development and adaptation studies, aims to confirm the hypothesized factor structure[\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. As a result of CFA, goodness of fit (ꭓ\u003csup\u003e2\u003c/sup\u003e (70, n\u0026thinsp;=\u0026thinsp;281) p\u0026thinsp;\u0026lt;\u0026thinsp;0.009; ꭓ\u003csup\u003e2\u003c/sup\u003e/sd\u0026thinsp;=\u0026thinsp;1.447; CMIN:101.301; RMSEA\u0026thinsp;=\u0026thinsp;0.040; CFI\u0026thinsp;=\u0026thinsp;0.980; GFI\u0026thinsp;=\u0026thinsp;0.952) was found in the first order factor structure with 14 items and three sub-dimensions. One of the important criteria for CFA is the RMSEA threshold. The model with RMSEA between 0.03 and 0.08 at 95% confidence interval is considered to have a good fit[\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. The scale fit is good, with an RMSEA value of 0.040 in this study. The χ2/df, RMSEA, AGFI, CFI, GFI, NFI and TLI values of the scale show acceptable compatibility. Due to the lack of goodness-of-fit results in scale validity and reliability studies in other countries, they could not be discussed.\u003c/p\u003e \u003cp\u003eThe results of the psychometric analysis revealed that the original structure of the scale with three factors and 14 items was compatible with Turkish culture. Vaccine literacy, which is based on health literacy, is a factor that directly affects individuals' vaccination decisions[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Poor vaccine literacy is known to cause vaccine hesitancy. Improving vaccination literacy helps society understand the value of vaccination, increases confidence in vaccination, and is thought to contribute to the immunization of the entire society with vaccines[\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. However, the tools that measure the vaccination literacy level of individuals are insufficient. It is thought that this study, in which AVLS was adapted to the Turkish population and found to be valid and reliable, can be used to evaluate the vaccine literacy of individuals and will make important contributions to the literature.\u003c/p\u003e \u003cp\u003eHealth literacy is a concept related to how individuals understand, interpret and apply health services and health-related information. The level of health literacy is a determining factor for individuals to make informed and correct decisions about their own health[\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. Inadequate health literacy level may lead to many negative consequences: Decrease in healthy lifestyle behaviors of individuals, difficulty in prevention and control of diseases, lack of information or information pollution, inability to use health services effectively, increase in chronic diseases and their complications, less use of preventive health services, dissatisfaction and decrease in quality of life are some of these consequences[\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn this study examining the relationship between vaccine literacy and health literacy in adults, the mean HLS score of the participants was 104.95\u0026thinsp;\u0026plusmn;\u0026thinsp;15.54. Considering that the highest score that can be obtained from the scale is 125, the score obtained is quite good. The total health literacy score of female participants in the study was 107.31, while that of male participants was 100.17. Similarly, studies using different measurement tools have shown that women's health literacy scores are relatively high[\u003cspan additionalcitationids=\"CR29\" citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. On the other hand, some studies have reported that men have higher health literacy levels[\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. However, no significant difference was found between education level and health literacy in the study (p\u0026thinsp;=\u0026thinsp;0.816). When the literature is reviewed, it is seen that there is a strong link between education level and health outcomes. Low education level causes a decrease in health literacy, difficulties in accessing health services and negative health behaviors[\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. Several studies in T\u0026uuml;rkiye have demonstrated that individuals with high levels of education also have high levels of health literacy[\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. Similarly, studies conducted in other countries have also shown that there is a significant positive relationship between education level and health literacy[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]. Due to the high educational level of the majority of the participants in this study, the difference between educational level and health literacy level did not create significance in the results.\u003c/p\u003e \u003cp\u003eThe results of the study showed that as the health literacy level of individuals increased, the level of vaccine literacy also increased (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) (r=-0.563). Ertaş and G\u0026ouml;de and Ertaş (2021) and the level of vaccine opposition, and that the perception of vaccine opposition decreased as the level of health literacy increased[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Similarly, Wang et al. (2018) found that as the level of health literacy increased, trust in vaccines increased and vaccination intention increased[\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e]. On the other hand, Johri et al. (2015) concluded that as the health literacy level of mothers improved, the vaccination rates of their children increased[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Contrary to our study, there are studies that have obtained different findings about the level of health literacy, vaccine literacy and anti-vaccine attitudes[\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]. The possible reason for this difference is thought to be the sharing of materials such as articles and written texts published by scientists with anti-vaccine attitudes, videos and animations containing many anti-vaccine views on television, social media and the internet.\u003c/p\u003e"},{"header":"CONCLUSION","content":"\u003cp\u003eThe validity and reliability analyses revealed that the three subdimensions of Adult Vaccine Literacy, with 14 items, are compatible with Turkish culture at an acceptable level. The scale is an important measurement tool that can be used to evaluate the knowledge and attitudes of participants, especially as a result of the vaccine literacy training given to health professionals. In addition, it has been revealed that individuals' health literacy levels develop in parallel with their vaccine literacy skills and that these two constructs support each other.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eAGFI\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eAdjusted goodness-of-fit index\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eAVLS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eAdult Vaccine Literacy Scale\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCFA\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eConfirmatory factor analysis\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCFI\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eComparative fit index\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCVI\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eContent validity index\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCVR\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eContent validity ratio\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eEFA\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eExploratory factor analysis\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eGFI\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eGoodness-of-fit index\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eHLS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eHealth Literacy Scale\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eKMO\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eKaiser‒Meyer‒Olkin\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eNFI\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eNormed Fit Index\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eRMSEA\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eRoot mean square error of approximation\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eTLI\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eTucker\u0026ndash;Lewis Index\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgements\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe thank all the participants who participated in this study.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contributions\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eConceptualization:\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eE.B., H.D., H.Y.D.; Methodology: E.B., H.D., G.A., H.Y.D; Resources, Writing-Original draft preparation: E.B., H.D., G.A.; Data Curation, Writing-Review \u0026amp; Editing:E.B., H.D., G.A., H.Y.D;; Supervision: E.B., H.D., G.A., H.Y.D;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analyzed during the current study are available from the first author upon reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eEthical Approval\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was conducted in accordance with the principles of the Declaration of Helsinki. Approval was granted by the Ethics Committee of Bartın University\u0026nbsp;(E-23688910-050.01.04-2200048907). In addition, before starting the study, permission was obtained via e-mail from the authors who developed the original version of the scale to conduct a Turkish validity and reliabilit study. Informed consent was obtained from all individual participants included in the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflict of interests\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical trial number:\u003c/strong\u003e Not applicable\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eBiasio LR. Vaccine literacy is undervalued. Hum Vaccines Immunotherapeutics. 2019;15:2552\u0026ndash;3. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1080/21645515.2019.1609850\u003c/span\u003e\u003cspan address=\"10.1080/21645515.2019.1609850\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDurmuş A, Mahmut Akbolat AM. COVID-19 Aşı Okuryazarlığı \u0026Ouml;l\u0026ccedil;eği\u0026rsquo;nin T\u0026uuml;rk\u0026ccedil;e ge\u0026ccedil;erlilik ve g\u0026uuml;venirliliği. Cukurova Med J. 2021;46:732\u0026ndash;41. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.17826/cumj.870432\u003c/span\u003e\u003cspan address=\"10.17826/cumj.870432\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGusar I, Konjevoda S, Babić G, Hnatešen D, Čebohin M, Orlandini R, et al. Pre-Vaccination COVID-19 vaccine literacy in a Croatian adult population: A cross-sectional study. Int J Environ Res Public Health. 2021;18:7073.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVaccines. Jan and immunization. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.who.int/health-topics/vaccines-and-immunization\u003c/span\u003e\u003cspan address=\"https://www.who.int/health-topics/vaccines-and-immunization\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Accessed 16 2025.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eG\u0026ouml;de A, Ertaş H. Sağlık Okuryazarlığı ile Aşı Karşıtlığı Arasındaki İlişkinin İncelenmesi: \u0026Uuml;niversite \u0026Ouml;ğrencileri \u0026Uuml;zerinde Bir Araştırma. J Acad Value Stud. 2021;7:1\u0026ndash;14.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLorini C, Collini F, Galletti G, Ierardi F, Forni S, Gatteschi C, et al. Vaccine literacy and source of information about vaccination among staff of nursing homes: a cross-sectional survey conducted in Tuscany (Italy). Vaccines. 2022;10:682.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAygun E, Tortop HS. Investigation of Parents\u0026rsquo; Vaccine Hesitation Levels and Reasons of Vaccine Refusal/Ebeveynlerin Asi Tereddut Duzeylerinin ve Karsitlik Nedenlerinin Incelenmesi. J Curr Pediatr. 2020;18:300\u0026ndash;17.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBiasio LR, Giambi C, Fadda G, Lorini C, Bonaccorsi G, D\u0026rsquo;Ancona F. Validation of an Italian tool to assess vaccine literacy in adulthood vaccination: A pilot study. Annali di igiene Med Preventiva e di Comunit\u0026agrave;. 2020;32:205\u0026ndash;22.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDo BN, Nguyen P-A, Pham KM, Nguyen HC, Nguyen MH, Tran CQ, et al. Determinants of health literacy and its associations with health-related behaviors, depression among the older people with and without suspected COVID-19 symptoms: a multi-institutional study. Front Public Health. 2020;8:581746.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJohri M, Subramanian SV, Sylvestre M-P, Dudeja S, Chandra D, Kon\u0026eacute; GK, et al. Association between maternal health literacy and child vaccination in India: a cross-sectional study. J Epidemiol Community Health. 2015;69:849\u0026ndash;57.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTemel AB, Aras Z. Evaluation of validity and reliability of the Turkish version of health literacy scale. Florence Nightingale J Nurs. 2017;25:85\u0026ndash;94.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTo\u0026ccedil;i E, Burazeri G, Sorensen K, Jerliu N, Ramadani N, Roshi E et al. Health literacy and socioeconomic characteristics among older people in transitional Kosovo. 2013.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBeaton DE, Bombardier C, Guillemin F, Ferraz MB. Guidelines for the process of cross-cultural adaptation of self-report measures. Spine (Phila Pa 1976). 2000;25:3186\u0026ndash;91. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1097/00007632-200012150-00014\u003c/span\u003e\u003cspan address=\"10.1097/00007632-200012150-00014\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLawshe CH. A quantitative approach to content validity. Personal Psychol. 1975;28(4):563\u0026ndash;75.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAkin ZC, Gonul BA, Basdas O. Psychometric properties of the Turkish version of the child food rejection scale. J Eat Disord. 2025;13:43. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1186/s40337-025-01228-8\u003c/span\u003e\u003cspan address=\"10.1186/s40337-025-01228-8\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDiscovering Statistics. Using IBM SPSS Statistics (PDFDrive).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eS\u0026oslash;rensen K, Van den Broucke S, Fullam J, Doyle G, Pelikan J, Slonska Z, et al. Health literacy and public health: A systematic review and integration of definitions and models. BMC Public Health. 2012;12:80. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1186/1471-2458-12-80\u003c/span\u003e\u003cspan address=\"10.1186/1471-2458-12-80\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYurdag\u0026uuml;l H. Use of content validity indeces in the scale development studies. In: XIV. National Education Sciences Congress.(Congress Book). Denizli. 2005, 28\u0026ndash;30, September, 1. 2005.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYaşlıoğlu MM. Factor analysis and validity in social sciences: Application of exploratory and confirmatory factor analyses. Istanbul Univ J School Bus. 2017;46 Special Issue:74\u0026ndash;85.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eErbil N, Bakır A. Developing inventory of professional attitude at occupation. J Hum Sci. 2009;6:290\u0026ndash;302.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTavşancıl. Tutumların \u0026Ouml;l\u0026ccedil;\u0026uuml;lmesi ve SPSS ile Veri Analizi. 6. baskı. Nobel Akademik Yayıncılık; 2019.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYang L, Zhen S, Li L, Wang Q, Yang G, Cui T, et al. Assessing vaccine literacy and exploring its association with vaccine hesitancy: A validation of the vaccine literacy scale in China. J Affect Disord. 2023;330:275\u0026ndash;82.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZhang F, Or PP-L, Chung JW-Y. The effects of health literacy in influenza vaccination competencies among community-dwelling older adults in Hong Kong. BMC Geriatr. 2020;20:103. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1186/s12877-020-1504-5\u003c/span\u003e\u003cspan address=\"10.1186/s12877-020-1504-5\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDeniz SŞ, \u0026Ouml;zer \u0026Ouml;, Sonğur C. Effect of Health Literacy on Health Perception: An Application in Individuals at Age 65 and Older. Social Work Public Health. 2018;33:85\u0026ndash;95. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1080/19371918.2017.1409680\u003c/span\u003e\u003cspan address=\"10.1080/19371918.2017.1409680\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMalik M, Zaidi RZ, Hussain A. Health literacy as a global public health concern: a systematic review. J Pharmacol Clin Res. 2017;4:1\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAyaz-Alkaya S, D\u0026uuml;lger H. Fear of coronavirus and health literacy levels of older adults during the COVID-19 pandemic. Geriatr Nurs. 2022;43:45\u0026ndash;50.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYigitbas C, Genc F. Yaşlılarda sağlık okuryazarlığı: T\u0026uuml;rkiye Doğu Karadeniz \u0026ouml;rneğinde nicel bir araştırma. Turkish J Public Health. 2021;19.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAbacigil F, Harlak H, Okyay P, Kiraz DE, Gursoy Turan S, Saruhan G, et al. Validity and reliability of the Turkish version of the European Health Literacy Survey Questionnaire. Health Promot Int. 2019;34:658\u0026ndash;67.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKuloğlu Y, Uslu K, GELECEĞİN SAĞLIK \u0026Ccedil;ALIŞANLARINDA SAĞLIK OKURYAZARLIK D\u0026Uuml;ZEYİNİN, SAĞLIK ALGISI \u0026Uuml;ZERİNDEKİ ETKİSİ. DOUJ. 2022;23:255\u0026ndash;77. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.31671/doujournal.955317\u003c/span\u003e\u003cspan address=\"10.31671/doujournal.955317\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTuğut N, Yılmaz A, \u0026Ccedil;elik BY. Hemşirelik \u0026ouml;ğrencilerinin sağlık okuryazarlığı d\u0026uuml;zeyleri ile sağlıklı yaşam bi\u0026ccedil;imi davranışlarının belirlenmesi. Instıtute Health Sci J. 2021;6:120\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e\u0026Ouml;nc\u0026uuml; E, Vayısoğlu SK, G\u0026uuml;ven Y, Aktaş G, Ceyhan H, Karakuş E. The evaluation of hypertensive individuals regarding chronic disease management and its relation to health literacy. Anatol J Family Med. 2018;1:31\u0026ndash;2.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eŠtefkov\u0026aacute; G, Čepov\u0026aacute; E, Kolarčik P, Geckov\u0026aacute; AM. The level of health literacy of students at medical faculties. Kontakt. 2018;20:e363\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003evan der Heide I, Uiters E, S\u0026oslash;rensen K, R\u0026ouml;thlin F, Pelikan J, Rademakers J, et al. Health literacy in Europe: the development and validation of health literacy prediction models. Eur J Public Health. 2016;26:906\u0026ndash;11.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNguyen HC, Nguyen MH, Do BN, Tran CQ, Nguyen TT, Pham KM, et al. People with suspected COVID-19 symptoms were more likely depressed and had lower health-related quality of life: the potential benefit of health literacy. J Clin Med. 2020;9:965.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVan Hoa H, Giang HT, Vu PT, Van Tuyen D, Khue PM. Factors Associated with Health Literacy among the Elderly People in Vietnam. Biomed Res Int. 2020;2020:3490635. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1155/2020/3490635\u003c/span\u003e\u003cspan address=\"10.1155/2020/3490635\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWang X, Zhou X, Leesa L, Mantwill S. The Effect of Vaccine Literacy on Parental Trust and Intention to Vaccinate after a Major Vaccine Scandal. J Health Communication. 2018;23:413\u0026ndash;21. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1080/10810730.2018.1455771\u003c/span\u003e\u003cspan address=\"10.1080/10810730.2018.1455771\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAharon AA, Nehama H, Rishpon S, Baron-Epel O. Parents with high levels of communicative and critical health literacy are less likely to vaccinate their children. Patient Educ Couns. 2017;100:768\u0026ndash;75.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Table 1 and 2 ","content":"\u003cp\u003eTable 1 and 2 are available in the Supplementary Files section.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Health Literacy, Reliability, Vaccine Literacy Scale, Vaccine, Validation","lastPublishedDoi":"10.21203/rs.3.rs-8555513/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8555513/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackround:\u003c/h2\u003e \u003cp\u003eVaccine literacy plays a critical role in enabling individuals to access accurate and reliable information about vaccines, understand and evaluate this information, and make informed and rational decisions about vaccination. This study aimed to adapt the Adult Vaccine Literacy Scale (AVLS) into Turkish and examine its psychometric properties and relationship with health literacy.\u003c/p\u003e\u003ch2\u003eMethod\u003c/h2\u003e \u003cp\u003eThe adaptation process of the scale included forward\u0026ndash;backward translation, expert review, and pilot testing. Construct validity was examined using exploratory and confirmatory factor analyses, while internal consistency was assessed with Cronbach\u0026rsquo;s alpha coefficient. Test\u0026ndash;retest reliability was evaluated to determine the temporal stability of the scale.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eThe three-factor structure of the 14-item scale explained 60.82% of the total variance. Model fit indices indicated a good fit (χ\u0026sup2;/df\u0026thinsp;=\u0026thinsp;1.447, RMSEA\u0026thinsp;=\u0026thinsp;0.040, CFI\u0026thinsp;=\u0026thinsp;0.980, GFI\u0026thinsp;=\u0026thinsp;0.952). The total Cronbach\u0026rsquo;s alpha was 0.846, with sub-dimension values ranging from 0.686 to 0.881. Results demonstrated that individuals\u0026rsquo; vaccination literacy improved as their health literacy levels increased (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001; r=-0.563). Test\u0026ndash;retest analysis demonstrated a strong positive correlation between the two measurements, indicating high temporal stability of the scale (r\u0026thinsp;=\u0026thinsp;0.830, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001).\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eThe Turkish version of the AVLS is a valid and reliable tool. It can be effectively used to assess vaccine literacy among adults in future research and public health studies.\u003c/p\u003e","manuscriptTitle":"Psychometric properties of Turkish version of the adult vaccine literacy scale","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-02-17 15:27:11","doi":"10.21203/rs.3.rs-8555513/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2026-02-28T05:55:51+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-02-25T08:29:17+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"84506104333979148430883508213172595440","date":"2026-02-21T16:13:59+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-02-20T20:26:18+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-02-17T10:34:54+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"94660616227687131885861585415331064173","date":"2026-02-16T06:20:09+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"291416383264394581060931458537449459733","date":"2026-02-15T10:46:24+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"176080752633091792454031482616861253333","date":"2026-02-14T05:21:32+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-02-12T11:38:19+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-01-21T12:37:50+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-01-14T07:57:47+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-01-13T12:46:54+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Public Health","date":"2026-01-13T12:28:54+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"8a1212a4-5e93-4481-b762-2ca9cfa84ea7","owner":[],"postedDate":"February 17th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-02-17T15:27:11+00:00","versionOfRecord":[],"versionCreatedAt":"2026-02-17 15:27:11","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8555513","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8555513","identity":"rs-8555513","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}