Validity and reliability of Health Literacy for School-Aged Children (HLSAC) scale to understand the health literacy among adolescents in Bangladesh: An observational study

Validity and reliability of Health Literacy for School-Aged Children (HLSAC) scale to understand the health literacy among adolescents in Bangladesh: An observational study | 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 Validity and reliability of Health Literacy for School-Aged Children (HLSAC) scale to understand the health literacy among adolescents in Bangladesh: An observational study Popi Rani Bhowmik, K. A. T. M. Ehsanul Huq, Abdulfatai Olamilekan Babaita, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5514171/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 13 May, 2025 Read the published version in BMC Public Health → Version 1 posted 8 You are reading this latest preprint version Abstract Background Health Literacy (HL) is an effective determinant of health and health behaviors. The HL for School-Aged Children (HLSAC) scale has five components, and a 10-item was developed by Paakkari in the Finnish language to measure the HL levels of adolescents. However, its validity and reliability were not tested among adolescents in the Bengali language. This study aimed to determine the validity and reliability of HLSAC among adolescents of secondary school children in Bangladesh. Methods A cross-sectional study was conducted among secondary school children in two different schools in Bangladesh. The schools were purposively selected, one from a rural community and another from an urban area. The participants were students graded between 7 and 9 at the time of enrollment. The validity and reliability of the HLSAC scale were checked by confirmatory factor analysis, convergent validity, Cronbach’s alpha, and test-retest reliability. Results A total of 312 students (mean age 13.5 years) were enrolled. The reliability of the HLSAC scale showed that Cronbach’s alpha was 0.759. The confirmatory factor analysis model fit appears robust as the p -value was not significant (p = 0.137), χ 2 /df 1.263, RMSEA 0.029 and CFI = 0.982. The test-retest reliability of this scale was 0.557 (moderate). For the convergent validity, the Bengali version of the HLSAC scale was positively correlated with the General Self-Efficacy and Perceived Knowledge scales (all, p < 0.05). Conclusion Our study found that the HLSAC scale, Bengali version is valid and reliable for school-aged adolescents in Bangladesh. This research finding allows for a suitable HLSAC scale to measure the level of HL among adolescents in Bangladesh. Health Literacy validity reliability Health Literacy for School-Aged Children (HLSAC) scale adolescents Figures Figure 1 Figure 2 Figure 3 Background Health literacy (HL) is an individual’s cognitive and social abilities to find, understand, and use information and services to make health-related decisions and actions for themselves and their surroundings [ 1 , 2 ]. To measure HL, an individual’s health status and health outcomes can be predicted [ 3 , 4 ]. It is also considered a key factor for determining the appropriate use of health information and making decisions for promoting a healthy lifestyle [ 3 ]. It was found that people with low HL had less understanding and less self-management ability of health which was the main cause of increased hospitalization, hospital expenses and high mortality [ 5 ]. According to the International Union for Health Promotion and Education (IUHPE) and the World Health Organization (WHO), HL serves as a health determinant and is a major force in maintaining health equity [ 6 , 7 ]. Therefore, HL is considered a vital empowerment approach to achieving lifetime sound health and well-being [ 8 , 9 ]. HL is a valuable and modifiable determinant of health for the benefit of children and adolescents’ present and future health status [ 8 – 10 ]. The United Nations (UN) Convention on the Rights of the Child states that all children must have age-specific health information for a safe and healthy life [ 11 ]. The Adolescent period is an effective key time for addressing HL [ 12 ]. Therefore, adolescent children are the crucial target population for health education intervention to get the best HL outcome [ 5 , 13 , 14 ]. HL in the adolescent period can aid them in gaining and understanding health information which can bring positive health outcomes and increase quality of life in adulthood [ 15 ]. Adolescents with health literacy can access and navigate health information, comprehend health messages, think critically about health claims, and make informed decisions about their health. They are also able to acquire health knowledge and apply it in new situations, communicate about health issues, use health information to improve their health, develop healthy habits, engage in healthy activities in communities, and avoid unnecessary health risks [ 13 , 14 , 16 ]. A study conducted in Germany found that 8.4% had difficulty understanding health information and 22.7% had a low level of health knowledge among adolescents [ 17 ]. Low levels of HL increase the risk of disease incidence and mortality rates, and less-than-optimal service utilization in Bangladesh [ 18 ]. One study conducted in a rural community in Bangladesh using a limited questionnaire concluded the necessity of having a systematic HL program [ 19 ]. According to researchers from a prior study, skill-based educational intervention in the school setting with the cooperation of all professional health personnel is particularly important to create long-term sustainable, positive behavioral changes and increase awareness among school-aged adolescents [ 20 ]. It also benefits the school by fostering a safe, encouraging environment and a child's favorable academic growth. This will benefit the school adolescents as well as their parents and surrounding people to improve health-related knowledge and prevent diseases, especially lifestyle-related non-communicable diseases (NCDs) in the early stage. To determine and improve HL precisely, it is imperative to develop and use a valid and reliable HL tool [ 21 , 22 ]. However, a few brief generic instruments are now available to measure HL among children and adolescents [ 23 ]. The Rapid Estimate of Adolescent Literacy in Medicine (REALM-Teen) [ 24 ] was developed based on the Rapid Estimate of Adult Literacy in Medicine (REALM) scale and is a visually oriented tool. This scale is simple to administer and highly feasible, with a measurement time of no more than 5 minutes. However, its measurement dimension is narrow, primarily focusing on cognitive ability while neglecting the assessment of comprehension skills. The Newest Vital Sign (NVS) scale [ 25 ] primarily focuses on the subject's performance in a single dimension of health literacy, which may not fully reflect the individual's overall health literacy level. Health Literacy for School-Aged Children (HLSAC) scale is a self-administered tool developed in Finland to measure the level of HL among adolescent school-going children. It includes ten items with five core components: (1) theoretical knowledge, (2) practical knowledge, (3) individual critical thinking, (4) self-awareness, and (5) citizenship [ 26 ]. This instrument measures HL comprehensively by considering all three domains including functional, interactive and critical. It considers participants' developmental changes and dependency. For that, it is regarded as appropriate to use school-aged adolescents for quick administration, satisfactory reliability and one-factor validity. However, the 8-item Health Literacy Assessment Tool (HLAT-8) was recommended, for its convergent validity and children and adolescents below 18 years have not been tested yet [ 23 ]. There has not been any established validated and reliable scale identified for measuring HL among children and adolescents in Bangladesh. However, adequate and accurate measurement of HL is essential for appropriate attention to improve an individual’s capabilities, ultimately leading to changes in the health system [ 27 ]. Therefore, it is imperative to develop an HLSAC scale in Bengali version to conduct research on HL among children in Bangladesh. Like other developing countries, Bangladeshi adults do not have sound health. Therefore, we aimed to foster school-aged adolescents who can contribute not only to themselves and their families but also to the community as change agents. Among all the established HL scales, we selected the HLSAC scale as we believe that citizenship is the most important component for Bangladeshi adolescents. The purpose of this research was to determine the validity and reliability of a Bengali-translated HLSAC scale among adolescents in secondary school children in Bangladesh. Methods Preparation of the Bengali version of the HLSAC scale 1) Translation and back-translation First, written permission was obtained from Paakkari O, the original author of the HLSAC instrument [26]. Then, the 10-item English version was translated into Bengali by bilingual research team members including two nurse researchers and one psychologist. The Bengali translation was done with an emphasis on semantic equivalence rather than linguistic surface equivalence. The back-translation into English was done by another two bilingual researchers. After that, one native English speaker evaluated the semantic equivalence between the original version and the back-translation and modified the wording in the Bengali version as appropriate; the first revision was made. 2) Pre-test A preliminary survey of the Bengali-translated version of the HLSAC was conducted to confirm and further revise the appropriateness of the Bengali wording and the ease of completing the questionnaire. For that, 20 students from the same school (rural) of the main study participated. To check the face validity in a rural setting, we administered the questionnaire only among the rural students to understand the local dialect, wording, orders of the items and response times of the participants. Pre-testing helped us to determine whether the participants understood the items as well as they could perform the task. The question item’s wording was modified as appropriate. Main survey 1) Study design This was a school-based cross-sectional study to test the validity and reliability of the HLSAC scale, Bengali version. At first, the Principal Investigator communicated with the headmasters of both rural and urban schools in August 2023 to conduct the study. After getting permission, the research team visited the schools in September 2023 and explained the purpose and procedures of this research to the headmasters including school teachers and obtained written permissions at the end of October 2023. The test was performed in January, 2024, and after 14 days, a re-test was conducted among the same students in January and February, 2024 for both school students. 2) Study site This study was conducted in two secondary schools, one from a rural community and another from an urban area in Bangladesh to obtain the diversification of the samples. The rural school is located in Tongibari Upazila, Munshigonj district and the urban school is located in Gazipur city in Bangladesh. These two schools are run by privately funded organizations/individuals under the Dhaka Education Board within the Bangladesh academic system, these secondary-level schools comprise grades 6 to 10 (ages 11 to 17). There are about 650 rural and 400 urban secondary school students in these two schools, in total of 1050. These two schools were selected purposely for convenience according to the following criteria: 1) schools affiliated with the Bangladesh Education Board, 2) give permission to conduct this study, 3) located in the rural community and urban area, and 4) provide education facilities for both genders (Fig. 1). 3) Study participants Inclusion criteria Students who studied in class grades 7 to 9 at the time of enrollment. Students of both genders. Students whose first language was Bengali. Students who were willing to participate. Students whose parents or legal guardians agreed to give consent and were willing to participate in the study. Exclusion criteria Students with cognitive and mental disorders (teachers excluded those students who were incapable of filling out the questionnaire). Students in grades 6 and 10 were excluded after being included in this study to maintain consistency with the inclusion of participants from the same grades in the previous study [26]. 4) Sample size calculation Based on the items in the questionnaires and suggestions from the previous research ideally, at least 200 samples are needed to estimate validity and reliability [28]. Moreover, for factor analysis, it is estimated that at least five cases per variable are needed and a minimum of 300 cases are recommended [29]. Therefore, we decided our sample size was 300. With a 10% dropout, the total estimated sample size was 330 from two different schools. However, due to the community-based study, we approached all the students between Grades 7 and 9 from the two schools for equal participation. 5) Study procedures The researchers received approval from school authorities for data collection from the designated schools. The school teachers set a convenient time for data collection from the school children through survey administration. Before enrolling in the study, assent was obtained from the students and written informed consent from their parents or legal guardians. Data were collected through a survey questionnaire for a two-hour session. The questionnaire was distributed at a time among the 7th to 9th-grade children in the school classroom. Test-retest The participants were reassessed using the same HLSAC scale two weeks apart, and out of 312, 304 participated in this survey (Fig. 1). The correlation coefficient of the total scores from the two measurements was calculated. A retest reliability coefficient of ≥ 0.70 indicates good temporal stability, and between 0.4 and 0.7 indicates moderate temporal stability. Measurements 1.The Health Literacy Scale for School-Aged Children (HLSAC) scale in Bengali version (Appendix 1) (10 items), The HLSAC scale had a four-point Likert scale ranging from 1 to 4 (1 = not at all true, 2 = not quite true, 3 = somewhat true, and 4 = absolutely true). The sum scores of 10 items were calculated from 10 to 40, with a higher score indicating more HL [22]. 2. General Self-Efficacy scale (GSE), Bengali version (Appendix 2) (10 items), The General Self-Efficacy scale (GSE) had also 10 items, a four-point Likert scale ranging from 1 to 4 (1 = not at all true, 2 = hardly true, 3 = moderately true, and 4 = exactly true). The total score was calculated as the sum of 10 items ranging between 10 and 40 with a higher score indicating more self-efficacy [30]. 3. Perceived knowledge to take care of one’s health (Appendix 3) (2 items) [31], The Perceived knowledge questionnaire contained physical and mental health components. Each component had a five-point Likert scale ranging from 1 to 5 (1 = have no knowledge, 2 = have very little knowledge, 3 = have little knowledge, 4 = have some knowledge, and 5 = have enough knowledge). The scale was translated by two professional translators from English to Bengali, and then another two translators back-translated the Bengali version to English. A modification was made in wording to make it more comprehensive for conceptual likeness between the English and Bengali versions of Perceived knowledge scales. We also collected participants' socio-demographic data (age, sex, education in grade level, family household income, father and mother educational level). Convergent validity Convergent validity ensures that tests are measured consistently with other validated scales [32]. To examine the convergent validity of the Bengali version of the HLSAC scale, the GSE and Perceived knowledge to take care of one’s health were used. We calculated the correlation coefficient such as Spearman to determine the strength of correlation among the scales HLSAC, GSE and Perceived knowledge scales. A high correlation indicates that the test has strong convergent validity. Data analysis To examine the reliability and validity of the questionnaire, the IBM SPSS Statistics version 25.0 and SPSS Amos version 28.0 were used, respectively, in this study for descriptive and factor analysis. Descriptive statistics including mean, standard deviation (SD), missing with skewness and kurtosis for each item were conducted. To understand the distribution of data, we performed a normality test. Skewness of data was considered when the value between − 1 and − 0.5 or between + 0.5 and + 1 was considered moderately skewed and less than − 1 or greater than + 1 was considered highly skewed. Kurtosis was considered as less than − 2 and more than + 2. To confirm the validity (structure of factors) of the HLSAC scale, a confirmatory factor analysis (CFA) was conducted. In CFA, a high factor loading indicates the factor strongly influences the variables. The value of factors loading below 0.32 is considered poor, ≥ 0.45 is fair, ≥ 0.55 is good, ≥ 0.63 is very good, and above 0.71 is considered excellent [33]. To observe the model fitness to assess the relationship between observed variables and the theoretical model (here, the HLSAC), the cutoff value of chi-square/degree of freedom (χ 2 /df) was considered ≤ 2 as a good fit, ≤ 3 as acceptable. We considered the root mean square error of approximation (RMSEA) (≤ 0.05 as a good fit, ≤ 0.10 as acceptable) and for standardized root means square residual (SRMS) (≤ 0.05 as good fit, ≤ 0.10 as acceptable). For the comparative fit index (CFI), goodness of fit index (GFI), normed fit index (NFI), relative fit index (RFI), incremental fit index (IFI) and the Tucker- Lewis index (TLI), we considered the value of ≥ 0.95 as a good fit and ≥ 0.90 as acceptable [34]. Likewise, convergent validity was tested to see the correlation among the HLSAC, GSE scale, and Perceived knowledge, Bengali version to take care of one’s health by Spearman’s correlations test. For the correlation analysis, the significance level of the p -value was set to 1%. To estimate the internal consistency of the components of different scales, reliability (test-retest) was tested for adequate Cronbach’s coefficient alpha. A reliability coefficient of ≥ 0.7 score was considered good for this study [35]. Results Sociodemographic characteristics of participants Out of a total of 850 school students, 312 participated (36.7%) and completed questionnaires from two different schools in grades 7 to 9; 96 from an urban school and 216 from a rural school. A description of the sample characteristics is in Table 1 . Table 1 Sociodemographic characteristics of the study participants (n = 312) Variables N (%) Age (years) (mean ± SD) 13.51 ± 1.25 11 9 2.9 12 63 20.2 13 85 27.2 14 95 30.4 15 42 13.5 16 12 3.8 17 6 1.9 Sex Male 53 17.0 Female 259 83.0 Religion Muslim 282 90.4 Hindu 30 9.6 Education (grade) 7 112 35.9 8 115 36.9 9 85 27.2 Mother’s education Primary not completed 37 11.9 Primary completed 1) 104 33.3 Secondary level completed 2) 95 30.4 Higher secondary completed 3) 54 17.3 Graduate level completed or more 22 7.1 Father’s education Primary not completed 63 20.2 Primary completed 1) 110 35.3 Secondary level completed 2) 59 18.9 Higher secondary completed 3) 43 13.8 Graduate level completed or more 37 11.9 Number of family members 3 38 12.2 4 121 38.8 5 99 31.7 > 5 54 17.3 Family monthly income (BDT) Do not know 197 63.1 20000 50 16.0 Main earning occupation Labor 29 9.3 Unemployed 45 14.4 Farmer 82 26.3 Business 97 31.1 Service holder 59 18.9 History of receiving health education Yes 135 43.3 No 177 56.7 1) 5 years formal education, 2) 10 years formal education, 3) 12 years formal education Distribution We analyzed the 10-item of the HLSAC scale. We present the total, mean, SD, statistics and standard error (SE) of skewness and kurtosis of each item. We examined the assumption of normality and found data were not normally distributed and skewness and kurtosis were significant. The mean score of 10 items ranged from 2.61 to 3.44 and the minimum score was 1 and the maximum was 4 (Table 2 ). Table 2 Description of item analysis of the HLSAC scale Item N Mean SD Skewness SE Kurtosis SE 1. I have good information about health 312 2.82 0.54 -0.98 0.14 2.07 0.28 2. When necessary, I am able to give ideas on how to improve health in my immediate surroundings (e.g., a nearby place or area, family, friends) 312 2.75 0.91 -0.26 0.14 -0.74 0.28 3. I can compare health-related information from different sources 312 2.61 0.92 -0.14 0.14 -0.79 0.28 4. I can follow the instructions given to me by healthcare personnel (e.g., nurse, doctor) 312 3.44 0.85 -1.53 0.14 1.57 0.28 5. I can easily give examples of things that promote health 312 3.03 0.85 -0.70 0.14 0.02 0.28 6. I can judge how my own actions affect the surrounding natural environment 312 3.22 0.74 -0.56 0.14 -0.33 0.28 7. When necessary, I find health-related information that is easy for me to understand 312 2.87 0.98 -0.43 0.14 -0.85 0.28 8. I can judge how my behaviour affects my health 312 2.89 0.85 -0.45 0.14 -0.38 0.28 9. I can usually figure out if some health-related information is right or wrong 312 2.77 0.92 -0.36 0.14 -0.68 0.28 10. I can give reasons for the choices I make regarding my health 312 3.25 1.00 -1.08 0.14 -0.09 0.28 SD: Standard Deviation, SE: Standard Error Factor validity (construct validity) Confirmatory factor analysis (CFA) As the HLSAC questionnaire has a well-established theoretical framework with predefined constructs and validated in previous research, for that, we conducted CFA to understand whether the predefined structure aligns with the actual data. The original 10 items HLSAC and 1-dimensional solution of the HLSAC scale revealed the model structure for estimating the statistical relationships between HLSAC and individual items. Table 3 shows the results of the indices. Two models were developed: one for 10-items (Model 1) and another 9-items which excluded item 6 (Model 2). We found robust model fit as the p -values for Model 1 and Model 2 were not significant ( p = 0.137 and 0.151, respectively). Since the p -values were > 0.05, the difference between the observed data (Figs. 2 and 3) and the theoretical model is not significant, suggesting a good fit. Moreover, for Models 1 and 2, the value (1.263 and 1.279) of χ 2 /df showed good fit (≤ 2), RMSEA 0.029 and 0.030 good fit (≤ 0.05), SRMR = 0.028 and 0.028 (≤ 0.05 as good fit), CFI = 0.982 and 0.985 (≥ 0.95 as good fit), GFI = 0.973 and 0.976 (≥ 0.95 as good fit), NFI = 0.920 and 0.936 (≥ 0.90 as acceptable), RFI = 0.897 and 0.914 (≥ 0.90 as acceptable), IFI = 0.982 and 0.985 (≥ 0.95 as good fit) and TLI = 0.977 and 0.980 (≥ 0.95 as good fit). However, in Model 1, the factor loading HL question (HLQ) 6 was 0.1 (< 0.3 is not ideal) (Fig. 2 ). Therefore, after removing HLQ6, a second CFA was conducted, resulting in Model 2 (Fig. 3). We found p -value was still not significant ( p = 0.151) and higher than Model 1. Table 3 Confirmatory factor analysis (CFA) of the HLSAC scale. Model fit indices Fit Measure Model 1 (10 items) Model 2 (9 items; exclude item 6) χ 2 44.203 34.541 P value 0.137 0.151 χ 2 /df 1.263 1.279 RMSEA 0.029 0.030 SRMR 0.028 0.028 CFI 0.982 0.985 GFI 0.973 0.976 NFI 0.920 0.936 RFI 0.897 0.914 IFI 0.982 0.985 TLI 0.977 0.980 χ 2 : chi-square, df: degrees of freedom, RMSEA: Root mean square error of approximation, SRMR: Standardized root mean square residual, CFI: Comparative fit index, GFI: Goodness of fit index, NFI: Normed fit index, RFI: Relative fit index, IFI: Incremental fit index, TLI: Tucker-Lewis index We performed Spearman’s correlation coefficient to measure the associations among the scales and found significant ( p < 0.001) positive correlations between HLSAC-10, HLSAC-9 (excluded HL scale item 6), GSE and Perceived knowledge (Table 4 ). Table 4 Convergent validity of the HLSAC scale Construct Mean SD Cronbach’s alpha Spearman’s correlation coefficient HLSAC-10 HLSAC-9 GSE Perceived knowledge HLSAC-10 2.96 0.486 0.759 1 0.833* 0.704* 0.618* HLSAC-9 2.89 0.593 0.776 0.833* 1 0.574* 0.540* GSE 3.04 0.481 0.728 0.704* 0.574* 1 0.570* Perceived knowledge 3.99 0.777 0.604 0.618* 0.540* 0.570* 1 HLSAC-10: Health Literacy for School-Aged Children 10-item, HLSAC-9: Health Literacy for School-Aged Children 9-item, GSE: General Self Efficacy, SD: Standard deviation *Significant at < 0.001 level Reliability The reliability of the HLSAC-10 and HLSAC-9 scales showed that Cronbach’s alpha were 0.759 and 0.776, respectively. The inter-item correlation values range between 0.117 and 0.371 for both HLSAC-10 and HLSAC-9 and the item means were 2.96 and 2.89, respectively. Test-retest A total of 304 participants completed the retest reliability assessment. The test-retest reliability of this scale was 0.557 and 0.576 for HLSAC 10 and 9 items, respectively. Discussion We demonstrated the validity and reliability of a Bengali version of the HLSAC scale among adolescents in secondary school children in Bangladesh. We observed the 10-item HLSAC scale Bengali version was significantly valid and reliable for this population group. Based on the original scale with 10 items and 1-dimension, confirmatory factor analysis was used to validate the Bengali version of the HLSAC scale. The results of Model 1 indicated that all fit indices met the requirements, suggesting a good fit of the scale. However, the factor loading of HLQ6 was less than 0.3, which is not ideal. Therefore, HLQ6 was deleted, and a second confirmatory factor analysis was conducted. The results showed that the 9-item, 1-dimension model had a better fit than Model 1. A similar finding was observed that HLQ6 had the poorest individual fit in adults [ 36 ]. One study was conducted among Norwegian school-aged adolescents and found that the original 10-item 1-dimensional solution had a poor fit. They observed that the HLSAC scale consisting of 1, 3, 6, 7, 9 and 10 items was statistically valid and reliable and suggested this shorter version HLSAC-6 scale for measuring HL for those adolescents [ 31 ]. Another large study was conducted in seven European countries with an HLSAC-5 (1, 3, 6, 7 and 10) instrument extracted from the original 10-item HLSAC scale and found that this brief scale was valid and reliable among the adolescents of those countries (Finland, Estonia, Poland, Czechia, Belgium, Slovakia and Germany) [ 37 ]. However, the HLSAC scale with the original 10-item was found suitable for German children and adolescents in the German version [ 38 ]. Therefore, modifications and use of the instrument indicate the need for further investigation of the HLSAC scale in diverse settings and different age groups. Convergent validity mainly reflects the correlation between the measurement tool and other related measurement tools. In this study, GSE and Perceived Knowledge were used as convergent indicators. The results showed that the Bengali version of the HLSAC-10 and HLSAC-9 scales were positively correlated with both GSE and Perceived Knowledge ( p < 0.05), indicating that the Bengali version of the HLSAC scale has good convergent validity. Internal consistency reflects the internal correlation of the measurement tool. The results of this study showed that the Cronbach's alpha of the Bengali version of the HLSAC-10 scale was 0.759 and HLSAC-9 was 0.776, indicating that the Bengali version of the HLSAC scale has good internal consistency. Test-retest reliability reflects the stability and consistency of the measurement tool over time. In this study, the test-retest reliability for HLSAC 10 and 9 were 0.557 and 0.576, respectively, which are at a moderate level. Strengths As this is the first study to establish a valid and reliable HLSAC scale in Bengali version among school-aged adolescents in Bangladesh, it can be widely used to evaluate the HL in this population. The findings of this study will provide valuable insights for further development of various HL instruments. Limitations This study has certain limitations. Although the scale is developed for adolescents, we included students from 7 to 9 grades; therefore, this did not cover other adolescents in the excluded grades. In this study, we included all the school-going students, while this is true of only 52.4% of the general population in the age group of 15–19 years in Bangladesh [ 39 ]. Hence, we recommend future studies with large sample sizes and including other upper and lower grades school students which would allow greater consistency and minimize biases. Our test-retest reliability has shown insufficient consistency among adolescents. Further longitudinal studies with different settings are needed for the testing and modification to establish a suitable HL scale in the Bengali language. Moreover, we did not perform measurement invariance across different groups based on gender, age, cultural background, etc., the scale may be susceptible to measurement errors. Therefore, additional investigations using multiple samples can confirm the measurement invariance of the HLSAC scale. Conclusions To assess the HL among adolescents, a valid and reliable HLSAC scale is essential for school-aged children in Bangladesh with Bengali language for better understanding. To the best of our knowledge, this is the first study that used the HLSAC scale in Bengali version for measuring HL among school-aged adolescents in Bangladesh. We found the 10-item and 1-dimension Bengali version of the HLSAC scale was a good fit, however, the 9-item (without HLQ6), the 1-dimension model was found to have a better fit than the 10-item for these school-aged adolescents. The scale demonstrated moderate test-retest reliability in terms of overall measure. Since there is currently no valid and reliable Bengali version of the HLSAC scale available to measure HL, this research will significantly impact the assessment of HL among adolescents. Further investigation with a larger sample size is needed to identify the predictors of the Bengali version of the HLSAC scale, and whether the 10-item or 9-item is suitable for this age group. More age-specific HL scales will guarantee a high probability to test and measure HL in different age groups including adults in the Bengali version for the population of Bangladesh. Abbreviations CFA confirmatory factor analysis CFI Comparative fit index Df degrees of freedom GFI Goodness of fit index GSE General Self-Efficacy scale HL Health Literacy HLAT Health Literacy Assessment Tool HLQ Health Literacy Questionnaire HLSAC Health Literacy for School-Aged Children IFI Incremental fit index NFI Normed fit index REALM Rapid Estimate of Adult Literacy in Medicine RFI Relative fit index RMSEA Root mean square error of approximation SRMR Standardized root mean square residual TLI Tucker-Lewis index Declarations Acknowledgments We would like to express our sincere gratitude to the headmasters and other teachers for their generous permission to conduct this study at their schools and the children who participated and gave their precious time for this study. We also thank all the research staff for their contribution to collecting data and preparing for analysis. Author contributions PRB conceptualization, data collection, prepared data for analysis and drafted the manuscript. KATMEH data analysis, drafted the manuscript and project administration. GH data analysis. AOB conceptualization and data analysis. MM conceptualization, and project administration, drafted the manuscript, and critically reviewed the manuscript. All authors provided input to improve the manuscript, read and approved the final version for submission. Funding This work was supported by JSPS KAKENHI (Grant Number JP 21H03250). The funder had no control over the interpretation, writing, or publication of this work. Data availability The data presented in this study are available upon request from the corresponding author. The data are not publicly available due to privacy restrictions. Ethics approval and consent to participate This study was approved by the Institutional Review Board/Ethics Review Committee (IRB/ERC) of North South University, Bangladesh (reference number: 2023/OR-NSU/IRB/0707). This study is being conducted according to the Declaration of Helsinki. Written informed consent was obtained from all the patients. Confidentiality of individual information was maintained at all steps of the research. Consent for publication Not applicable. Competing interests The authors declare no competing interests. References World Health Organization (WHO) 2021. WHO health promotion glossary of terms 2021. Geneva. Available from: https://www.who.int/publications/i/item/9789240038349 (accessed on January 14, 2024). Center for Disease Control and Prevention 2023. What is health literacy? Atlanta, Georgia. Available from: https://www.cdc.gov/healthliteracy/learn/index.html (accessed on June 24, 2024). 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IUHPE Position statement on health literacy: a practical vision for a health literate world. Paris: IUHPE; 2018. Available from: https://www.researchgate.net/publication/329467998_IUHPE_Position_Statement_on_Health_Literacy_a_practical_vision_for_a_health_literate_world (accessed on January 22, 2024). World Health Organization (WHO) 2024. Shanghai declaration on promoting health in the 2030 agenda for sustainable development. 9th Global Conference on Health Pormotion, Shanghai, 21-24 November 2016. Available from: https://www.who.int/publications/i/item/WHO-NMH-PND-17.5 (accessed on June 24, 2024). Fleary SA, Joseph P, Pappagianopoulos JE. Adolescent health literacy and health behaviors: A systematic review. J Adolesc. 2018;62:116-127. doi: 10.1016/j.adolescence.2017.11.010. World Health Organization (WHO), Regional Office for Europe. Health literacy in the context of health, well-being and learning outcomes the case of children and adolescents in schools: The case of children and adolescents in schools, License: CC BY-NC-SA 30 IGO. Geneva: WHO; 2020. Simonsen N, Wackström N, Roos E, Suominen S, Välimaa R, Tynjälä J, Paakkari L. Does health literacy explain regional health disparities among adolescents in Finland? Health Promot Int. 2021 Dec 23;36(6):1727-1738. doi: 10.1093/heapro/daaa122. United Nations Children’s Fund UK. The United Nations convention on the rights of the child. 1989. https:// www. ohchr. org/ en/profe ssion alint erest/ pages/ crc. aspx (accessed 5 January 2024). Sansom-Daly UM, Lin M, Robertson EG, Wakefield CE, McGill BC, Girgis A, Cohn RJ. Health literacy in adolescents and young adults: an updated review. J Adolesc Young Adult Oncol. 2016 Jun;5(2):106-18. doi: 10.1089/jayao.2015.0059. Okan O, Pakkari L, Dadaczynski K. Health literacy in schools: state of the art. Finland and Germany, 2020. Available from: https://www.researchgate.net/publication/344202587_Health_literacy_in_schools_State_of_the_art (accessed January 30, 2024). Chu-Ko F, Chong ML, Chung CJ, Chang CC, Liu HY, Huang LC. Exploring the factors related to adolescent health literacy, health-promoting lifestyle profile, and health status. BMC Public Health. 2021 Dec 1;21(1):2196. doi: 10.1186/s12889-021-12239-w. Manganello JA. Health literacy and adolescents: a framework and agenda for future research. Health Educ Res . 2008; 23(5):840-7. doi: 10.1093/her/cym069. Paakkari L, Inchley J, Schulz A, Weber MW, Okan O. Addressing health literacy in schools in the European region. Public Health Panor. 2019; 5(2-3): 186–90. https://apps.who.int/iris/handle/10665/327055. Fleary SA, Joseph P, Pappagianopoulos JE. Adolescent health literacy and health behaviors: a systematic review. J Adolesc. 2018; 62: 116–27. https://doi.org/10.1016/j.adolescence.2017.11.010. Islam MK, Nasrin N, Jaber A, Hossain MT. Association between health literacy and BMI: a cross-sectional study of suburban adult population in Bangladesh . Journal of Population and Social Studies (JPSS). 2022; 30: 288-308. http://doi.org/10.25133/JPSSv302022.018. Das S, Mia MN, Hanifi SMA, Hoque S, Bhuiya A. Health literacy in a community with low levels of education: findings from Chakaria, a rural area of Bangladesh. BMC Public Health. 2017; 17(1). https://doi.org/10.1186/s12889-017-4097-y. Furukawa Y, Fumihiko Y, Maruf RI, Nishikitani M, Kikuchi K, Ahmed A, Nakashima N. School-based educational intervention to improve adolescents’s oral health-related behaviors in rural Bangladesh. South East Asia J. Public Heal. 2018; 7(2): 27–33. Available from: doi:10.3329/seajph.v7i2.38853. Bröder J, Okan O, Bauer U, Bruland D, Schlupp S, Bollweg TM, Saboga-Nunes L, Bond E, Sørensen K, Bitzer EM, Jordan S, Domanska O, Firnges C, Carvalho GS, Bittlingmayer UH, Levin-Zamir D, Pelikan J, Sahrai D, Lenz A, Wahl P, Thomas M, Kessl F, Pinheiro P. Health literacy in childhood and youth: a systematic review of definitions and models. BMC Public Health. 2017;17(1):361. doi: 10.1186/s12889-017-4267-y. Erratum in: BMC Public Health. 2017;17(1):419. doi: 10.1186/s12889-017-4365-x. Sørensen K, Van den Broucke S, Fullam J, Doyle G, Pelikan J, Slonska Z, Brand H; (HLS-EU) Consortium Health Literacy Project European. Health literacy and public health: a systematic review and integration of definitions and models. BMC Public Health. 2012;12:80. doi: 10.1186/1471-2458-12-80. Guo S, Armstrong R, Waters E, Sathish T, Alif SM, Browne GR, Yu X. Quality of health literacy instruments used in children and adolescents: a systematic review. BMJ Open. 2018;8(6):e020080. doi: 10.1136/bmjopen-2017-020080. Davis TC, Wolf MS, Arnold CL, Byrd RS, Long SW, Springer T, Kennen E, Bocchini JA. Development and validation of the Rapid Estimate of Adolescent Literacy in Medicine (REALM-Teen): a tool to screen adolescents for below-grade reading in health care settings. Pediatrics. 2006;118(6):e1707-e1714. doi:10.1542/peds.2006-1139 Weiss BD, Mays MZ, Martz W, Castro KM, DeWalt DA, Pignone MP, Mockbee J, Hale FA. Quick assessment of literacy in primary care: the newest vital sign. Ann Fam Med. 2005 Nov-Dec;3(6):514-22. doi: 10.1370/afm.405. Erratum in: Ann Fam Med. 2006 Jan-Feb;4(1):83. Paakkari O, Torppa M, Kannas L, Paakkari L. Subjective health literacy: development of a brief instrument for school-aged children. Scand J Public Health. 2016;44(8):751-757. doi: 10.1177/1403494816669639. Institute of Medicine (US) Roundtable on Health Literacy. Measures of health literacy: workshop summary. Washington (DC): National Academies Press (US); 2009. 2, An overview of measures of health literacy. Available from: https://www.ncbi.nlm.nih.gov/books/NBK45375/ Frost MH, Reeve BB, Liepa AM, Stauffer JW, Hays RD; Mayo/FDA. Patient-reported outcomes consensus meeting group; what is sufficient evidence for the reliability and validity of patient-reported outcome measures? Value Health. 2007;10 Suppl 2:S94-S105. doi: 10.1111/j.1524-4733.2007.00272.x. Tabachnick BG, Fidell LS. Using Multivariate Statistics (3rd edn). New York: Harper Collins, 1996. Luszczynska A, Scholz U, Schwarzer R. The general self-efficacy scale: multicultural validation studies. J Psychol. 2005;139(5):439-57. doi: 10.3200/JRLP.139.5.439-457. Bjørnsen HN, Moksnes UK, Eilertsen MB, Espnes GA, Haugan G. Validation of the brief instrument "Health Literacy for School-Aged Children" (HLSAC) among Norwegian adolescents. Sci Rep. 2022 Dec 21;12(1):22057. doi: 10.1038/s41598-022-26388-4. Chin CL, Yao G. 2014. Convergent Validity. In: Michalos, A.C. (eds) Encyclopedia of quality of life and well-being research. Springer, Dordrecht. https://doi.org/10.1007/978-94-007-0753-5_573 Sharma S. Applied Multivariate Techniques. John Wiley & Sons, Inc., ISBN: 978-0-471-31064-8, 1995. https://www.wiley.com/en-br/Applied+Multivariate+Techniques+-p-9780471310648 (accessed on August 24, 2024). Jöreskog KG, Olsson UH, Wallentin FY. Multivariate Analysis with LISREL. Springer Nature, published in 2016; pages 283-339. https://link.springer.com/book/10.1007/978-3-319-33153-9 (accessed on September 25, 2024). Hair JF, Black WC, Babin BJ, Anderson RE. Multivariate data analysis, Seventh edition; Pearson Prentice Hall, 2010. Available from: https://www.drnishikantjha.com/papersCollection/Multivariate%20Data%20Analys`is.pdf (accessed on October 24, 2024). Rasmussen SE, Aaby A, Søjbjerg A, Mygind A, Maindal HT, Paakkari O, Christensen KS. The brief health literacy scale for adults: adaptation and validation of the health literacy for school-aged children questionnaire. Int J Environ Res Public Health. 2023 Nov 16;20(22):7071. doi: 10.3390/ijerph20227071. Paakkari O, Kulmala M, Lyyra N, Torppa M, Mazur J, Boberova Z, Paakkari L. The development and cross-national validation of the short health literacy for school-aged children (HLSAC-5) instrument. Sci Rep. 2023 Oct 31;13(1):18769. doi: 10.1038/s41598-023-45606-1. Saskia M. Fischer, Kevin Dadaczynski, Gorden Sudeck, Katharina Rathmann, Olli Paakkari, Leena Paakkari, Ludwig Bilz, and the HBSC Study Group Germany. Measuring Health Literacy in Childhood and Adolescence with the Scale Health Literacy in School-Aged Children – German Version: The Psychometric Properties of the German-Language Version of the WHO Health Survey Scale HLSAC. Diagnostica, 2022;68, 4, 184–196. https://doi.org/10.1026/0012-1924/a000296. National Institute of Population Research and Training (NIPORT) and ICF. 2024. Bangladesh Demographic and Health Survey 2022: Final Report. Dhaka, Bangladesh, and Rockville, Maryland, USA: NIPORT and ICF. https://dhsprogram.com/pubs/pdf/FR386/FR386.pdfPer. Appendices Appendix files 1-3 are not available with this version. Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-5514171","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":433981424,"identity":"0b7c285f-81cc-49f5-82cb-79c023e4683a","order_by":0,"name":"Popi Rani Bhowmik","email":"","orcid":"","institution":"Hiroshima University","correspondingAuthor":false,"prefix":"","firstName":"Popi","middleName":"Rani","lastName":"Bhowmik","suffix":""},{"id":433981426,"identity":"812e545a-b76f-4b79-9bac-6fef8022eaca","order_by":1,"name":"K. A. T. M. Ehsanul Huq","email":"","orcid":"","institution":"Hiroshima University","correspondingAuthor":false,"prefix":"","firstName":"K.","middleName":"A. T. M. Ehsanul","lastName":"Huq","suffix":""},{"id":433981427,"identity":"6dcce4b8-eb68-46dd-999e-67bf2a979979","order_by":2,"name":"Abdulfatai Olamilekan Babaita","email":"","orcid":"","institution":"Hiroshima University","correspondingAuthor":false,"prefix":"","firstName":"Abdulfatai","middleName":"Olamilekan","lastName":"Babaita","suffix":""},{"id":433981428,"identity":"981fadd8-310a-4d4d-af80-9fe7a9552758","order_by":3,"name":"Gao Huiying","email":"","orcid":"","institution":"Hiroshima University","correspondingAuthor":false,"prefix":"","firstName":"Gao","middleName":"","lastName":"Huiying","suffix":""},{"id":433981429,"identity":"336c2299-bb75-45fe-bfa0-d20b3cf61b51","order_by":4,"name":"Michiko Moriyama","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA/UlEQVRIiWNgGAWjYJCCAwwGDAn8EowNIDYPXBjMx6dFcgYpWkAgweAGVDtBoNve+/DQjQK7POPbzW0fPvy5I6PbfoBNgqHGjoF5NnZrzM4cNzicY5BcbHbnYPPMmW3PeMzOJAC1HEtmYJyD3UqzG2kMQC0HErfdSGxm5m04zGN2IP+bBAPbAQbGGQn4tWyeAdTC8weo5fwDoC3/iNCyQQKkhQ2o5QbQYYxteLScOQbSkpw4A+gwxpltIC0PmC0S+5J5cPrleBvz55w/don9M9IfM3z4c9je7HwC440P3+zkDHGEGA4AdBKP4QxSdICBvATJWkbBKBgFo2B4AgA0bWXF9W6pegAAAABJRU5ErkJggg==","orcid":"","institution":"Hiroshima University","correspondingAuthor":true,"prefix":"","firstName":"Michiko","middleName":"","lastName":"Moriyama","suffix":""}],"badges":[],"createdAt":"2024-11-24 13:23:18","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-5514171/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5514171/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12889-025-23005-7","type":"published","date":"2025-05-13T15:57:29+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":79549529,"identity":"2b867961-a0ac-4c13-9b3a-1d2bd189a02e","added_by":"auto","created_at":"2025-03-31 06:26:47","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":91392,"visible":true,"origin":"","legend":"\u003cp\u003eStudy flowchart\u003c/p\u003e","description":"","filename":"1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-5514171/v1/4339075be372d70c6c0111d1.jpg"},{"id":79549532,"identity":"1bc1a14e-5966-4cd8-9938-4e3ddf74a14a","added_by":"auto","created_at":"2025-03-31 06:26:47","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":191646,"visible":true,"origin":"","legend":"\u003cp\u003eConfirmatory factor analysis of HLSAC scale among adolescents (Model 1)\u003c/p\u003e\n\u003cp\u003eNote: c\u003csup\u003e2\u003c/sup\u003e=44.203, \u003cem\u003eP\u003c/em\u003e=0.137, df=35, c\u003csup\u003e2\u003c/sup\u003e/df=1.263, RMSEA=0.029, RMR=0.028, GFI=0.973, NFI=0.920, RFI=0.897, IFI=0.982, TLI=0.977, CFI=0.982.\u003c/p\u003e","description":"","filename":"2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-5514171/v1/d6c3f68ff7551a7a3af633fa.jpg"},{"id":79549536,"identity":"6d62bd65-5a72-496e-bd88-ef78189d573d","added_by":"auto","created_at":"2025-03-31 06:26:47","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":63290,"visible":true,"origin":"","legend":"\u003cp\u003eConfirmatory factor analysis of HLSAC scale among adolescents (Model 2)\u003c/p\u003e\n\u003cp\u003eNote: c\u003csup\u003e2\u003c/sup\u003e=34.541, \u003cem\u003eP\u003c/em\u003e=0.151, df=27, c\u003csup\u003e2\u003c/sup\u003e/df=1.279, RMSEA=0.030, RMR=0.028, GFI=0.976, NFI=0.936, RFI=0.914, IFI=0.985, TLI=0.980, CFI=0.985.\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-5514171/v1/57d376d7f1c6b8735abf6672.png"},{"id":83067807,"identity":"dc58c56d-d976-44f3-aabe-17ab882789eb","added_by":"auto","created_at":"2025-05-19 16:06:31","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1349597,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5514171/v1/a2623e2f-844c-42c3-9e39-d6e0ae2f1e22.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Validity and reliability of Health Literacy for School-Aged Children (HLSAC) scale to understand the health literacy among adolescents in Bangladesh: An observational study","fulltext":[{"header":"Background","content":"\u003cp\u003eHealth literacy (HL) is an individual\u0026rsquo;s cognitive and social abilities to find, understand, and use information and services to make health-related decisions and actions for themselves and their surroundings [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. To measure HL, an individual\u0026rsquo;s health status and health outcomes can be predicted [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. It is also considered a key factor for determining the appropriate use of health information and making decisions for promoting a healthy lifestyle [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. It was found that people with low HL had less understanding and less self-management ability of health which was the main cause of increased hospitalization, hospital expenses and high mortality [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. According to the International Union for Health Promotion and Education (IUHPE) and the World Health Organization (WHO), HL serves as a health determinant and is a major force in maintaining health equity [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Therefore, HL is considered a vital empowerment approach to achieving lifetime sound health and well-being [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eHL is a valuable and modifiable determinant of health for the benefit of children and adolescents\u0026rsquo; present and future health status [\u003cspan additionalcitationids=\"CR9\" citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. The United Nations (UN) Convention on the Rights of the Child states that all children must have age-specific health information for a safe and healthy life [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. The Adolescent period is an effective key time for addressing HL [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Therefore, adolescent children are the crucial target population for health education intervention to get the best HL outcome [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. HL in the adolescent period can aid them in gaining and understanding health information which can bring positive health outcomes and increase quality of life in adulthood [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Adolescents with health literacy can access and navigate health information, comprehend health messages, think critically about health claims, and make informed decisions about their health. They are also able to acquire health knowledge and apply it in new situations, communicate about health issues, use health information to improve their health, develop healthy habits, engage in healthy activities in communities, and avoid unnecessary health risks [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eA study conducted in Germany found that 8.4% had difficulty understanding health information and 22.7% had a low level of health knowledge among adolescents [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Low levels of HL increase the risk of disease incidence and mortality rates, and less-than-optimal service utilization in Bangladesh [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. One study conducted in a rural community in Bangladesh using a limited questionnaire concluded the necessity of having a systematic HL program [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAccording to researchers from a prior study, skill-based educational intervention in the school setting with the cooperation of all professional health personnel is particularly important to create long-term sustainable, positive behavioral changes and increase awareness among school-aged adolescents [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. It also benefits the school by fostering a safe, encouraging environment and a child's favorable academic growth. This will benefit the school adolescents as well as their parents and surrounding people to improve health-related knowledge and prevent diseases, especially lifestyle-related non-communicable diseases (NCDs) in the early stage.\u003c/p\u003e \u003cp\u003eTo determine and improve HL precisely, it is imperative to develop and use a valid and reliable HL tool [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. However, a few brief generic instruments are now available to measure HL among children and adolescents [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. The Rapid Estimate of Adolescent Literacy in Medicine (REALM-Teen) [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e] was developed based on the Rapid Estimate of Adult Literacy in Medicine (REALM) scale and is a visually oriented tool. This scale is simple to administer and highly feasible, with a measurement time of no more than 5 minutes. However, its measurement dimension is narrow, primarily focusing on cognitive ability while neglecting the assessment of comprehension skills. The Newest Vital Sign (NVS) scale [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e] primarily focuses on the subject's performance in a single dimension of health literacy, which may not fully reflect the individual's overall health literacy level. Health Literacy for School-Aged Children (HLSAC) scale is a self-administered tool developed in Finland to measure the level of HL among adolescent school-going children. It includes ten items with five core components: (1) theoretical knowledge, (2) practical knowledge, (3) individual critical thinking, (4) self-awareness, and (5) citizenship [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. This instrument measures HL comprehensively by considering all three domains including functional, interactive and critical. It considers participants' developmental changes and dependency. For that, it is regarded as appropriate to use school-aged adolescents for quick administration, satisfactory reliability and one-factor validity. However, the 8-item Health Literacy Assessment Tool (HLAT-8) was recommended, for its convergent validity and children and adolescents below 18 years have not been tested yet [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThere has not been any established validated and reliable scale identified for measuring HL among children and adolescents in Bangladesh. However, adequate and accurate measurement of HL is essential for appropriate attention to improve an individual\u0026rsquo;s capabilities, ultimately leading to changes in the health system [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. Therefore, it is imperative to develop an HLSAC scale in Bengali version to conduct research on HL among children in Bangladesh. Like other developing countries, Bangladeshi adults do not have sound health. Therefore, we aimed to foster school-aged adolescents who can contribute not only to themselves and their families but also to the community as change agents. Among all the established HL scales, we selected the HLSAC scale as we believe that citizenship is the most important component for Bangladeshi adolescents. The purpose of this research was to determine the validity and reliability of a Bengali-translated HLSAC scale among adolescents in secondary school children in Bangladesh.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e\u003cstrong\u003ePreparation of the Bengali version of the HLSAC scale\u003c/strong\u003e\u003c/p\u003e\n\u003cdiv id=\"Sec3\"\u003e\n \u003ch3\u003e1) Translation and back-translation\u003c/h3\u003e\n \u003cp\u003eFirst, written permission was obtained from Paakkari O, the original author of the HLSAC instrument [26]. Then, the 10-item English version was translated into Bengali by bilingual research team members including two nurse researchers and one psychologist. The Bengali translation was done with an emphasis on semantic equivalence rather than linguistic surface equivalence. The back-translation into English was done by another two bilingual researchers. After that, one native English speaker evaluated the semantic equivalence between the original version and the back-translation and modified the wording in the Bengali version as appropriate; the first revision was made.\u003c/p\u003e\n\u003c/div\u003e\n\u003ch3\u003e2) Pre-test\u003c/h3\u003e\n\u003cp\u003eA preliminary survey of the Bengali-translated version of the HLSAC was conducted to confirm and further revise the appropriateness of the Bengali wording and the ease of completing the questionnaire. For that, 20 students from the same school (rural) of the main study participated. To check the face validity in a rural setting, we administered the questionnaire only among the rural students to understand the local dialect, wording, orders of the items and response times of the participants. Pre-testing helped us to determine whether the participants understood the items as well as they could perform the task. The question item\u0026rsquo;s wording was modified as appropriate.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMain survey\u003c/strong\u003e\u003c/p\u003e\n\u003ch3\u003e1) Study design\u003c/h3\u003e\n\u003cp\u003eThis was a school-based cross-sectional study to test the validity and reliability of the HLSAC scale, Bengali version. At first, the Principal Investigator communicated with the headmasters of both rural and urban schools in August 2023 to conduct the study. After getting permission, the research team visited the schools in September 2023 and explained the purpose and procedures of this research to the headmasters including school teachers and obtained written permissions at the end of October 2023. The test was performed in January, 2024, and after 14 days, a re-test was conducted among the same students in January and February, 2024 for both school students.\u003c/p\u003e\n\u003ch3\u003e2) Study site\u003c/h3\u003e\n\u003cp\u003eThis study was conducted in two secondary schools, one from a rural community and another from an urban area in Bangladesh to obtain the diversification of the samples. The rural school is located in Tongibari Upazila, Munshigonj district and the urban school is located in Gazipur city in Bangladesh. These two schools are run by privately funded organizations/individuals under the Dhaka Education Board within the Bangladesh academic system, these secondary-level schools comprise grades 6 to 10 (ages 11 to 17). There are about 650 rural and 400 urban secondary school students in these two schools, in total of 1050. These two schools were selected purposely for convenience according to the following criteria: 1) schools affiliated with the Bangladesh Education Board, 2) give permission to conduct this study, 3) located in the rural community and urban area, and 4) provide education facilities for both genders (Fig.\u0026nbsp;1).\u003c/p\u003e\n\u003ch3\u003e3) Study participants\u003c/h3\u003e\n\u003cdiv id=\"Sec8\"\u003e\n \u003ch2\u003eInclusion criteria\u003c/h2\u003e\n \u003cul\u003e\n \u003cli\u003e\n \u003cp\u003eStudents who studied in class grades 7 to 9 at the time of enrollment.\u003c/p\u003e\n \u003c/li\u003e\n \u003cli\u003e\n \u003cp\u003eStudents of both genders.\u003c/p\u003e\n \u003c/li\u003e\n \u003cli\u003e\n \u003cp\u003eStudents whose first language was Bengali.\u003c/p\u003e\n \u003c/li\u003e\n \u003cli\u003e\n \u003cp\u003eStudents who were willing to participate.\u003c/p\u003e\n \u003c/li\u003e\n \u003cli\u003e\n \u003cp\u003eStudents whose parents or legal guardians agreed to give consent and were willing to participate in the study.\u003c/p\u003e\n \u003c/li\u003e\n \u003c/ul\u003e\n\u003c/div\u003e\n\u003ch3\u003eExclusion criteria\u003c/h3\u003e\n\u003cul\u003e\n \u003cli\u003e\n \u003cp\u003eStudents with cognitive and mental disorders (teachers excluded those students who were incapable of filling out the questionnaire).\u003c/p\u003e\n \u003c/li\u003e\n \u003cli\u003e\n \u003cp\u003eStudents in grades 6 and 10 were excluded after being included in this study to maintain consistency with the inclusion of participants from the same grades in the previous study [26].\u003c/p\u003e\n \u003c/li\u003e\n\u003c/ul\u003e\n\u003ch3\u003e4) Sample size calculation\u003c/h3\u003e\n\u003cp\u003eBased on the items in the questionnaires and suggestions from the previous research ideally, at least 200 samples are needed to estimate validity and reliability [28]. Moreover, for factor analysis, it is estimated that at least five cases per variable are needed and a minimum of 300 cases are recommended [29]. Therefore, we decided our sample size was 300. With a 10% dropout, the total estimated sample size was 330 from two different schools. However, due to the community-based study, we approached all the students between Grades 7 and 9 from the two schools for equal participation.\u003c/p\u003e\n\u003cdiv id=\"Sec11\"\u003e\n \u003ch2\u003e5) Study procedures\u003c/h2\u003e\n \u003cp\u003eThe researchers received approval from school authorities for data collection from the designated schools. The school teachers set a convenient time for data collection from the school children through survey administration. Before enrolling in the study, assent was obtained from the students and written informed consent from their parents or legal guardians. Data were collected through a survey questionnaire for a two-hour session. The questionnaire was distributed at a time among the 7th to 9th-grade children in the school classroom.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec12\"\u003e\n \u003ch2\u003eTest-retest\u003c/h2\u003e\n \u003cp\u003eThe participants were reassessed using the same HLSAC scale two weeks apart, and out of 312, 304 participated in this survey (Fig. 1). The correlation coefficient of the total scores from the two measurements was calculated. A retest reliability coefficient of \u0026ge;\u0026thinsp;0.70 indicates good temporal stability, and between 0.4 and 0.7 indicates moderate temporal stability.\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eMeasurements\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e1.The Health Literacy Scale for School-Aged Children (HLSAC) scale in Bengali version (Appendix 1) (10 items),\u003c/p\u003e\n \u003cp\u003eThe HLSAC scale had a four-point Likert scale ranging from 1 to 4 (1\u0026thinsp;=\u0026thinsp;not at all true, 2\u0026thinsp;=\u0026thinsp;not quite true, 3\u0026thinsp;=\u0026thinsp;somewhat true, and 4\u0026thinsp;=\u0026thinsp;absolutely true). The sum scores of 10 items were calculated from 10 to 40, with a higher score indicating more HL [22].\u003c/p\u003e\n \u003cp\u003e2. General Self-Efficacy scale (GSE), Bengali version (Appendix 2) (10 items),\u003c/p\u003e\n \u003cp\u003eThe General Self-Efficacy scale (GSE) had also 10 items, a four-point Likert scale ranging from 1 to 4 (1\u0026thinsp;=\u0026thinsp;not at all true, 2\u0026thinsp;=\u0026thinsp;hardly true, 3\u0026thinsp;=\u0026thinsp;moderately true, and 4\u0026thinsp;=\u0026thinsp;exactly true). The total score was calculated as the sum of 10 items ranging between 10 and 40 with a higher score indicating more self-efficacy [30].\u003c/p\u003e\n \u003cp\u003e3. Perceived knowledge to take care of one\u0026rsquo;s health (Appendix 3) (2 items) [31],\u003c/p\u003e\n \u003cp\u003eThe Perceived knowledge questionnaire contained physical and mental health components. Each component had a five-point Likert scale ranging from 1 to 5 (1\u0026thinsp;=\u0026thinsp;have no knowledge, 2\u0026thinsp;=\u0026thinsp;have very little knowledge, 3\u0026thinsp;=\u0026thinsp;have little knowledge, 4\u0026thinsp;=\u0026thinsp;have some knowledge, and 5\u0026thinsp;=\u0026thinsp;have enough knowledge). The scale was translated by two professional translators from English to Bengali, and then another two translators back-translated the Bengali version to English. A modification was made in wording to make it more comprehensive for conceptual likeness between the English and Bengali versions of Perceived knowledge scales.\u003c/p\u003e\n \u003cp\u003eWe also collected participants\u0026apos; socio-demographic data (age, sex, education in grade level, family household income, father and mother educational level).\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec13\"\u003e\n \u003ch2\u003eConvergent validity\u003c/h2\u003e\n \u003cp\u003eConvergent validity ensures that tests are measured consistently with other validated scales [32]. To examine the convergent validity of the Bengali version of the HLSAC scale, the GSE and Perceived knowledge to take care of one\u0026rsquo;s health were used. We calculated the correlation coefficient such as Spearman to determine the strength of correlation among the scales HLSAC, GSE and Perceived knowledge scales. A high correlation indicates that the test has strong convergent validity.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec14\"\u003e\n \u003ch2\u003eData analysis\u003c/h2\u003e\n \u003cp\u003eTo examine the reliability and validity of the questionnaire, the IBM SPSS Statistics version 25.0 and SPSS Amos version 28.0 were used, respectively, in this study for descriptive and factor analysis. Descriptive statistics including mean, standard deviation (SD), missing with skewness and kurtosis for each item were conducted. To understand the distribution of data, we performed a normality test. Skewness of data was considered when the value between \u0026minus;\u0026thinsp;1 and \u0026minus;\u0026thinsp;0.5 or between +\u0026thinsp;0.5 and +\u0026thinsp;1 was considered moderately skewed and less than \u0026minus;\u0026thinsp;1 or greater than +\u0026thinsp;1 was considered highly skewed. Kurtosis was considered as less than \u0026minus;\u0026thinsp;2 and more than +\u0026thinsp;2. To confirm the validity (structure of factors) of the HLSAC scale, a confirmatory factor analysis (CFA) was conducted. In CFA, a high factor loading indicates the factor strongly influences the variables. The value of factors loading below 0.32 is considered poor, \u0026ge; 0.45 is fair, \u0026ge; 0.55 is good, \u0026ge; 0.63 is very good, and above 0.71 is considered excellent [33]. To observe the model fitness to assess the relationship between observed variables and the theoretical model (here, the HLSAC), the cutoff value of chi-square/degree of freedom (\u0026chi;\u003csup\u003e2\u003c/sup\u003e /df) was considered\u0026thinsp;\u0026le;\u0026thinsp;2 as a good fit, \u0026le; 3 as acceptable. We considered the root mean square error of approximation (RMSEA) (\u0026le;\u0026thinsp;0.05 as a good fit, \u0026le; 0.10 as acceptable) and for standardized root means square residual (SRMS) (\u0026le;\u0026thinsp;0.05 as good fit, \u0026le; 0.10 as acceptable). For the comparative fit index (CFI), goodness of fit index (GFI), normed fit index (NFI), relative fit index (RFI), incremental fit index (IFI) and the Tucker- Lewis index (TLI), we considered the value of \u0026ge;\u0026thinsp;0.95 as a good fit and \u0026ge;\u0026thinsp;0.90 as acceptable [34]. Likewise, convergent validity was tested to see the correlation among the HLSAC, GSE scale, and Perceived knowledge, Bengali version to take care of one\u0026rsquo;s health by Spearman\u0026rsquo;s correlations test. For the correlation analysis, the significance level of the \u003cem\u003ep\u003c/em\u003e-value was set to 1%. To estimate the internal consistency of the components of different scales, reliability (test-retest) was tested for adequate Cronbach\u0026rsquo;s coefficient alpha. A reliability coefficient of \u0026ge;\u0026thinsp;0.7 score was considered good for this study [35].\u003c/p\u003e\n\u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eSociodemographic characteristics of participants\u003c/h2\u003e \u003cp\u003eOut of a total of 850 school students, 312 participated (36.7%) and completed questionnaires from two different schools in grades 7 to 9; 96 from an urban school and 216 from a rural school. A description of the sample characteristics is in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSociodemographic characteristics of the study participants (n\u0026thinsp;=\u0026thinsp;312)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariables\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge (years) (mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13.51\u0026thinsp;\u0026plusmn;\u0026thinsp;1.25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e63\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e20.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e85\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e27.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e95\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e30.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e13.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSex\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e53\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e17.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e259\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e83.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eReligion\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMuslim\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e282\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e90.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHindu\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e9.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEducation (grade)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e112\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e35.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e115\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e36.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e85\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e27.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMother\u0026rsquo;s education\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrimary not completed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e37\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e11.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrimary completed\u003csup\u003e1)\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e104\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e33.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSecondary level completed\u003csup\u003e2)\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e95\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e30.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHigher secondary completed\u003csup\u003e3)\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e54\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e17.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGraduate level completed or more\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e7.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFather\u0026rsquo;s education\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrimary not completed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e63\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e20.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrimary completed\u003csup\u003e1)\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e110\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e35.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSecondary level completed\u003csup\u003e2)\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e59\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e18.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHigher secondary completed\u003csup\u003e3)\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e43\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e13.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGraduate level completed or more\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e37\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e11.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNumber of family members\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e38\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e12.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e121\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e38.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e99\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e31.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026gt; 5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e54\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e17.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFamily monthly income (BDT)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDo not know\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e197\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e63.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026lt; 10000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e7.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e10000 to 20000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e43\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e13.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026gt;20000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e16.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMain earning occupation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLabor\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e9.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUnemployed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e14.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFarmer\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e82\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e26.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBusiness\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e97\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e31.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eService holder\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e59\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e18.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHistory of receiving health education\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e135\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e43.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e177\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e56.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"3\"\u003e\u003csup\u003e1)\u003c/sup\u003e5 years formal education, \u003csup\u003e2)\u003c/sup\u003e10 years formal education, \u003csup\u003e3)\u003c/sup\u003e12 years formal education\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003eDistribution\u003c/h2\u003e \u003cp\u003eWe analyzed the 10-item of the HLSAC scale. We present the total, mean, SD, statistics and standard error (SE) of skewness and kurtosis of each item. We examined the assumption of normality and found data were not normally distributed and skewness and kurtosis were significant. The mean score of 10 items ranged from 2.61 to 3.44 and the minimum score was 1 and the maximum was 4 (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDescription of item analysis of the HLSAC scale\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"8\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eItem\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMean\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSD\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eSkewness\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eSE\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eKurtosis\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003eSE\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1. I have good information about health\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e312\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2.82\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.54\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e-0.98\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e2.07\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.28\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2. When necessary, I am able to give ideas on how to improve health in my immediate surroundings (e.g., a nearby place or area, family, friends)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e312\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2.75\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.91\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e-0.26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e-0.74\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.28\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3. I can compare health-related information from different sources\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e312\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2.61\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.92\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e-0.14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e-0.79\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.28\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4. I can follow the instructions given to me by healthcare personnel (e.g., nurse, doctor)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e312\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3.44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.85\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e-1.53\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e1.57\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.28\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e5. I can easily give examples of things that promote health\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e312\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3.03\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.85\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e-0.70\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.02\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.28\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e6. I can judge how my own actions affect the surrounding natural environment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e312\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3.22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.74\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e-0.56\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e-0.33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.28\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e7. When necessary, I find health-related information that is easy for me to understand\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e312\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2.87\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.98\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e-0.43\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e-0.85\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.28\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e8. I can judge how my behaviour affects my health\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e312\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2.89\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.85\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e-0.45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e-0.38\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.28\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e9. I can usually figure out if some health-related information is right or wrong\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e312\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2.77\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.92\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e-0.36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e-0.68\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.28\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e10. I can give reasons for the\u0026nbsp;choices I make regarding my health\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e312\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3.25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e-1.08\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e-0.09\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.28\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"8\"\u003eSD: Standard Deviation, SE: Standard Error\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003eFactor validity (construct validity)\u003c/h2\u003e \u003cdiv id=\"Sec19\" class=\"Section3\"\u003e \u003ch2\u003eConfirmatory factor analysis (CFA)\u003c/h2\u003e \u003cp\u003eAs the HLSAC questionnaire has a well-established theoretical framework with predefined constructs and validated in previous research, for that, we conducted CFA to understand whether the predefined structure aligns with the actual data. The original 10 items HLSAC and 1-dimensional solution of the HLSAC scale revealed the model structure for estimating the statistical relationships between HLSAC and individual items. Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e shows the results of the indices. Two models were developed: one for 10-items (Model 1) and another 9-items which excluded item 6 (Model 2). We found robust model fit as the \u003cem\u003ep\u003c/em\u003e-values for Model 1 and Model 2 were not significant (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.137 and 0.151, respectively). Since the \u003cem\u003ep\u003c/em\u003e-values were \u0026gt;\u0026thinsp;0.05, the difference between the observed data (Figs.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e2\u003c/span\u003e and 3) and the theoretical model is not significant, suggesting a good fit. Moreover, for Models 1 and 2, the value (1.263 and 1.279) of χ\u003csup\u003e2\u003c/sup\u003e /df showed good fit (\u0026le;\u0026thinsp;2), RMSEA 0.029 and 0.030 good fit (\u0026le;\u0026thinsp;0.05), SRMR\u0026thinsp;=\u0026thinsp;0.028 and 0.028 (\u0026le;\u0026thinsp;0.05 as good fit), CFI\u0026thinsp;=\u0026thinsp;0.982 and 0.985 (\u0026ge;\u0026thinsp;0.95 as good fit), GFI\u0026thinsp;=\u0026thinsp;0.973 and 0.976 (\u0026ge;\u0026thinsp;0.95 as good fit), NFI\u0026thinsp;=\u0026thinsp;0.920 and 0.936 (\u0026ge;\u0026thinsp;0.90 as acceptable), RFI\u0026thinsp;=\u0026thinsp;0.897 and 0.914 (\u0026ge;\u0026thinsp;0.90 as acceptable), IFI\u0026thinsp;=\u0026thinsp;0.982 and 0.985 (\u0026ge;\u0026thinsp;0.95 as good fit) and TLI\u0026thinsp;=\u0026thinsp;0.977 and 0.980 (\u0026ge;\u0026thinsp;0.95 as good fit). However, in Model 1, the factor loading HL question (HLQ) 6 was 0.1 (\u0026lt;\u0026thinsp;0.3 is not ideal) (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Therefore, after removing HLQ6, a second CFA was conducted, resulting in Model 2 (Fig.\u0026nbsp;3). We found \u003cem\u003ep\u003c/em\u003e-value was still not significant (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.151) and higher than Model 1.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eConfirmatory factor analysis (CFA) of the HLSAC scale. Model fit indices\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFit Measure\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eModel 1 (10 items)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eModel 2 (9 items; exclude item 6)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eχ\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e44.203\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e34.541\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eP value\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.137\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.151\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eχ\u003csup\u003e2\u003c/sup\u003e /df\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.263\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.279\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRMSEA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.029\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.030\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSRMR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.028\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.028\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCFI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.982\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.985\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGFI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.973\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.976\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNFI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.920\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.936\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRFI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.897\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.914\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIFI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.982\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.985\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTLI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.977\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.980\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eχ\u003csup\u003e2\u003c/sup\u003e: chi-square, df: degrees of freedom, RMSEA: Root mean square error of approximation, SRMR: Standardized root mean square residual, CFI: Comparative fit index, GFI: Goodness of fit index, NFI: Normed fit index, RFI: Relative fit index, IFI: Incremental fit index, TLI: Tucker-Lewis index\u003c/p\u003e \u003cp\u003eWe performed Spearman\u0026rsquo;s correlation coefficient to measure the associations among the scales and found significant (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001) positive correlations between HLSAC-10, HLSAC-9 (excluded HL scale item 6), GSE and Perceived knowledge (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eConvergent validity of the HLSAC scale\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"8\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eConstruct\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eMean\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eSD\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eCronbach\u0026rsquo;s alpha\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"4\" nameend=\"c8\" namest=\"c5\"\u003e \u003cp\u003eSpearman\u0026rsquo;s correlation coefficient\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eHLSAC-10\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eHLSAC-9\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eGSE\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003ePerceived knowledge\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHLSAC-10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2.96\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.486\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.759\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.833*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.704*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.618*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHLSAC-9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2.89\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.593\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.776\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.833*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.574*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.540*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGSE\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3.04\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.481\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.728\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.704*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.574*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.570*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePerceived knowledge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3.99\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.777\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.604\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.618*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.540*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.570*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"8\"\u003eHLSAC-10: Health Literacy for School-Aged Children 10-item, HLSAC-9: Health Literacy for School-Aged Children 9-item, GSE: General Self Efficacy, SD: Standard deviation\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"8\"\u003e*Significant at \u0026lt;\u0026thinsp;0.001 level\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec20\" class=\"Section2\"\u003e \u003ch2\u003eReliability\u003c/h2\u003e \u003cp\u003eThe reliability of the HLSAC-10 and HLSAC-9 scales showed that Cronbach\u0026rsquo;s alpha were 0.759 and 0.776, respectively. The inter-item correlation values range between 0.117 and 0.371 for both HLSAC-10 and HLSAC-9 and the item means were 2.96 and 2.89, respectively.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec21\" class=\"Section2\"\u003e \u003ch2\u003eTest-retest\u003c/h2\u003e \u003cp\u003eA total of 304 participants completed the retest reliability assessment. The test-retest reliability of this scale was 0.557 and 0.576 for HLSAC 10 and 9 items, respectively.\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eWe demonstrated the validity and reliability of a Bengali version of the HLSAC scale among adolescents in secondary school children in Bangladesh. We observed the 10-item HLSAC scale Bengali version was significantly valid and reliable for this population group.\u003c/p\u003e \u003cp\u003eBased on the original scale with 10 items and 1-dimension, confirmatory factor analysis was used to validate the Bengali version of the HLSAC scale. The results of Model 1 indicated that all fit indices met the requirements, suggesting a good fit of the scale. However, the factor loading of HLQ6 was less than 0.3, which is not ideal. Therefore, HLQ6 was deleted, and a second confirmatory factor analysis was conducted. The results showed that the 9-item, 1-dimension model had a better fit than Model 1. A similar finding was observed that HLQ6 had the poorest individual fit in adults [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e]. One study was conducted among Norwegian school-aged adolescents and found that the original 10-item 1-dimensional solution had a poor fit. They observed that the HLSAC scale consisting of 1, 3, 6, 7, 9 and 10 items was statistically valid and reliable and suggested this shorter version HLSAC-6 scale for measuring HL for those adolescents [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. Another large study was conducted in seven European countries with an HLSAC-5 (1, 3, 6, 7 and 10) instrument extracted from the original 10-item HLSAC scale and found that this brief scale was valid and reliable among the adolescents of those countries (Finland, Estonia, Poland, Czechia, Belgium, Slovakia and Germany) [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]. However, the HLSAC scale with the original 10-item was found suitable for German children and adolescents in the German version [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e]. Therefore, modifications and use of the instrument indicate the need for further investigation of the HLSAC scale in diverse settings and different age groups.\u003c/p\u003e \u003cp\u003eConvergent validity mainly reflects the correlation between the measurement tool and other related measurement tools. In this study, GSE and Perceived Knowledge were used as convergent indicators. The results showed that the Bengali version of the HLSAC-10 and HLSAC-9 scales were positively correlated with both GSE and Perceived Knowledge (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05), indicating that the Bengali version of the HLSAC scale has good convergent validity.\u003c/p\u003e \u003cp\u003eInternal consistency reflects the internal correlation of the measurement tool. The results of this study showed that the Cronbach's alpha of the Bengali version of the HLSAC-10 scale was 0.759 and HLSAC-9 was 0.776, indicating that the Bengali version of the HLSAC scale has good internal consistency. Test-retest reliability reflects the stability and consistency of the measurement tool over time. In this study, the test-retest reliability for HLSAC 10 and 9 were 0.557 and 0.576, respectively, which are at a moderate level.\u003c/p\u003e \u003cdiv id=\"Sec23\" class=\"Section2\"\u003e \u003ch2\u003eStrengths\u003c/h2\u003e \u003cp\u003eAs this is the first study to establish a valid and reliable HLSAC scale in Bengali version among school-aged adolescents in Bangladesh, it can be widely used to evaluate the HL in this population. The findings of this study will provide valuable insights for further development of various HL instruments.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec24\" class=\"Section2\"\u003e \u003ch2\u003eLimitations\u003c/h2\u003e \u003cp\u003eThis study has certain limitations. Although the scale is developed for adolescents, we included students from 7 to 9 grades; therefore, this did not cover other adolescents in the excluded grades. In this study, we included all the school-going students, while this is true of only 52.4% of the general population in the age group of 15\u0026ndash;19 years in Bangladesh [\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e]. Hence, we recommend future studies with large sample sizes and including other upper and lower grades school students which would allow greater consistency and minimize biases. Our test-retest reliability has shown insufficient consistency among adolescents. Further longitudinal studies with different settings are needed for the testing and modification to establish a suitable HL scale in the Bengali language. Moreover, we did not perform measurement invariance across different groups based on gender, age, cultural background, etc., the scale may be susceptible to measurement errors. Therefore, additional investigations using multiple samples can confirm the measurement invariance of the HLSAC scale.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusions","content":"\u003cp\u003eTo assess the HL among adolescents, a valid and reliable HLSAC scale is essential for school-aged children in Bangladesh with Bengali language for better understanding. To the best of our knowledge, this is the first study that used the HLSAC scale in Bengali version for measuring HL among school-aged adolescents in Bangladesh. We found the 10-item and 1-dimension Bengali version of the HLSAC scale was a good fit, however, the 9-item (without HLQ6), the 1-dimension model was found to have a better fit than the 10-item for these school-aged adolescents. The scale demonstrated moderate test-retest reliability in terms of overall measure. Since there is currently no valid and reliable Bengali version of the HLSAC scale available to measure HL, this research will significantly impact the assessment of HL among adolescents. Further investigation with a larger sample size is needed to identify the predictors of the Bengali version of the HLSAC scale, and whether the 10-item or 9-item is suitable for this age group. More age-specific HL scales will guarantee a high probability to test and measure HL in different age groups including adults in the Bengali version for the population of Bangladesh.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eCFA\u0026nbsp; \u0026nbsp;\u0026nbsp;confirmatory factor analysis\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eCFI\u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Comparative fit index\u003c/p\u003e\n\u003cp\u003eDf\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;degrees of freedom\u003c/p\u003e\n\u003cp\u003eGFI\u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Goodness of fit index\u003c/p\u003e\n\u003cp\u003eGSE\u0026nbsp; \u0026nbsp; \u0026nbsp;General Self-Efficacy scale\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eHL\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Health Literacy\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eHLAT\u0026nbsp;\u0026nbsp;Health Literacy Assessment Tool\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eHLQ\u0026nbsp; \u0026nbsp;\u0026nbsp;Health Literacy Questionnaire\u003c/p\u003e\n\u003cp\u003eHLSAC Health Literacy for School-Aged Children\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIFI\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Incremental fit index\u003c/p\u003e\n\u003cp\u003eNFI\u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Normed fit index\u003c/p\u003e\n\u003cp\u003eREALM Rapid Estimate of Adult Literacy in Medicine\u003c/p\u003e\n\u003cp\u003eRFI\u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Relative fit index\u003c/p\u003e\n\u003cp\u003eRMSEA Root mean square error of approximation\u003c/p\u003e\n\u003cp\u003eSRMR\u0026nbsp;Standardized root mean square residual\u003c/p\u003e\n\u003cp\u003eTLI \u0026nbsp; \u0026nbsp; \u0026nbsp;Tucker-Lewis index\u0026nbsp;\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgments\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe would like to express our sincere gratitude to the headmasters and other teachers for their generous permission to conduct this study at their schools and the children who participated and gave their precious time for this study. We also thank all the research staff for their contribution to collecting data and preparing for analysis. \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePRB conceptualization, data collection, prepared data for analysis and drafted the manuscript. KATMEH data analysis, drafted the manuscript and project administration. GH data analysis. AOB conceptualization and data analysis. MM conceptualization, and project administration, drafted the manuscript, and critically reviewed the manuscript. All authors provided input to improve the manuscript, read and approved the final version for submission.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis work was supported by JSPS KAKENHI (Grant Number JP 21H03250). The funder had no control over the interpretation, writing, or publication of this work.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data presented in this study are available upon request from the corresponding author. The data are not publicly available due to privacy restrictions.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was approved by the Institutional Review Board/Ethics Review Committee (IRB/ERC) of North South University, Bangladesh (reference number: 2023/OR-NSU/IRB/0707). This study is being conducted according to the Declaration of Helsinki. \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWritten informed consent was obtained from all the patients. Confidentiality of individual information was maintained at all steps of the research.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eWorld Health Organization (WHO) 2021. WHO health promotion glossary of terms 2021. Geneva. Available from: https://www.who.int/publications/i/item/9789240038349 (accessed on January 14, 2024).\u003c/li\u003e\n\u003cli\u003eCenter for Disease Control and Prevention 2023. What is health literacy? Atlanta, Georgia. 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Erratum in: Ann Fam Med. 2006 Jan-Feb;4(1):83. \u003c/li\u003e\n\u003cli\u003ePaakkari O, Torppa M, Kannas L, Paakkari L. Subjective health literacy: development of a brief instrument for school-aged children. Scand J Public Health. 2016;44(8):751-757. doi: 10.1177/1403494816669639.\u003c/li\u003e\n\u003cli\u003eInstitute of Medicine (US) Roundtable on Health Literacy. Measures of health literacy: workshop summary. Washington (DC): National Academies Press (US); 2009. 2, An overview of measures of health literacy. Available from: https://www.ncbi.nlm.nih.gov/books/NBK45375/\u003c/li\u003e\n\u003cli\u003eFrost MH, Reeve BB, Liepa AM, Stauffer JW, Hays RD; Mayo/FDA. Patient-reported outcomes consensus meeting group; what is sufficient evidence for the reliability and validity of patient-reported outcome measures? Value Health. 2007;10 Suppl 2:S94-S105. doi: 10.1111/j.1524-4733.2007.00272.x. \u003c/li\u003e\n\u003cli\u003eTabachnick BG, Fidell LS. Using Multivariate Statistics (3rd edn). New York: Harper Collins, 1996.\u003c/li\u003e\n\u003cli\u003eLuszczynska A, Scholz U, Schwarzer R. The general self-efficacy scale: multicultural validation studies. J Psychol. 2005;139(5):439-57. doi: 10.3200/JRLP.139.5.439-457. \u003c/li\u003e\n\u003cli\u003eBj\u0026oslash;rnsen HN, Moksnes UK, Eilertsen MB, Espnes GA, Haugan G. Validation of the brief instrument \u0026quot;Health Literacy for School-Aged Children\u0026quot; (HLSAC) among Norwegian adolescents. Sci Rep. 2022 Dec 21;12(1):22057. doi: 10.1038/s41598-022-26388-4. \u003c/li\u003e\n\u003cli\u003eChin CL, Yao G. 2014. Convergent Validity. In: Michalos, A.C. (eds) Encyclopedia of quality of life and well-being research. Springer, Dordrecht. https://doi.org/10.1007/978-94-007-0753-5_573\u003c/li\u003e\n\u003cli\u003eSharma S. Applied Multivariate Techniques. John Wiley \u0026amp; Sons, Inc., ISBN: 978-0-471-31064-8, 1995. https://www.wiley.com/en-br/Applied+Multivariate+Techniques+-p-9780471310648 (accessed on August 24, 2024).\u003c/li\u003e\n\u003cli\u003eJ\u0026ouml;reskog KG, Olsson UH, Wallentin FY. Multivariate Analysis with LISREL. Springer Nature, published in 2016; pages 283-339. https://link.springer.com/book/10.1007/978-3-319-33153-9 (accessed on September 25, 2024).\u003c/li\u003e\n\u003cli\u003eHair JF, Black WC, Babin BJ, Anderson RE. Multivariate data analysis, Seventh edition; Pearson Prentice Hall, 2010. Available from: https://www.drnishikantjha.com/papersCollection/Multivariate%20Data%20Analys`is.pdf (accessed on October 24, 2024).\u003c/li\u003e\n\u003cli\u003eRasmussen SE, Aaby A, S\u0026oslash;jbjerg A, Mygind A, Maindal HT, Paakkari O, Christensen KS. The brief health literacy scale for adults: adaptation and validation of the health literacy for school-aged children questionnaire. Int J Environ Res Public Health. 2023 Nov 16;20(22):7071. doi: 10.3390/ijerph20227071.\u003c/li\u003e\n\u003cli\u003ePaakkari O, Kulmala M, Lyyra N, Torppa M, Mazur J, Boberova Z, Paakkari L. The development and cross-national validation of the short health literacy for school-aged children (HLSAC-5) instrument. Sci Rep. 2023 Oct 31;13(1):18769. doi: 10.1038/s41598-023-45606-1. \u003c/li\u003e\n\u003cli\u003eSaskia M. Fischer, Kevin Dadaczynski, Gorden Sudeck, Katharina Rathmann, Olli Paakkari, Leena Paakkari, Ludwig Bilz, and the HBSC Study Group Germany. Measuring Health Literacy in Childhood and Adolescence with the Scale Health Literacy in School-Aged Children \u0026ndash; German Version: The Psychometric Properties of the German-Language Version of the WHO Health Survey Scale HLSAC. Diagnostica, 2022;68, 4, 184\u0026ndash;196. https://doi.org/10.1026/0012-1924/a000296.\u003c/li\u003e\n\u003cli\u003eNational Institute of Population Research and Training (NIPORT) and ICF. 2024. Bangladesh Demographic and Health Survey 2022: Final Report. Dhaka, Bangladesh, and Rockville, Maryland, USA: NIPORT and ICF. https://dhsprogram.com/pubs/pdf/FR386/FR386.pdfPer.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Appendices","content":"\u003cp\u003eAppendix files 1-3 are not available with this version.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"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, validity, reliability, Health Literacy for School-Aged Children (HLSAC) scale, adolescents","lastPublishedDoi":"10.21203/rs.3.rs-5514171/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5514171/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eHealth Literacy (HL) is an effective determinant of health and health behaviors. The HL for School-Aged Children (HLSAC) scale has five components, and a 10-item was developed by Paakkari in the Finnish language to measure the HL levels of adolescents. However, its validity and reliability were not tested among adolescents in the Bengali language. This study aimed to determine the validity and reliability of HLSAC among adolescents of secondary school children in Bangladesh.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eA cross-sectional study was conducted among secondary school children in two different schools in Bangladesh. The schools were purposively selected, one from a rural community and another from an urban area. The participants were students graded between 7 and 9 at the time of enrollment. The validity and reliability of the HLSAC scale were checked by confirmatory factor analysis, convergent validity, Cronbach\u0026rsquo;s alpha, and test-retest reliability.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eA total of 312 students (mean age 13.5 years) were enrolled. The reliability of the HLSAC scale showed that Cronbach\u0026rsquo;s alpha was 0.759. The confirmatory factor analysis model fit appears robust as the \u003cem\u003ep\u003c/em\u003e-value was not significant (p\u0026thinsp;=\u0026thinsp;0.137), χ\u003csup\u003e2\u003c/sup\u003e /df 1.263, RMSEA 0.029 and CFI\u0026thinsp;=\u0026thinsp;0.982. The test-retest reliability of this scale was 0.557 (moderate). For the convergent validity, the Bengali version of the HLSAC scale was positively correlated with the General Self-Efficacy and Perceived Knowledge scales (all, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05).\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eOur study found that the HLSAC scale, Bengali version is valid and reliable for school-aged adolescents in Bangladesh. This research finding allows for a suitable HLSAC scale to measure the level of HL among adolescents in Bangladesh.\u003c/p\u003e","manuscriptTitle":"Validity and reliability of Health Literacy for School-Aged Children (HLSAC) scale to understand the health literacy among adolescents in Bangladesh: An observational study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-03-31 06:26:43","doi":"10.21203/rs.3.rs-5514171/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-04-04T06:58:21+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-03-31T17:00:53+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"282502789506147685565859512628000338083","date":"2025-03-31T15:03:40+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-03-28T16:45:22+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"16238379662122729980149553340306904414","date":"2025-03-28T16:22:48+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-03-25T22:50:09+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-03-21T10:50:48+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Public Health","date":"2025-03-21T08:51:45+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":"937168b5-32ad-4d51-b522-f7ce45081c69","owner":[],"postedDate":"March 31st, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-05-19T16:00:37+00:00","versionOfRecord":{"articleIdentity":"rs-5514171","link":"https://doi.org/10.1186/s12889-025-23005-7","journal":{"identity":"bmc-public-health","isVorOnly":false,"title":"BMC Public Health"},"publishedOn":"2025-05-13 15:57:29","publishedOnDateReadable":"May 13th, 2025"},"versionCreatedAt":"2025-03-31 06:26:43","video":"","vorDoi":"10.1186/s12889-025-23005-7","vorDoiUrl":"https://doi.org/10.1186/s12889-025-23005-7","workflowStages":[]},"version":"v1","identity":"rs-5514171","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5514171","identity":"rs-5514171","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}