Development and validation of an adolescent health literacy scale in Ethiopia: A mixed methods approach

Adolescent health literacy (HL) is a significant public health concern, especially in developing countries with predominantly young populations like Ethiopia, as it impacts both their immediate and long-term health outcomes, and consequently, the overall wellbeing of their societies. Since HL is influenced by socio-cultural contexts, a locally developed and validated HL scale is essential for generating quality data and designing effective interventions. However, such a context-specific, validated HL scale for this age group is currently lacking in Ethiopia. This study, therefore, aims to develop and validate an adolescent HL scale tailored to the socio-cultural context of Ethiopia, to support measurement and intervention efforts.

This study employed a mixed methods approach, conducted in three stages between March 09, 2023 and January 25, 2024. In the first stage, concepts, categories/dimensions, and items were generated, using in-depth interviews and focus group discussions as data collection methods, to inform scale design, and the scale was subsequently developed based on these elements. The second stage comprised evaluating the scale's content, cognitive, and usability standards through expert reviews/evaluations, cognitive interviews, and a pilot survey, followed by modifications based on these evaluations. The third stage involved further evaluation of the validity and reliability of the scale on a larger random sample, using confirmatory factor analysis and reliability tests, respectively. Purposive, convenience, and random sampling techniques were employed to select participants. The study was conducted in Afaan Oromo and Amharic languages as per the participants' preferences. Data analysis was conducted using Atlas.ti (version 7.5.18) and SPSS with AMOS (version 23.0).

In the first stage of the study, an initial pool of 88 items was generated and then reduced to 40 items following a rigorous review of their coverage and uniqueness. In the second stage, evaluations for content, cognitive, and usability standards further refined the items to 33 covering five dimensions: health information competency, communication, health awareness and knowledge, decision-making and behavior, and citizenship and responsibility. Finally, in the third stage, validity and reliability testing of the 33-item scale yielded strong results. For instance, confirmatory factor analysis produced CFI, TLI, and RMSEA values of 0.976, 0.974, and 0.034, respectively, and reliability testing provided a Cronbach's alpha of 0.973 for the full scale and 0.850-0.937 for the subscales in the Afaan Oromo version. For the Amharic version, the corresponding values were 0.965, 0.962, and 0.039, with Cronbach's alpha values of 0.970 for the full scale and 0.783-0.937 for the subscales.

The study developed and validated an adolescent HL scale, using a mixed methods approach within the socio-cultural context of Ethiopia, addressing a critical gap in this area. This scale is multidimensional, encompassing HL knowledge, skills, abilities, and related attributes or qualities essential for adolescents today. The scale can be adapted and used with populations beyond adolescents and in other contexts in future studies. It is also vital for designing effective strategies aimed at improving HL in adolescents.