The 58-question reproductive health literacy questionnaire for Chinese unmarried youth was developed for evaluating reproductive health literacy among Chinese young people. The validation study was carried out among 1587 students from 12 high schools and colleges in 4 districts of Shanghai, which was a representative sample of Shanghai. The range of the reproductive health score is between 0 and 100, with median of 64.67, and a higher score indicates higher reproductive health literacy level. Psychometric analysis results indicated that it has good reliability and validity and could be a useful instrument for assessing reproductive health literacy for unmarried youth in the Chinese context.
The development of reproductive health literacy questionnaire for Chinese unmarried youth is in line with the opinion from Nutbeam who proposed that the measurement of health literacy would be best achieved where content and context were well defined. This study was based on the conceptual framework of health literacy, that is to say, reproductive health literacy integrated the content of medical services and public health, formed by three domains (medical services, disease prevention and health promotion) and four abilities (acquisition, understanding, evaluation and application). The application of this conceptual framework provides a theoretical basis for the development of instruments for assessing reproductive health literacy, with which we developed and applied the first measurement in China for assessing reproductive health literacy among young people.
The psychometric evaluation of the reproductive health literacy questionnaire for Chinese unmarried youth produced plausible results. The overall 58-question questionnaire was reliable, demonstrated by high internal consistency, spilt-half reliability and test-retest reliability (all coefficients > 0.7). For the three domains, all reliability coefficients were over 0.6 which was considered as acceptable reliability, except for the health promotion. It may be due to the less amount of questions in this domain, therefore, we recommend that the questionnaire should be administered as a whole when applying in the future studies. The results of confirmatory factor analysis suggested that the construct of the questionnaire fitted well with the theoretical model, represented an acceptable fit[20, 24]. On the other hand, we applied various methods to ensure the content validity of the questionnaire, including literature review, professional consultation and exiting evidence reference, as well as application of the health literacy integration conceptual framework. In the meantime, a qualitative interview was conducted among campus students with different backgrounds to get feedbacks, thereby to guarantee the reliability of the questionnaire.
The total reproductive health literacy score among youth in our study was around 60, indicating that the overall reproductive health literacy of the unmarried youth in Shanghai is at an intermediate level. Our study found that the unmarried youth got the highest score in "disease prevention", and the lowest in "health promotion", which suggests that unmarried youth in China have a poor understanding of the social determinants of reproductive health determinants. The reasons may be that they do not recognise the importance of reproductive health or they cannot effectively identify the social determinants of reproductive health in daily life, which reminds that the social environment and policy system for the reproductive health of unmarried youth need to be further optimised and improved. Additionally, we found that youth scored lower in the competences of accessing, understanding and appraising, compared with the competence of applying, indicating that a comprehensive health literacy intervention is needed to empower youth to access, understand and appraise health information. Rather than the “knowledge, attitude and practice” model, health literacy covers the acquisition and evaluation of health information. Also, we found that youth scored lower in these two ability factors, indicating young people still lack access to health information and authorities should establish more professional platforms to reduce barriers in acquiring reproductive health information and provide professional and accessible information to the public via audience-friendly ways.
The main social determinants that affect the scores of high school and college students' reproductive health literacy were gender and the living area in junior and high school. We found that unmarried girls aged 15–24 had higher scores than boys and the difference is statistically significant, which is consistent with other studies on health literacy among Chinese young people[27–30]. It may be due to the fact that girls are sexually mature earlier than boys and are more concerned about their own health. Additionally, the living area during junior and high school was associated with the scores of reproductive health literacy among college students. Specifically, college students who lived in rural areas when they were at middle and high school age got lower score than those living in large cities, small and medium-sized cities and suburbs. This may be because the middle and high school stage is a key period for sexual development, with relatively good plasticity and health awareness. Meanwhile, the quality of health services and the implementation of health education are better in cities compared with rural areas. However, we did not find significant effects of family social status (parents’ occupation and education) and family income per capita on the reproductive health score among unmarried youth, suggesting that reproductive health literacy level in the 15–24 age group is hardly influenced by the family, which is inconsistent with the results from Xu et al.. It may be that reproductive health is different from other health areas, and it is still a private and sensitive topic in the Chinese family environment. The acquisition and exchange of reproductive health information may come more from school and peer education than family[33, 34]. Thus, future interventions for reproductive health promotion should be considered to implement in school context.
The development and validation of an appropriate measurement is fundamental and essential for youth reproductive health literacy research. To the best of our knowledge, this is the first study proposing the concept of reproductive health literacy and also the first time developing and evaluating reproductive health literacy questionnaire for unmarried youth in China. Additionally, this study suggests that improving reproductive health literacy can be a good way to promote reproductive health. Improving the reproductive health literacy of unmarried youth will help reduce and prevent reproductive health problems in this age group, improve the utilisation rate of reproductive health services and compliance of reproductive health related diseases treatment, and thereby promote the reproductive health and decrease social burden of related disease.
However, some limitations of this study should be concerned. Firstly, the reproductive health literacy presented in this study only included unmarried youth in schools and colleges but not the same age population outside schools. Secondly, since the participants were all from Shanghai, which are not representative enough for the whole country, further studies are needed to generalise this measurement in other regions and settings of China. Thirdly, response bias cannot be avoided as the questionnaire is based on self-reporting.