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Peer-reviewed | Manuscript received: : March 22, 2016 | Revision accepted: July 07, 2016
Nutrition-specific health literacy:
development and testing of a
multi-dimensional questionnaire
Corinna Krause, Kathrin Sommerhalder, Sigrid Beer-Borst, Bern/Switzerland
actions, including eating behavior
Summary and physical activity [4]. The con-
Nutritional knowledge, food skills, and an awareness of one’s eating behavior are cept is therefore also of interest to
core competencies in the concept of nutrition-specific health literacy. There are nutritional science and education
very few instruments to measure this increasingly important concept in health and [5, 6]. Scientific literature uses the
nutritional science. This study describes the stepwise development of a comprehen- terms ‘nutrition literacy’ or ‘food
sive questionnaire for the self-evaluation of nutrition-specific health literacy among literacy’ to describe this concept,
adults. The questions were developed in accordance with a working definition and albeit inconsistently. However, as
were assessed as to their applicability and comprehensibility in a two-stage pre-test both terms describe specific forms
among a target group. The final questionnaire comprises 16 questions and is cur- of HL [6, 7], this study has adopted
rently being used for the first time in a Swiss intervention study in an occupational the term ‘nutrition-specific health
setting. Further validation (construct validity) will show whether this instrument is literacy’.
suitable for use in other studies. Based on Nutbeam’s concept, this
term encompasses nutritional
Keywords: health literacy, nutrition literacy, food literacy, questionnaire, nutritional knowledge, food skills, the ability
education, Public Health Nutrition to communicate about nutritio-
nal issues and to critically reflect
on one’s eating behavior and the
effects of consumption decisions
Introduction [8, 9].
At present, there are only a few
The World Health Organization de- instruments which assess nutri-
fines health literacy as the cognitive tion-specific HL. The present work
and social skills that motivate and describes the development and
enable individuals to adopt a life- pre-testing of a German-language
style that is beneficial to their health questionnaire which aims to mea-
[1]. Nutbeam distinguishes between sure nutrition-specific HL as a multi-
three forms of health literacy (HL): dimensional concept. The ques-
(1) Functional HL describes the abil- tionnaire was developed as part of
ity to find and understand an intervention study to reduce salt
health-related information. consumption among Swiss wor-
(2) Interactive HL describes the abil- kers. The study aims to promote
ity to exchange views about health nutrition-specific HL by means of a
issues in one’s environment and combined behavioral and environ-
Citation to transfer the information recei- mental approach and to thereby
Krause C, Sommerhalder K, Beer- ved to one’s own situation. positively influence individuals’
Borst S (2016) Nutrition-specific (3) Critical HL describes the ability selection of food [10].
health literacy: development and to critically assess and question
testing of a multi-dimensional information in order to actively
questionnaire. Ernahrungs promote one’s own and others’ Methodology
Umschau 63(11): 214–220 health [2, 3].
This article is available online: The concept of HL provides a basis The questionnaire was developed
DOI: 10.4455/eu.2016.046 for a more comprehensive un- and tested in a three-stage process
derstanding of everyday healthy (• Figure 1).
214 Ernaehrungs Umschau international | 11/2016
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Reproduction and dissemination – also partial – applicable to all media only with
written permission of Umschau Zeitschriftenverlag GmbH, Wiesbaden.
ACQUISITION OF QUESTIONNAIRE TWO-STAGE PRE-TEST
BACKGROUND MATERIALS DEVELOPMENT • Cognitive pre-test and content
• Working definition of nutriti- • Adaption of existing questions analysis
on-specific health literacy and development of new • Adaption of questionnaire
• Overview and assessment of questions Questionnaire V0.3
instruments/questions Questionnaire V0.1
• Checking of face validity with • Standard pre-test and
experts descriptive analysis
• Adaption of questionnaire • Expert discussion
Questionnaire V0.2 • Adaption of questionnaire
Final version of
questionnaire V1.0
Fig. 1: Process of questionnaire development
Acquisition of background Questionnaire develop- A research group of experts in nu-
materials (stage 1) ment (stage 2) trition, health literacy and questi-
onnaire development checked the
In a first step, authors analyzed the All questions from the suitable in- first version of the questionnaire
definitions of nutrition literacy [9, struments were listed and where (V0.1) in accordance with the
11] and food literacy [12–16] and possible assigned to the themes of working definition for face vali-
their core elements, in comparison the working definition (• Table 1). dity (face validity checks whether
to established concepts of HL [2, 3, In the event that no suitable ques- the questions are meaningful and
17]. The authors produced a grid tions for a theme were available, new appropriate and whether they
(• Table 1) which summarizes the questions were developed. Questions fully capture the construct to be
definitions in twelve themes and which served to assess general HL in tested [18]). In an iterative pro-
assigns them to the three forms of the original instrument were adapted cess, changes were recorded by the
HL (functional, interactive, critical). to the subject of nutrition. The focus authors and the adjusted ques-
This grid provided a working defini- was always on a balanced and heal- tions were again discussed within
tion which guided the development thy nutrition. The questions were the research group.
of the questionnaire. phrased in comprehensible language,
A search of scientific publications avoiding the use of technical terms.
in German, English and French
(12/2014–03/2015; databases: Psy-
chInfo, CINAHL, ERIC, MEDLINE, Nutrition-specific HL themes Forms of HL
Web of Knowledge, Google Scholar; 1 Ability to acquire information about food, food preparation and the influ -
search terms: health literacy, nutri- ence of nutrition on health
tion literacy, food literacy, instru- 2 Ability to understand information about food (e.g. nutrition labelling on
ment, questionnaire, survey, valid*, food)
reliab*) produced 110 validated in- 3 “Having knowledge” of: functional
struments to measure general or • healthy nutrition (what does healthy nutrition involve?)
nutrition-specific HL among adults. • nutritional recommendations, food preparation, salt content
The instruments were subsequently 4 Ability to prepare a balanced meal in accordance with available resources
assessed as to their suitability ac- and financial means
cording to the evaluation criteria 5 Ability to make a healthy choice
illustrated in • Figure 2 (traffic light 6 Ability to talk about nutrition with friends and family
model). 7 Ability to apply information one has read about nutrition to one’s own interactive
24 instruments were classified as situation
suitable (yellow/green), as they co- 8 Ability to assess nutritional information from different sources
vered at least two forms of HL (func- 9 Ability to assess whether a food contributes to healthy nutrition;
tional and interactive or critical) or ability to distinguish between healthy and less healthy options
focused on nutrition. 10 Ability to understand the connection between nutrition and health critical
11 Ability to advocate health promoting conditions
12 Ability to understand nutrition and health related topics in the larger
societal context
Tab. 1: Working definition of nutrition-specific health literacy (HL)
Ernaehrungs Umschau international | 11/2016
215
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Exclusion:
Instrument is directed solely at assessing respondents’ ability to read or calculate in the area of health (part of
functional HL)
Further checking:
Instrument measures at least one other form of HL in addition to functional HL and/or a nutrition-specific com-
ponent such as nutritional knowledge is included
Inclusion:
Instrument measures functional, interactive, and critical HL and/or nutrition-specific HL
Fig. 2: Evaluation criteria for inclusion and exclusion of instruments to measure health literacy (HL)
Two-stage pre-test (stage 3) problems and anomalies, as the re- scale was used as the response
spondents are expected to answer categories for self-assessment.
The second version of the questi- all the questions under the same The newly developed questions
onnaire (V0.2) was then pre-tes- conditions as those in the main excluded a neutral mid-category
ted (cognitive pre-test) focusing survey [20]. to avoid confounding [21]; re-
on the quality of the individual The participants were invited to sponse categories for questions
questions, i.e. whether the target record any technical weaknesses, from other sources were car-
group understood the questions any difficulties they had in answe- ried over unchanged. The term
and the corresponding response ring individual questions and any ‘healthy’ was systematically
formats [19]. other anomalies as well as the time used in connection with nutrition
To this end, an author carried out taken to fill in the questionnaire (e.g. healthy nutrition) and the
semi-structured interviews with in an evaluation sheet which was term ‘balanced’ only in relation to
13 people who were recruited in given to them at the same time. a meal.
a local administrative office and The evaluation sheet underwent a A face validity check led to a reduc-
at the university. The Interview qualitative analysis. The comple- tion in the number of themes from
guideline determined the testing ted questionnaires were subjec- 12 to 11 and in the number of ques-
technique for each question. The ted to a descriptive data analysis. tions from 25 to 17, as they were
interviewer primarily applied the Questions with little variation in considered either redundant or un-
techniques of probing and thin- the chosen response categories answerable. Theme 12 “Ability to
king aloud, to evaluate how spe- or missing values and questions understand nutrition and health re-
cific terms and formulations were which caused the participants dif- lated topics in the larger societal con-
understood by the interviewees ficulties were revised. text” and the corresponding question
and what thought processes the Final adjustments were made as a were regarded as unanswerable due
interviewees used to arrive at their result of a discussion with two ex- to a high dependence on situatio-
responses [19]. The maximum ternal experts on questionnaire de- nal context and was therefore re-
duration of the interviews was 60 velopment, producing the final ver- moved. Questionnaire V0.2 compri-
minutes. All the interviews were sion of the questionnaire (V1.0). sed six new questions, eight ques-
recorded, transcribed, and sum- tions from existing German-lan-
marized. As a result of this pro- guage instruments on general HL
cess, proposed changes were pre- Results [22–24], which had been adapted to
pared and worked on by the three Questionnaire development the field of nutrition (no. 1–2, 9–12,
authors based on a consensus 15–16) (• Table 2), and three ques-
process and implemented in the Version V0.1 of the questionnaire tions (no. 3, 5, 13) originating from
third version of the questionnaire comprised 25 questions covering an English-language instrument to
(V0.3). all the themes of the working de- measure nutrition literacy [25].
The questionnaire was subse- finition. Six of the questions were
quently tested as part of the study newly developed by the authors Two-stage pre-test
survey among 110 students from based on the working definition;
the first and fifth semesters at a 19 questions were adapted from Cognitive pre-test
local university of applied health original sources. Aside from a Four men and nine women (aged
sciences. This approach (standard knowledge question on the healthy 27–67) from different educational
pre-test) helps to identify general plate model, a 4- or 5-point Likert backgrounds (eight with higher
216 Ernaehrungs Umschau international | 11/2016
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Reproduction and dissemination – also partial – applicable to all media only with
written permission of Umschau Zeitschriftenverlag GmbH, Wiesbaden.
education and five with a lower die man isst dann ist es offensicht- pendent on the respective context.
level of education) took part in the lich, z. B. wenn man Durchfall hat”] Composing a balanced meal would,
cognitive pre-test. As a result of (Participant no. 8). The term “long- e.g., be easier if the fridge was full
this test, seven questions were ad- term” was added to this question. and more difficult if one was invited
apted in language and content and The participants felt that the two out or was expecting guests. Several
one question was removed. questions which either addressed questions were consequently exten-
The pre-test method of thinking the composition or preparation of a ded to include the words “in gene-
aloud showed that the participants balanced meal were indistinct/syn- ral” or “on a normal day”, in order
did not understand three of the onymous. The question “How easy to emphasize a general evaluation of
questions as intended. These ques- is it for you to prepare a balanced abilities.
tions were therefore supplemented meal?” was thus removed. Some The technique of probing showed
with further information. This was participants also stressed that their that the participants understood
particularly evident in the question abilities were situationally, i.e. de- the terms ‘healthy’ and ‘balanced’
on the comprehensibility of in-
formation from different sources
(• Table 2, Question 2). The in- Question wording Theme
terviewees differentiated in their 1 When I have questions on healthy nutrition, I know where I can find informa- 1
responses between the different tion on this issue.
sources as intended, but equated 2 In general, how well do you understand the following types of nutritional infor-
comprehensibility with quality for mation?
some of the named sources, and This is not about the quality of the information but how well you understand it.
particularly for the question on the (A) Nutrition information leaflets 2
(B) Food label information
comprehensibility of information (C) TV or radio program on nutrition
from one’s personal environment. (D) Oral recommendations regarding nutrition from professionals
One participant said: “That’s quite (E) Nutrition advice from family members or friends
bad, because they often have no idea, 3 How familiar are you with the Swiss Food Pyramid? 3
as they simply repeat anything they 4 A balanced meal is composed of different foods. […]
have heard” [original citation: “Das Please check the image that best represents the proportion of a balanced 3
ist ganz schlecht, weil die häufig meal.
keine Ahnung haben, da wird einfach 5 I know the official Swiss recommendations about fruit and vegetable 3
irgendwas nachgeschwätzt”] (Par- consumption.
ticipant no. 9). A note was added 6 I know the official Swiss recommendations about salt intake. 3
to the question, stating that the 7 Think about a usual day: how easy or difficult is it for you to compose a 4/5
question referred only to the com- balanced meal at home?
prehensibility of the information. 8 And if you are eating out on a usual day, in a restaurant, canteen, etc.: 5
The cognitive pre-test also showed how easy or difficult is it for you to compose a balanced meal?
that some terms were associated 9 In the past, how often were you able to help your family members or a friend 6
with another context as intended. if they had questions concerning nutritional issues?
The wording was therefore chan- 10 In the past, when you have had questions concerning nutritional issues, how 6
ged in four questions (e.g., partici- often did you get information and advice from others (families and friends)?
pants understood Question 15 in a 11 There is a lot of information available on healthy nutrition today. 7
different temporal context; • Table How well do you manage to choose the information relevant to you?
2). The wording “How easy is it for 12 How easy is it for you to judge if media information on nutritional issues 8
can be trusted?
you to judge how your eating habits 13 Commercials often relate foods with health. How easy is it for you to judge
relate to your health?” tended to be if the presented associations are appropriate or not? 8
associated with the short-term reac- 14 How easy is it for you to evaluate if a specific food is relevant for a
tions of the body rather than with healthy diet? 9
the long-term effects of nutrition on 15 How easy is it for you to evaluate the longer-term impact of your dietary
health, i.e.: “Depending on what I eat, habits on your health? 10
what happens then in my body […] 16 How easy is it for you to advocate a healthy nutrition?
There are certain things that you eat (A) In your family
then it’s obvious, e.g. when you have (B) In your circle of friends and acquaintances 10
diarrhea” [original citation: “Je nach- (C) At work
dem was ich esse, was passiert dann (D) In your neighborhood (e.g. residential area, community)
im Körper […] Es gibt gewisse Sachen, Tab. 2: Final questionnaire (V1.0) on nutrition-specific health literacy (HL)
Ernaehrungs Umschau international | 11/2016 217
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