Exposure to violence and other determinants of health literacy among Palestinian adolescents: a cross-sectional study
Health literacy is acknowledged for its importance in adolescents . At this transitional stage, adolescents develop physical, cognitive, and psychosocial levels . These affect their feelings, thoughts, decision making, and interactions with the surrounding world . Possessing these skills should enable people to access, understand, appraise, and apply the health information they acquire . Additionally, adolescents develop health-related competencies , and they gain more independence and responsibility for their health-related decisions . Moreover, exposure to a trustworthy and reliable source of health information is associated with better health literacy . Compared to people with suitable health literacy, those with poor or limited health literacy might find it difficult to use the received health information effectively . Health literacy is affected by a wide range of demographic and socio-economic characteristics . These factors include educational level, race, gender, location of residence, age, and cultural background . Lower levels of health literacy are observed among people with low socioeconomic status, lower educational levels, and younger age groups . Moreover, mental health issues, such as distress, can be negatively associated with health literacy levels in adolescents . Understanding health literacy and its associated factors is fundamental for adolescents to have healthy lives . However, empirical evidence on the determinants of health literacy among children and adolescents is limited . Health literacy in adolescents and young adults is still an under-researched topic compared to adult populations . However, attention to health literacy in this age group has increased rapidly over the past decade. Since 2020, adolescent and young adult health literacy has been addressed in 60 studies conducted in the Eastern Mediterranean Region. Nevertheless, research in Arabic countries remains less than that in Iran and Turkey . Some existing examples of health literacy research targeting adolescents include a study in Tunisia that reported higher HIV-related health literacy among adolescents jailed in a juvenile detention centre after a Peer-led HIV/AIDS education program . In Jordan, low levels of health literacy were associated with age, gender, smoking status, year, and field of study . Health literacy and its associated factors, particularly among adolescents, are newly researched concepts in Palestine. In Palestine, only one study has addressed the factors associated with health literacy, targeting a convenience sample of students from a Palestinian university . However, the predictors of health literacy among adolescents remains unaddressed. Having a complete understanding of health literacy and its associated factors is crucial for Palestinian adolescents given the unstable conditions they live in and its impact on their health outcomes . In particular, health literacy might be necessary for adolescents to face challenges related to accessing health care, having a healthy lifestyle, preventing chronic diseases, preventing substance abuse (e.g. tobacco), and receiving mental health care among others. Addressing health literacy and its determinants would be an important factor for achieving the sustainable developmental goals such as reducing inequalities in health and ensuring good wellbeing and healthy lives for those adolescents. Therefore, in this study, we aimed to identify the factors, particularly exposure to violence, associated with health literacy among Palestinian middle school students. 

Study design and sampling We conducted a cross-sectional study that followed a multistage sampling to recruit adolescents who lived in urban, rural and refugee camp localities in the Ramallah and Al-Bireh District of the West Bank, Palestine. Each location was divided into multiple locations and then blocks. Each block comprised approximately 150 households, 20 of which were randomly chosen for student recruitment. The population sizes of refugee camp localities in the Ramallah and Al-Bireh districts were lower than those of the rural and urban localities. Consequently, we oversampled respondents from refugee camp localities. The probability of recruiting an adolescent differed by locality, and was calculated as the product of the probabilities of choosing a block within the location, household within the block, household with an eligible adolescent, and adolescent within the household. This probability was used to calculate the sampling weights, which were the inverse of the total probability. The total study sample included 1,200 adolescents. However, for this study, we targeted adolescents who were in middle school: seventh, eighth, and ninth grades; excluding those who were in the sixth grade and those who dropped out of school. A detailed description of the sampling process and characteristics of the complete sample is available elsewhere . After recruiting adolescents and taking the required permissions from them and their parents, the field workers conducted face-to-face interviews with adolescents in private, ensuring the confidentiality of their responses. These fieldworkers were experienced and well trained in fieldwork. In addition, all fieldworkers attended an intensive one-day training session prior to the start of data collection. The aim of this training was to familiarise the fieldworkers with the research objectives and to ensure that they had a clear understanding of all the questionnaire items. Outcome variable The outcome of this study was health literacy. We used the Health Literacy Assessment Scale for Adolescents, which was validated in Arabic. This scale uses 15 items to measure three health literacy related constructs: communication, confusion, and functional . The communication health literacy subscale concerns comfort during verbal communication and asking healthcare professionals questions. Confusion health literacy measures the level of confusion among adolescents about the health information they received. Finally, the ability of reading and understanding health information was assessed through the functional health literacy subscale. The scores for each subscale were divided into two categories (0 = high health literacy, 1 = low health literacy). Scoring ≤ 14 out of 20, ≥ 8 out of 16, and ≥ 12 out of 24 indicated ‘low health literacy’ on the communication, confusion and functional health literacy subscales, respectively . Exposure variables The main exposure variables in this study were exposure to political violence and domestic and school violence. First, we evaluated exposure to violence by adapting a questionnaire previously used among Palestinian adolescents . We asked the adolescents five questions to assess whether they had been exposed to various forms of political violence from the Israeli army. It includes being beaten or non-physically humiliated by a soldier, having an encounter with tear gas, passing through checkpoints on their way to school, or having trouble reaching school owing to Israeli checkpoints. Restriction of movement caused by checkpoints is an inherently violent act that puts adolescents under stress and fear of humiliation or physical assault. We also asked the adolescents six questions to determine if they were exposed to domestic or school violence by being beaten or non-physically humiliated: at home by family members, at school by other students, or at school by the principal or any other teacher. Sources of health information Based on a previous study targeting Palestinian adolescents , we asked adolescents whether they referred to 14 sources of health information. These sources included healthcare professionals, parents, schools (teachers and counsellors), friends, and media (e.g. TV, Radio, and social media). We then calculated the total number of sources each adolescent usually consults for health information. The number of sources was divided into three categories based on the quartiles: ‘less than 4’ sources, ‘4–10’ sources, and ’11–14’ sources. Demographic and socio-economic factors We also included demographic and socioeconomic variables in the study, including age, sex, locality type, father’s education level, mother’s education level, father’s work, mother’s work, and Internet access. Statistical analyses We conducted bivariate analyses using chi-square tests to determine the association between categorical variables and health literacy. Subsequently, we used binary logistic regression to identify the factors associated with each health literacy subscale. Sampling weights were used for the analyses. IBM ® SPSS ® Statistics software Version 24 was used for all data analyses. 

We conducted a cross-sectional study that followed a multistage sampling to recruit adolescents who lived in urban, rural and refugee camp localities in the Ramallah and Al-Bireh District of the West Bank, Palestine. Each location was divided into multiple locations and then blocks. Each block comprised approximately 150 households, 20 of which were randomly chosen for student recruitment. The population sizes of refugee camp localities in the Ramallah and Al-Bireh districts were lower than those of the rural and urban localities. Consequently, we oversampled respondents from refugee camp localities. The probability of recruiting an adolescent differed by locality, and was calculated as the product of the probabilities of choosing a block within the location, household within the block, household with an eligible adolescent, and adolescent within the household. This probability was used to calculate the sampling weights, which were the inverse of the total probability. The total study sample included 1,200 adolescents. However, for this study, we targeted adolescents who were in middle school: seventh, eighth, and ninth grades; excluding those who were in the sixth grade and those who dropped out of school. A detailed description of the sampling process and characteristics of the complete sample is available elsewhere . After recruiting adolescents and taking the required permissions from them and their parents, the field workers conducted face-to-face interviews with adolescents in private, ensuring the confidentiality of their responses. These fieldworkers were experienced and well trained in fieldwork. In addition, all fieldworkers attended an intensive one-day training session prior to the start of data collection. The aim of this training was to familiarise the fieldworkers with the research objectives and to ensure that they had a clear understanding of all the questionnaire items. 

The outcome of this study was health literacy. We used the Health Literacy Assessment Scale for Adolescents, which was validated in Arabic. This scale uses 15 items to measure three health literacy related constructs: communication, confusion, and functional . The communication health literacy subscale concerns comfort during verbal communication and asking healthcare professionals questions. Confusion health literacy measures the level of confusion among adolescents about the health information they received. Finally, the ability of reading and understanding health information was assessed through the functional health literacy subscale. The scores for each subscale were divided into two categories (0 = high health literacy, 1 = low health literacy). Scoring ≤ 14 out of 20, ≥ 8 out of 16, and ≥ 12 out of 24 indicated ‘low health literacy’ on the communication, confusion and functional health literacy subscales, respectively . 

The main exposure variables in this study were exposure to political violence and domestic and school violence. First, we evaluated exposure to violence by adapting a questionnaire previously used among Palestinian adolescents . We asked the adolescents five questions to assess whether they had been exposed to various forms of political violence from the Israeli army. It includes being beaten or non-physically humiliated by a soldier, having an encounter with tear gas, passing through checkpoints on their way to school, or having trouble reaching school owing to Israeli checkpoints. Restriction of movement caused by checkpoints is an inherently violent act that puts adolescents under stress and fear of humiliation or physical assault. We also asked the adolescents six questions to determine if they were exposed to domestic or school violence by being beaten or non-physically humiliated: at home by family members, at school by other students, or at school by the principal or any other teacher. 

Based on a previous study targeting Palestinian adolescents , we asked adolescents whether they referred to 14 sources of health information. These sources included healthcare professionals, parents, schools (teachers and counsellors), friends, and media (e.g. TV, Radio, and social media). We then calculated the total number of sources each adolescent usually consults for health information. The number of sources was divided into three categories based on the quartiles: ‘less than 4’ sources, ‘4–10’ sources, and ’11–14’ sources. 

We also included demographic and socioeconomic variables in the study, including age, sex, locality type, father’s education level, mother’s education level, father’s work, mother’s work, and Internet access. 

We conducted bivariate analyses using chi-square tests to determine the association between categorical variables and health literacy. Subsequently, we used binary logistic regression to identify the factors associated with each health literacy subscale. Sampling weights were used for the analyses. IBM ® SPSS ® Statistics software Version 24 was used for all data analyses. 

Overview of adolescents’ characteristics The total number of the weighted sample analysed in this study was 816 students. The mean age was 14.2 years (Standard Deviation [SD] = 0.9). The weighted sample consisted of 379 (46.4%) boys and 437 (53.6%) girls. Moreover, 421 (51.5%) of the adolescents lived in urban areas, while 354 (43.3%) and 42 (5.1%) lived in rural and refugee camps, respectively. Among the adolescents, 16.5% were exposed to political violence, while 57.3% were exposed only to domestic and school violence. The prevalence of low functional health literacy among adolescents was 20.4%, whereas 30.5% and 50.5% had low levels of confusion and communication health literacy, respectively. Table presents the characteristics of the study participants. Bivariate analysis Table presents the results of the bivariate analysis. Exposure to political violence was associated with both confusion and functional health literacy subscales, whereas exposure to domestic and school violence was associated with confusion in health literacy ( p < 0.05). The number of sources referred to by adolescents was also associated with the three health literacy subscales ( p < 0.05). Furthermore, fathers’ educational levels were associated with confusion health literacy. Mothers’ educational levels, parents’ work, and internet access were associated with communication health literacy ( p < 0.05). Factors associated with low health literacy Exposure to violence Adolescents exposed to political violence were almost 2.65 times more likely to have low functional health literacy (Odds Ratio [OR]: 2.65, 95% Confidence Interval [CI]: 1.71–4.08). They were also approximately two times more likely to have low confusion health literacy (OR: 1.96, 95%CI: 1.31–2.94). Furthermore, adolescents who were exposed to domestic and school violence were 82% more likely to have low confusion health literacy (OR: 1.82, 95% CI: 1.30–2.55; Table ). Sources of health information Adolescents who consulted 11 or more sources were 47% less likely to have low communication health literacy (OR: 0.53, 95% CI: 0.30–0.95) and three times more likely to have low confusion health literacy (OR: 3.12, 95% CI: 1.59–6.09) compared with those who referred to three or less sources (Table ). Demographic and socio-economic factors Adolescents who had fathers with an educational level higher than high school were 52% less likely to have low confusion health literacy (OR 0.48, 95% CI: 0.31–0.74). Having only a working mother was associated with 5.5 times higher odds of having low communication health literacy (OR: 5.50, 95% CI: 1.60–19.5). Furthermore, it was associated with almost three times higher odds of having low communication health literacy (OR: 3.17, 95% CI: 1.45–7.0) (Table ). 

The total number of the weighted sample analysed in this study was 816 students. The mean age was 14.2 years (Standard Deviation [SD] = 0.9). The weighted sample consisted of 379 (46.4%) boys and 437 (53.6%) girls. Moreover, 421 (51.5%) of the adolescents lived in urban areas, while 354 (43.3%) and 42 (5.1%) lived in rural and refugee camps, respectively. Among the adolescents, 16.5% were exposed to political violence, while 57.3% were exposed only to domestic and school violence. The prevalence of low functional health literacy among adolescents was 20.4%, whereas 30.5% and 50.5% had low levels of confusion and communication health literacy, respectively. Table presents the characteristics of the study participants. 

Table presents the results of the bivariate analysis. Exposure to political violence was associated with both confusion and functional health literacy subscales, whereas exposure to domestic and school violence was associated with confusion in health literacy ( p < 0.05). The number of sources referred to by adolescents was also associated with the three health literacy subscales ( p < 0.05). Furthermore, fathers’ educational levels were associated with confusion health literacy. Mothers’ educational levels, parents’ work, and internet access were associated with communication health literacy ( p < 0.05). 

Exposure to violence Adolescents exposed to political violence were almost 2.65 times more likely to have low functional health literacy (Odds Ratio [OR]: 2.65, 95% Confidence Interval [CI]: 1.71–4.08). They were also approximately two times more likely to have low confusion health literacy (OR: 1.96, 95%CI: 1.31–2.94). Furthermore, adolescents who were exposed to domestic and school violence were 82% more likely to have low confusion health literacy (OR: 1.82, 95% CI: 1.30–2.55; Table ). Sources of health information Adolescents who consulted 11 or more sources were 47% less likely to have low communication health literacy (OR: 0.53, 95% CI: 0.30–0.95) and three times more likely to have low confusion health literacy (OR: 3.12, 95% CI: 1.59–6.09) compared with those who referred to three or less sources (Table ). Demographic and socio-economic factors Adolescents who had fathers with an educational level higher than high school were 52% less likely to have low confusion health literacy (OR 0.48, 95% CI: 0.31–0.74). Having only a working mother was associated with 5.5 times higher odds of having low communication health literacy (OR: 5.50, 95% CI: 1.60–19.5). Furthermore, it was associated with almost three times higher odds of having low communication health literacy (OR: 3.17, 95% CI: 1.45–7.0) (Table ). 

Adolescents exposed to political violence were almost 2.65 times more likely to have low functional health literacy (Odds Ratio [OR]: 2.65, 95% Confidence Interval [CI]: 1.71–4.08). They were also approximately two times more likely to have low confusion health literacy (OR: 1.96, 95%CI: 1.31–2.94). Furthermore, adolescents who were exposed to domestic and school violence were 82% more likely to have low confusion health literacy (OR: 1.82, 95% CI: 1.30–2.55; Table ). 

Adolescents who consulted 11 or more sources were 47% less likely to have low communication health literacy (OR: 0.53, 95% CI: 0.30–0.95) and three times more likely to have low confusion health literacy (OR: 3.12, 95% CI: 1.59–6.09) compared with those who referred to three or less sources (Table ). 

Adolescents who had fathers with an educational level higher than high school were 52% less likely to have low confusion health literacy (OR 0.48, 95% CI: 0.31–0.74). Having only a working mother was associated with 5.5 times higher odds of having low communication health literacy (OR: 5.50, 95% CI: 1.60–19.5). Furthermore, it was associated with almost three times higher odds of having low communication health literacy (OR: 3.17, 95% CI: 1.45–7.0) (Table ). 

Principal findings This study identified factors associated with health literacy among Palestinian adolescents. Exposure to political violence was associated with low levels of confusion and functional health literacy, whereas exposure to domestic and school violence was associated with low confusion health literacy. Other variables associated with health literacy included the number of sources consulted, parents’ work, and fathers’ educational level. Exposure to political, domestic, and school violence were associated with lower levels of confusion and functional health literacy. Few studies have focused on the association between violence exposure and health literacy. In Brazil, the percentage of high literacy adolescents was lower than that of adolescents with poor health literacy among those who suffered from violence. However, this association was not statistically significant . Adolescents had lower academic achievement when they were exposed to physical or non-physical violence, whether it was linked to war or when they were at school . Better educational achievements during adolescence are associated with a higher level of health literacy in adulthood . Palestine has no signs of a solution to the political situation in the near future. It is vital for adolescents to invest in a safer school climate, accompanied by improved educational approaches, to develop their health literacy. This enables them to access, understand, evaluate, and apply relevant health information . In this study, almost two-thirds of the adolescents reported experiencing violence. Frequent direct or indirect exposure to violence makes adolescents vulnerable to psychological problems, such as distress . In Germany, health literacy levels were found to be lower among those with mental disorders (i.e. depression and mood disorders) . In another study conducted in the USA, moderate distress was related to lower levels of mental health literacy among college students . In this study, adolescents who consulted more sources were less likely to have low health literacy on the communication subscale and more likely to have low health literacy on the confusion subscale. Adolescents seek clarification from various sources, such as their parents, teachers, the community, and the health system . Therefore, receiving health information from various sources can encourage and increase adolescents’ ability to communicate, deal with, and ask questions with the ease and comfort of healthcare professionals. However, when the communication process and quality are inadequate, and information is unclear, it can lead to confusion which can eventually deteriorate health literacy and status . In this study, having too many sources might have contributed to the students’ confusion in processing the received information. This suggests that adolescents have lower critical health literacy. They may lack the skills to integrate and critically appraise information from a wide range of sources, thereby limiting their ability to make informed decisions regarding the determinants of health. Having a poor understanding of the impact of various events and situations on health can lead to incorrect decisions, which increase the risk of adverse health outcomes . Fathers’ educational level was significantly associated with confusion health literacy among adolescents. A similar association was observed among Palestinian and Chinese university students . Children and adolescents have higher health literacy when their parents have a postgraduate education . In Sri Lanka, adolescents whose fathers achieved higher levels of education had significantly higher mental health literacy and greater ability to recognise mental health problems . Additionally, educated parents likely possess adequate health information . They can spend quality time with their children to provide them with the necessary health information, which will eventually improve their children’s health literacy levels . Parents’ work was associated with health literacy levels. Having only a working mother was associated with higher odds of low health literacy in the communication subscale. Furthermore, having both working parents was associated with higher odds of low functional health literacy. Having only a working father suggests the availability of the mother, giving the adolescents the opportunity to spend more time with their mothers. It has been reported that African American adolescents tend to ask their mothers and not their fathers about their health . Therefore, when mothers are working, they spend less time with their children . This may affect the children’s health literacy and outcomes. However, studies in Palestine and Saudi Arabia have reported contradictory results, showing that working mothers are positively associated with their children’s health literacy . Other variables can also contribute to this association, such as the educational attainment of mothers and their time management ability. Future research should focus more on parental characteristics that might influence adolescents’ health literacy. Limitations This study uses a representative sample from the Ramallah and Al-Bireh Districts in Palestine. However, this study has some limitations. First, we could have missed some valuable information, given the differences in the demographic and socioeconomic characteristics of the other Palestinian districts. Second, the questionnaire was directed only towards adolescents; we did not collect data from parents. Consequently, we could not assess the influence of parental characteristics, such as demographic and socioeconomic factors (i.e. accurate level of income), exposure to violence, and, more importantly, health literacy and behaviours. This issue needs to be addressed in future studies. Third, we could not identify other studies that used the Health Literacy Assessment Scale for Adolescents which limited our ability to compare our results with those of other studies. This scale was chosen because it covers three important constructs of health literacy. Furthermore, we targeted seventh to ninth grade adolescents; however, we did not include older adolescents at the high school level. Therefore, we cannot generalise the results of this study to older adolescents as their health literacy may be predicted by different factors. Social desirability bias may be an additional limitation of this study, especially for questions about exposure to violence. The same may be true for the health literacy questions, where adolescents may have provided answers that were more favorable to others. However, to minimize the possibility of social desirability bias, we were strict in asking parents to conduct the interviews in a separate room where the fieldworker and the adolescent were alone. Finally, given the design of this study, causality cannot be inferred from the results. Future longitudinal research should be conducted to better understand the factors that influence health literacy among Palestinian adolescents, particularly exposure to violence. 

This study identified factors associated with health literacy among Palestinian adolescents. Exposure to political violence was associated with low levels of confusion and functional health literacy, whereas exposure to domestic and school violence was associated with low confusion health literacy. Other variables associated with health literacy included the number of sources consulted, parents’ work, and fathers’ educational level. Exposure to political, domestic, and school violence were associated with lower levels of confusion and functional health literacy. Few studies have focused on the association between violence exposure and health literacy. In Brazil, the percentage of high literacy adolescents was lower than that of adolescents with poor health literacy among those who suffered from violence. However, this association was not statistically significant . Adolescents had lower academic achievement when they were exposed to physical or non-physical violence, whether it was linked to war or when they were at school . Better educational achievements during adolescence are associated with a higher level of health literacy in adulthood . Palestine has no signs of a solution to the political situation in the near future. It is vital for adolescents to invest in a safer school climate, accompanied by improved educational approaches, to develop their health literacy. This enables them to access, understand, evaluate, and apply relevant health information . In this study, almost two-thirds of the adolescents reported experiencing violence. Frequent direct or indirect exposure to violence makes adolescents vulnerable to psychological problems, such as distress . In Germany, health literacy levels were found to be lower among those with mental disorders (i.e. depression and mood disorders) . In another study conducted in the USA, moderate distress was related to lower levels of mental health literacy among college students . In this study, adolescents who consulted more sources were less likely to have low health literacy on the communication subscale and more likely to have low health literacy on the confusion subscale. Adolescents seek clarification from various sources, such as their parents, teachers, the community, and the health system . Therefore, receiving health information from various sources can encourage and increase adolescents’ ability to communicate, deal with, and ask questions with the ease and comfort of healthcare professionals. However, when the communication process and quality are inadequate, and information is unclear, it can lead to confusion which can eventually deteriorate health literacy and status . In this study, having too many sources might have contributed to the students’ confusion in processing the received information. This suggests that adolescents have lower critical health literacy. They may lack the skills to integrate and critically appraise information from a wide range of sources, thereby limiting their ability to make informed decisions regarding the determinants of health. Having a poor understanding of the impact of various events and situations on health can lead to incorrect decisions, which increase the risk of adverse health outcomes . Fathers’ educational level was significantly associated with confusion health literacy among adolescents. A similar association was observed among Palestinian and Chinese university students . Children and adolescents have higher health literacy when their parents have a postgraduate education . In Sri Lanka, adolescents whose fathers achieved higher levels of education had significantly higher mental health literacy and greater ability to recognise mental health problems . Additionally, educated parents likely possess adequate health information . They can spend quality time with their children to provide them with the necessary health information, which will eventually improve their children’s health literacy levels . Parents’ work was associated with health literacy levels. Having only a working mother was associated with higher odds of low health literacy in the communication subscale. Furthermore, having both working parents was associated with higher odds of low functional health literacy. Having only a working father suggests the availability of the mother, giving the adolescents the opportunity to spend more time with their mothers. It has been reported that African American adolescents tend to ask their mothers and not their fathers about their health . Therefore, when mothers are working, they spend less time with their children . This may affect the children’s health literacy and outcomes. However, studies in Palestine and Saudi Arabia have reported contradictory results, showing that working mothers are positively associated with their children’s health literacy . Other variables can also contribute to this association, such as the educational attainment of mothers and their time management ability. Future research should focus more on parental characteristics that might influence adolescents’ health literacy. 

This study uses a representative sample from the Ramallah and Al-Bireh Districts in Palestine. However, this study has some limitations. First, we could have missed some valuable information, given the differences in the demographic and socioeconomic characteristics of the other Palestinian districts. Second, the questionnaire was directed only towards adolescents; we did not collect data from parents. Consequently, we could not assess the influence of parental characteristics, such as demographic and socioeconomic factors (i.e. accurate level of income), exposure to violence, and, more importantly, health literacy and behaviours. This issue needs to be addressed in future studies. Third, we could not identify other studies that used the Health Literacy Assessment Scale for Adolescents which limited our ability to compare our results with those of other studies. This scale was chosen because it covers three important constructs of health literacy. Furthermore, we targeted seventh to ninth grade adolescents; however, we did not include older adolescents at the high school level. Therefore, we cannot generalise the results of this study to older adolescents as their health literacy may be predicted by different factors. Social desirability bias may be an additional limitation of this study, especially for questions about exposure to violence. The same may be true for the health literacy questions, where adolescents may have provided answers that were more favorable to others. However, to minimize the possibility of social desirability bias, we were strict in asking parents to conduct the interviews in a separate room where the fieldworker and the adolescent were alone. Finally, given the design of this study, causality cannot be inferred from the results. Future longitudinal research should be conducted to better understand the factors that influence health literacy among Palestinian adolescents, particularly exposure to violence. 

This study provides baseline evidence on the factors associated with health literacy among Palestinian middle school students. It also provides baseline knowledge of the association between exposure to different forms of violence and low health literacy among adolescents. These results had significance not only for adolescents in Palestine and neighboring Middle Eastern countries, but also for regions globally affected by political instability, armed conflicts, and wars. This study identified the need for middle school students to acquire the skills required to analyse and integrate the health information they receive. Therefore, there is a need for regular interventions to increase their critical health literacy. This can be achieved through joint efforts between the health and education sectors. 

Below is the link to the electronic supplementary material. Supplementary Material 1 

