摘要
研究背景
目前,国际上对健康素养的定义仍不统一,世界上许多组织机构均对健康素养给出了自己的定义,比较公认的是世界卫生组织的定义。内涵是对概念的深化,因为对健康素养定义的不一致,国际上对健康素养的内涵及其维度的认知也差别较大。根据不同的研究背景和研究目的,健康素养的内涵研究通常基于两种类型的视角,即公共卫生的视角和临床的视角,这两种视角在研究对象、对健康关注的阶段及研究目标方面,均存在很大的不同。
2009年,《中共中央国务院关于深化医药卫生体制改革的意见》关于深化医药卫生体制改革的总体目标提出“人人享有基本医疗卫生服务”,要实现这一目标,不仅需要从“供方”的角度完善医疗卫生系统,也需要从“需方”的角度,促进居民对医疗卫生服务的合理利用。国际上探讨健康素养与居民卫生服务利用相关性的研究较多,作为一个重要的影响因素,健康素养不足对居民卫生服务的利用具有巨大的负面影响。国际上关于健康素养与卫生服务利用的相关研究,多是基于临床的视角,探讨健康素养对门急诊和住院利用的频次和程度的影响。而我国目前对健康素养的研究,多是基于公共卫生的视角,所用健康素养测评工具不宜用于评估临床环境中居民的健康素。但健康素养的测量,不能照搬国外的健康素养测量工具,首先直接翻译国外的量表,不符合我国的社会文化和语言背景。在我国现有的社会文化和语言背景下,简单照搬国外的测量方法行不通,如将量表直接翻译成中文版,容易产生语言系统隔阂和文化差异；其次,简单照搬国外的测量方法也不能反映我国居民的健康素养水平。不同的国家和不同时期应当有符合自己国家和时代特征的健康素养标准,在别的国家运行良好的健康素养测评工具,不一定符合我国民众的健康素养现况。
因此,本研究提出了以下三个研究问题：①基于临床视角的健康素养包括哪些维度?如何开发适合我国居民的基于临床视角的健康素养测评问卷?②山东省农村居民健康素养现状如何?其影响因素包括哪些方面?③基于临床视角的健康素养对农村居民卫生服务利用的影响如何?
研究目的
本研究的总体目标是开发基于临床视角的健康素养测评工具,了解山东省农村居民健康素养水平及其影响因素,探讨山东省农村居民健康素养对卫生服务利用的影响,为通过健康教育与健康促进等来提高农村居民的健康素养,进而促进其对卫生服务的合理利用提供相应的参考依据。具体目标分为：①开发基于临床视角的居民健康素养测评工具；②评估山东省农村居民健康素养水平并分析其影响因素；③探讨山东省农村居民健康素养对卫生服务利用的影响；④提出提高农村居民健康素养以改善农村居民对卫生服务利用的政策建议。
研究方法
健康素养测评工具的开发和检验方面,本研究在分析国际上各机构和组织对健康素养的定义,主要是世界卫生组织的定义的基础上,从临床的角度出发,根据文献分析的结果,首先对健康素养的维度进行界定。并在参考国内外健康素养测评工具的基础上,构建健康素养测评工具。对初步构建的问卷进行预调查和问卷的信度、效度检验,并根据预调查和问卷分析评价的结果,初步评价调查问卷的可行性,根据分析和评价的结果,对问卷进行修改,再次进行预调查和问卷的信度和效度的检验,直至形成具有良好信、效度的健康素养测评问卷。
本研究所用数据来自现场调查和二手资料。其中现场调查数据来自济南大学、山东省医学科学院医学与生命科学学院《农村居民健康知识与就医行为调查》研究,调查由山东省医学科学院下属单位山东省医药卫生科技信息研究所组织实施,在济南大学、山东省医学科学院医学与生命科学学院的协助下完成。二手资料主要包括卫生服务体系指标和山东省农村居民人均纯收入数据,其中卫生服务体系的相关指标来自2012年《山东省卫生统计年鉴》、农村居民人均纯收入数据来自2013年《山东统计年鉴》。本研究为横断面调查研究,于2013年6月进行。调查在兼顾经济状况和地理位置的基础上,抽样选择了6个具有一定代表性的地市：烟台、青岛、济南、泰安、菏泽和德州,分别位于山东省的东、中、西部,经济方面兼顾了经济好、中、差三方面。每市随机抽取2个县(市),再从每个县(市)随机抽取2个乡镇,每个乡镇随机抽取3个行政村,最后从每个行政村随机抽取20户左右的居民进行调查,对调查对象进行面对面的入户调查。共发放问卷1260份,回收有效问卷1194份,有效回收率为94.76%。本研究调查主要针对山东省农村居民,调查对象为16-85岁的农村居民。问卷调查包括健康素养、卫生服务利用和健康相关生命质量三部分。
统计学分析主要包括三部分：第一部分是现状描述,主要是调查对象的基本情况及卫生服务利用情况、山东省农村居民健康素养的现状及其影响因素,这一部分主要是采用描述性统计分析方法和单因素统计分析方法。其中分类变量主要采用率、构成比来进行描述。单因素统计分析主要用于比较不同分组之间各项指标的差异。本研究主要包括比较不同特征人群的健康素养差异,同时单因素统计分析还用于分析不同的一般状况、社会支持、健康素养、健康状况、卫生服务体系人群对卫生服务利用的差别,一方面分析卫生服务利用的影响因素,另一方面为自变量是否纳入多因素分析模型提供依据。主要采用Pearson卡方检验,如果不符合卡方检验的条件,则使用Fisher确切概率法。第二部分主要是分析健康素养对门诊卫生服务利用的影响,主要采用二元Logistic回归分析方法,用于健康素养对农村居民门诊卫生服务利用的影响分析,目的是在引入控制变量的情况下观察健康素养对农村居民门诊卫生服务利用的影响。第三部分主要是分析健康素养对住院卫生服务利用的影响,主要采用二元Logistic回归分析方法,目的是在引入控制变量的情况下观察健康素养对农村居民住院卫生服务利用的影响。自变量和模型的检验水准均取0.05。
主要研究结果
(1)健康素养测评工具的开发及检验：本研究概括了国际上各机构和组织对健康素养的定义,从临床的角度出发,在文献综述的基础上,将健康素养的维度界定为四个,即：①健康知识；②阅读和理解；③计算；④交流。并参考我国《首次中国居民健康素养调查报告》使用的健康素养调查问卷健康知识相关的问题,阅读材料来源于与常见病和慢病相关的健康相关材料,构建了健康素养调查问卷。经过2次预调查和信度、效度的检验,最终形成了具有良好信、效度的居民健康素养调查问卷。问卷共包含14个问题,其中：健康知识6个题目,内容主要涉及营养与食品卫生、慢病、传染病、心理卫生、常用标识的认知等方面的内容；阅读和理解4个题目,选取高血压相关的健康知识,测试受试者对信息的获取、理解、分析和使用的能力；计算部分选取某种药品的说明书,共3个题目,由易到难,考察受试者的计算能力。交流方面的内容,测试受试者能否在医疗环境中与医务人员有效沟通,1个题目。每个题目提供3个选择项,个别题目提供4个回答选择项。问卷总体答题时间控制在14分钟左右。
(2)山东省农村居民健康素养现状及其影响因素：健康知识中,对世界卫生组织推荐的食盐的摄取量知晓率较低,1194名调查对象中,仅有24.1%的被调查者答对。对慢性病的防治、传染病知识、医疗环境常用标识的知晓率较高,其中对“肥胖的人更容易得高血压”知晓率是82.2%；对“蚊子会传播疾病”的知晓率为76.5%；对“乙肝母婴传播”的知晓率为70.9%；对“OTC”标志的知晓率为62.0%。另外,大部分被调查者(91.9%)能够认识心理卫生对健康的重要性。得6分的为0人,得4分的比例最高,共432人,占36.2%,其次是得分为3、2、5者,分别为402、162、115人,分别占33.7%、13.6%、9.6%,全部答错或仅答对1个题目者为83人,占全部调查对象的7.0%。说明还有相当一部分农村居民的健康知识比较匮乏。阅读和理解部分4道题目,得4分的为170人,占14.2%,0分的有38人,占3.2%,得3分的为512人,占全部调查对象的42.9%,得2分的为354人,占29.6%。从结果可知,大部分调查对象可以正确理解和利用获得的信息,但也仍有部分被调查者阅读与理解能力较低。计算部分共3道计算题,得3分的为53.4%,得2、1、0分的分别占25.8%、14.7%、6.1%,说明大部分被调查者计算能力较强,但仍有部分农村居民对用药的计算并不准确。交流方面,有865人选择了能准确地向医生介绍病情,占全部调查对象的72.4%,还有27.6%(329人)认为在向医生介绍病情时,存在一定的困难。
健康素养的影响因素主要是年龄、文化程度、婚姻状况、职业和收入。不同年龄段的农村居民,其健康知识、阅读理解能力、计算能力和沟通能力存在差异。健康知识、阅读理解能力、计算能力和沟通均呈现随年龄增加而下降的趋势。文化程度对健康素养的四个维度均有影响,健康知识、阅读理解能力和计算能力均随文化程度增高而增强。沟通能力方面,大专及以上学历的农村居民自认可以有效介绍病情的比例远高于小学及以下者。婚姻状况对健康素养四个维度方面的影响均一致,在健康知识、阅读理解能力、计算和沟通能力四个方面,均是未婚农村居民的水平高于已婚,而离婚和丧偶的农村居民各方面的水平最低。职业对对健康素养的四个方面均有影响。另外,收入仅对健康素养四个维度中的沟通这一维度有影响,收入水平高的农村居民,自认沟通无问题的比例高收入水平低的农村居民。
(3)低健康素养对农村居民门诊卫生服务的利用有负面影响。单因素分析结果表明,健康素养的四个维度中,健康知识(X2=26.207,P<0.001)、阅读和理解(X2=16.211,P=0.003)两个维度对农村居民门诊卫生服务利用的影响有统计学意义,健康知识对患者四周就诊率的影响呈倒U形,得分为3的农村居民患病后患者四周就诊率最高,为86.73%,其次是得分为2、4的农村居民,患者四周就诊率分别为77.78%、76.07%,患者四周就诊率最低的则是得分为0-1、5的农村居民,患者四周就诊率分别是69.23%、45.95%。阅读理解能力对农村居民患者四周就诊率的影响,除了得分为1的组别,其余各组的趋势是得分越高,患者四周就诊率则越低,而计算能力(X2=6.060,P=-0.109)、沟通能力(X2=3.312,P=-0.069)对农村居民门诊卫生服务利用的影响没有统计学意义。多因素分析结果中,健康素养的四个维度中,健康知识、计算、沟通三个维度对农村居民患者四周就诊率的影响均没有统计学意义(均P>0.05),但阅读理解能力对农村居民患者四周就诊率的影响有统计学意义(P=-0.020),阅读和理解能力越高的农村居民,患者四周就诊率越低(OR=-0.684),低健康素养对农村居民门诊卫生服务的利用有负面影响。
低健康素养对山东省农村居民住院卫生服务的利用也有负面影响。单因素分析结果表明,健康素养的四个维度健康知识(X2=26.037,P<0.001)、阅读理解(X2=39.152,P<0.001)、计算(X2=10.445,P=0.015)和沟通(X2=4.523,P=0.033)对农村居民住院卫生服务利用的影响均有统计学意义。其中,健康知识得分越高,住院率越低,健康知识得分为5的农村居民,住院率只有1.74%,而得分0-1的农村居民,住院率则高达20.48%；阅读理解能力得分越高的农村居民,其住院率越低,得分为4的农村居民,其住院率只有2.94%,而得分为0的农村居民,其住院率则高达23.68%；计算能力越高的农村居民,其住院率越低；沟通方面,认为自己在就诊时和医生沟通完全没问题的农村居民,其住院率为8.67%,低于沟通有问题组(12.77%)。多因素分析结果中,健康素养四个维度中,健康知识(P=0.043)和阅读理解能力(P<0.001)对农村居民住院率的影响有统计学意义,其中健康知识得分越高,住院率越低；阅读理解能力越强,住院率越低(OR=0.798；OR=0.617)。计算能力(P=0.603)和沟通能力(P=0.799)对农村居民住院率的影响则没有统计学意义。
结论与政策建议
本研究从临床的角度出发,将健康素养的维度界定为四个,即健康知识、阅读和理解、计算和沟通。构建了具有良好信、效度的健康素养调查问卷。我省农村居民健康素养较低的情况普遍存在。还有相当一部分农村居民的健康知识非常匮乏,部分农村居民阅读与理解能力较低,大部分农村居民具备较强的计算能力,但仍有一部分农村居民对用药量的计算并不准确,有待加强；在沟通维度方面,大部分人能准确地第向医生介绍病情,但仍有将近30%的农村居民自认为在向医生介绍病情时,存在一定的困难。健康素养的影响因素主要是年龄、文化程度、婚姻状况、职业和收入。低健康素养对农村居民门诊和住院卫生服务利用均具有负面影响。健康素养四个维度中,健康知识、计算、沟通三个维度对农村居民患者四周就诊率的影响均没有统计学意义,仅阅读理解能力对农村居民患者四周就诊率的影响有统计学意义,阅读和理解能力越低的农村居民,患者四周就诊率越高；阅读和理解能力越高的农村居民,患者四周就诊率越低。健康素养水平也可以影响住院卫生服务的利用。健康素养四个维度中,健康知识、阅读和理解能力对农村居民住院率的影响有统计学意义,其中健康知识得分越低,住院率越高,健康知识得分越高,住院率越低；阅读理解能力越低,住院率越高,越读理解能力越强,住院率越低。
为了提高我省农村居民的健康素养,从“需方”的角度促进卫生服务的合理利用,本研究提出了以下政策建议：
(1)进一步优化健康素养评价工具,合理设置健康素养评价标准。我国健康素养研究应在借鉴国外研究成果的同时,根据我国的现实情况,考虑临床视角和公共卫生视角的不同侧重点,探讨健康素养内涵结构的本土化,进一步优化健康素养评价工具,合理设置健康素养评价标准,在此基础上建立科学的健康素养评价体系。
(2)有针对性地逐步推进我省农村居民健康素养的提升。促进我省农村居民健康素养的提升需要针对不同的群体,分别采取不同的措施,有针对性地、渐进地进行。在提高健康素养的方式方面,需要根据我省农村居民健康素养的现状,研究适合我省农村居民的健康教育所需的材料和方法。行为干预方面,可以利用村委会或基层医疗机构、学校的场所来进行。另外,农村居民健康素养教育应当是渐进的,而且是终生的。
(3)发挥卫生服务提供者在促进健康素养中的作用,促进农村居民对卫生服务的合理利用。提高卫生服务提供者在促进健康素养中的作用,对于改善医患沟通效果、提高患者的依从性,进而促进卫生服务的有效利用,具有十分重要的意义。卫生服务机构和医务人员需加强对健康素养问题的认识,提高沟通意识和沟通技巧。医疗卫生服务机构可以依据我省农村居民的健康素养水平通过采用适宜的健康相关材料、控制信息量、专业术语的日常化、评价健康相关信息的理解效果等措施来促进患者对健康相关信息的获取和理解。另一方面,临床医务工作者应重视健康素养在医患沟通中的作用,采取相应的措施,加强引导,减少使用复杂的专业术语,改善医患沟通的效果,确保患者能理解并正确执行医嘱,达到预期疗效,保证卫生服务的有效利用。
创新与不足
本研究的创新性：(1)目前我国对健康素养维度的界定,多是基于公共卫生的视角。本研究从临床的视角出发,在世界卫生组织关于健康素养定义的基础上,基于文献分析,并结合本研究的研究背景和研究目的,确定了健康素养内涵的四个维度：健康知识、阅读理解、计算和交流。(2)目前我国对健康素养的测评工具多是基于公共卫生的视角,本研究自行开发设计了符合我国语言文化环境的、适用于临床环境的居民健康素养测评问卷。(3)本研究采用二分类Logistic回归分析,在引入农村居民个体特征、健康状况、社会支持、卫生服务体系控制变量的基础上,基于临床的视角,探讨了农村居民个体健康素养对其门诊和住院卫生服务利用的影响,为从农村居民个体因素方面改善卫生资源的利用效率从而实现新医改提出的“人人享有基本医疗”的基本目标,提供了科学依据。
本研究的不足：(1)本研究的现场调查只在山东省部分农村地区进行,只是分析了山东省农村居民健康素养对卫生服务利用的影响。受样本量的限制,本研究的结论外推到全国其他地区尚需谨慎。进一步的研究应在更大的范围内展开调查,以进一步验证健康素养对农村居民卫生服务利用的影响。(2)本研究是横断面研究,只是分析了某个时间点居民的健康素养对卫生服务利用的影响,未对居民的健康素养进行干预,得出的结论可能有一定的局限性。
Background
At present, although many organizations have given their own definitions of health literacy, there hasn't been an internationally agreed definition of health literacy, among which the World Health Organization's definition is more accepted. Connotation is the profound concept, and the international understandings of health literacy connotation and its dimensions are also quite different as to the different definitions of health literacy. Depending on different research background and purposes, researches about health literacy connotation are usually based on two perspectives:a clinical perspective and a public health perspective, which are quite different in the study objects, health stage and research goals.
In2009"Opinions of the CPC Central Committee and State Council on Deepening the Health Care System Reform", the overall goal of deepening the health care system is proposed as "universal access to basic health services". To achieve this goal, improving the health system only considering the "supply side" is not enough, and to promote the residents' rational use of health care services from the "demand-side" perspective is also needed. There are many studies to exploring the roles of health literacy on residents health services internationally, and as an important factor, insufficient health literacy has a huge negative impact on residents health services utilization. Most of the international researches of the impact of health literacy on health service use are from the clinical perspective, and explore the impact of health literacy on emergency and hospitalization utilization frequency and extent. Most of current domestic studies on health literacy are based on the public health perspective and the health literacy assessment tools should not be used to evaluate the residents health literacy in the clinical environment, and then to study the effects of health literacy on health services utilization. However, the measurement tools of health literacy, can't be copied abroad, because the scales directly translated from the abroad do not necessarily conform to our country's social, cultural and linguistic background. In the existing socio-cultural and linguistic backgrounds of our country, simply following the measurement methods abroad does not work. Firstly, if the scales are directly translated into Chinese, there will be language barriers and cultural differences; secondly, simply follow the measurement methods abroad also does not reflect the health literacy level of domestic residents. Different countries and different periods should be in line with the health literacy standards of their own country and the era, and the well-run health literacy assessment tools in other countries would not necessarily be in line with the current status of health literacy of our country.
Therefore, this study puts forward the following three research questions:(1)What dimensions are included in health literacy form the clinical perspective? How to develop the health literacy assessment questionnaire suitable for our residents from the clinical perspective?(2) What is the health literacy status of rural residents in Shandong Province? And its influencing factors include what?(3) Whetherthe health literacy based on clinical perspective can affect residents utilization of health services?
Objectives
The overall objective of this study is to develop a health literacy assessment tool from clinical perspective, and understand the current status of the health literacy of rural residents in Shandong Province and its influencing factors, and to explore the effect of health literacy on rural residents health services utilization in Shandong Province, thus to provide reference for promoting the rational use of health services through improving the health literacy of rural residents by health education and health promotion. The specific objectives are divided into the following four parts:(1) to develop a residents' health literacy assessment tool based on clinical perspective;(2) to assess the current status of the health literacy of rural residents in Shandong Province and to analyze its influencing factors;(3) to explore the effect of health literacy on rural residents health services utilization in Shandong Province;(4) to propose policy recommendations for increasing rural residents' health literacy and then to improve rural residents health services utilization.
Methods
From the respect of development and testing of health literacy assessment tools, this study analyzed the definition on health literacy of international agencies and organizations, mainly the World Health Organization, and then defined the dimensions of health literacy from a clinical perspective according to the literature analysis results. The health literacy assessment tool was developed based on the reference to domestic and foreign health literacy assessment tools. The pre-survey was conducted, and the reliability and validity of the initial constructed questionnaire were tested. According to the results of the pre-survey and questionnaire analysis, the feasibility of the questionnaire was preliminarily evaluated, and the questionnaire was modified according to the results. Then we conducted pre-survey and analyed the reliability and validity of the questionnaires, until health literacy assessment questionnaire with good reliability and validity was formed.
Data used in this study was from site survey and secondary sources. Site survey data was collected from the study of "Health Knowledge and Health Seeking Behaviors Survey of Rural Residents" of College of Medicine and Life Sciences, Jinan University&Shandong Academy of Medical Sciences. The survey was conducted by Shandong Institute of Medicine and Health Information, and was assisted by College of Medicine and Life Sciences, Jinan University&Shandong Academy of Medical Sciences. The secondary data included health care system indicators (from2012"Health Statistics Yearbook of Shandong Province") and per capita net income data od of rural residents in Shandong Province (from the2013"Shandong Statistical Yearbook"). This study was a cross-sectional survey, conducted in June2013. Considering the economic situation and geographical location, six cities with different economic levels were selected:Yantai, Qingdao, Jinan, Tai'an, Heze and Dezhou. These six cities are located in the eastern, central and western districts of Shandong province respectively. Two counties (cities) were randomly selected from each city, and then two towns were randomly selected from each county (city), and three administrative villages were randomly selected from each town, and in the last20or so residents were randomly selected from each administrative village to investigate. The survey was conducted face to face.1,260questionnaires were distributed and1,194valid questionnaires were collected, the effective rate was94.76%. This study focused on the rural residents in Shandong Province, and the survey objects were aged from16to85. The questionnaire included three parts:health literacy, health care utilization and health-related life quality.
Statistical analysis consisted of three parts:The first part described the status quo of the basic information and health services utilization of the investigation objects, the health literacy status of rural residents in Shandong Province and its influencing factors. This part was mainly analyzed with descriptive statistical analysis method and univariate statistical analysis. Categorical variables are described as rate and proportion. Univariate statistical analysis was used to compare the differences between the main indicators of different groups. Univariate statistical analysis was also used to analyze the effect of general information, social support, health literacy, health status and health service system on the health service utilization, which could provide the basis for the multivariate analysis. The univariate statistical analysis was mainly used Pearson chi-square test,and if the data did not meet the chi-square test, Fisher exact test was used. In the second part, the impact of health literacy on health service utilization was analyzed by using binary Logistic regression analysis, and the purpose was to analyze the impact of health literacy on the residents outpatient health services utilization in the case of taking into account the control variables. In the third part, the impact of health literacy on residents hospital utilization was analyzed by using primarily using binary Logistic regression analysis, and the purpose was to analyze the impact of health literacy on the residents hospital services utilization in the case of taking into account the control variables. And the test standards for independent variables and the models were both0.05.
Main results
1. The health literacy assessment tool development and test:this study summarized the definition of different agencies and organizations on health literacy, and defined the health literacy as four dimensions based on the literature review from the clinical perspective:health knowledge, reading and comprehension ability, numeracy and communication. The health knowledge related questions with reference to the health knowledge questions of the "Report of the First Health Literacy Survey of Chinese Residents"; and the relevant reading material was from a common and chronic diseases related materials. After two times of the pre-survey and the reliability and validity test, the health literacy questionnaire was eventually formed with a good reliability and validity. The questionnaire contained14questions including:(1) six health knowledge questions, mainly related to the content of nutrition and food hygiene, chronic diseases, infectious diseases, mental health, the health direction;(2) four reading and comprehension questions related with hypertension knowledge, testing the subjects ability of accessing to, understanding, analyzing and using of the information;(3) numeracy section included three questions related with a drug manual from easy to difficult, testing the subjects calculating ability;(4) communication section, just one question, tested the subjects communication ability with medical staffs in the medical environment. Each question offered three options, or four answer choices. The overall answer time was more or less14minutes.
2. The status of health literacy of rural residents in Shandong Province and its influencing factors:
(1) In health knowledge, the awareness rate of salt intake recommended by the World Health Organization was low (only24.1%). And the awareness of chronic disease prevention, infectious disease knowledge, directions in health care environment was high, in which the awareness rate of "obese people are susceptible to high blood pressure" was82.2%, of "mosquito spread disease" was76.5%, and of "mothers can transmit of hepatitis B to child" was70.9%, and of "OTC" meaning was62.0%. In addition, the majority of respondents (91.9%) could recognize the importance of mental health on health. No one scored6, the highest proportion was of the group scored4points(432people,36.2%), followed by a score of3,2,5, respectively, accounting for33.7%,13.6%and9.6%respectively.83objects scored0or1, accounting for7.0%of all survey objects. These results indicated there were a considerable number of residents in health knowledge relatively deficient. In reading and comprehension parts, there were four questions.170objects scored4, accounting for14.2%,38people (3.2%) scored0,512objects scored3, accounting for42.9%of all respondents, and354objects scored2, accounting for29.6%. The results showed that the majority of respondents could correctly understand and use the information, but there were still some respondents had lower reading and comprehension skills. In calculation part, there were three questions,53.4%objects scored3, and objects scored2,1,0accounted for25.8%,14.7%,6.1%respectively, which indicated a majority of residents had higher calculation capability, but there were still some residents with lower calculation capability. In communication section, there were865people could communicate with doctors accurately, accounting for72.4%, as well as329people (27.6%) thought there were some difficulties to communicate with the doctors.
(2) The main affecting factors of health literacy were age, education, marital status, occupation and income. Residents of different ages had differences in their health knowledge, reading and comprehension ability, numeracy and communication skills. Health knowledge, reading and comprehension, numeracy and communication skills showed a downward trend with increasing age. Educational level affected the four dimensions of health literacy, among which health knowledge, reading and comprehension, numeracy skills were enhanced with increased education. And in the communication skills respect, the proportion of residents who could effectively communicate with the doctors was higher in those with college and higher education than those with primary school and below. Impact of marital status on the four dimensions of health literacy were consistent, the levels in health knowledge, reading and comprehension, numeracy and communication skills dimensions were all highest in unmarried residents, and higher in married residents,and lower in divorced and widowed residents. Occupation affected the four aspects of health literacy. In addition, the income only affected communication dimension, the proportion of communicating with doctors efficiently was higher in high-income residents than that in low-income residents.
3. Low health literacy of rural residents had a negative impact on the use of outpatient health services. Univariate analysis showed that health knowledge (X2=26.207, P<0.001), reading and comprehension (X2=16.211,P=0.003) dimensions the four dimensions of health literacy had impact on the outpatient health services utilization of rural residents. And the curve of the effect of health knowledge on the patients four-week consultation rate showed inverted U-shaped. Residents scored3had the highest patients four-week consultation rate for86.73%, followed by those scored of2,4, the patients four-week consultation rates were77.78%,76.07%respectively, and the lowest patients four-week consultation rate were69.23%,45.95%respective for those scored0-1and5. The effect of reading and comprehension on the patients four-week consultation rate of rural residents showed a trend of the higher the score, the lower the patients four-week consultation rate except those scored1. While the calculation dimension (X2=6.060, P＝0.109) and communication dimension (X2=3.312, P=0.069) didn't have statistically significant impact on the outpatient health services utilization of rural residents. Multivariate analysis results indicated that health knowledge, calculation, communication dimensions didn't affect patients four-week consultation rate (P>0.05), but reading and comprehension affected the patients four-week consultation rate of (P=0.020), the higher the reading and comprehension level, the lower the patients four-week consultation rate (OR=0.684). Low health literacy had a negative impact on outpatient health services of rural residents.
Low health literacy also had a negative impact on hospital utilization of health services in rural residents in Shandong Province. Univariate analysis showed that health knowledge (X2=26.037, P<0.000), reading and comprehension (X2=39.152, P<0.000), calculation (X2=10.445, P=0.015) and communication(X2=4.523, P=O.O33) dimensions of health literacy affected hospitalization rate of rural residents. The higher the health knowledge score, the lower the hospitalization rate. The hospitalization rate of those scored5was only1.74%, while those scored0-1was as high as20.48%. The reading and comprehension score higher, the lower the hospitalization rate. The hospitalization rate of those scored4was only2.94%, and the hospitalization rate of those scored0was as high as23.68%. The higher the calculation, the lower the hospitalization rate. In communication aspects,the hospitalization rate of those who thought there was no problem in communicating with doctors was8.67%, which was lower than that of those with communication problem (12.77%). Multivariate analysis results showed that in the four dimensions of health literacy, health knowledge (P=0.043), reading and comprehension (P<0.000) affected the hospitalization rate of rural residents.The higher the health knowledge score, the lower the hospitalization rate; and the higher the reading comprehension score(OR=0.798), the lower the hospitalization rate(OR=0.617). Calculation (P=0.603) and communication skills(P=0.799) had no effect on the hospitalization rate of rural residents.
Conclusions and Recommendations
This study defined health literacy as four dimensions from a clinical point of view, namely health knowledge, reading and comprehension, calculation and communication, and constructed health literacy questionnaire with good reliability and validity. Low health literacy is common in the rural residents of Shandong Province. There is a considerable part of the population with deficient health knowledge, and part of residents have lower reading and comprehension level. Most of the residents have high calculation ability, but some residents still can't calculate the amount of the drugs accurately, and their calculation ability needs to be strengthened. In communication dimension, most people can accurately describe the condition to the doctor, but there are still nearly30%residents can't communicate with the doctors efficiently. The main affecting factors of health literacy are age, education, marital status, occupation and income. Low health literacy has negative impacts both on outpatient and hospitalization utilization of rural residents. In four dimensions of health literacy, health knowledge, calculation, and communication dimensions have no influence on patients four-week consultation rate of rural residents. And only the reading and comprehension ability can affect the four-week consultation rate of rural residents, the lower the reading and comprehension ability,the higher the four-week consultation rate. Health literacy can also affect the hospitalization services use. In four dimensions of health literacy, the impacts of health knowledge, reading and comprehension ability on hospitalization rates are statistically significant. The lower the health knowledge level, the higher the hospitalization rate, and the higher the health knowledge score, the lower the hospitalization rate. And the lower the reading comprehension capacity, the higher the hospitalization rate;and the higher the reading and comprehension capability, the lower the hospitalization rate.
In order to improve the health literacy of rural residents in our province, and to promote the rational use of health services from the "demand side" perspective, the study proposes the following policy recommendations:
(1) To further optimize health literacy assessment tools, and to establish reasonable evaluation criteria of health literacy. Domestic studies of health literacy should learn from foreign research results,and explore the localization of health literacy structure and connotation according to China's realities, from public health and clinical perspective,and then further optimize health literacy assessment tools, and then set a reasonable evaluation criteria, and finally establish a scientific evaluation system of health literacy on this basis.
(2) To promote the health literacy of rural residents in our province purposefully and gradually. To improve health literacy of rural residents needs targeting different groups, and taking different measures,conducting gradually. Materials and methods should be studied to improve health literacy according to the health literacy status of our province. Behavioral interventions can be conducted by the villages or primary medical institutions or schools. In addition, residents'health literacy education should be gradual, and is lifelong.
(3) To play the roles of health service providers in the promotion of health literacy, and to promote the rational use of the health services of residents. To improve the role of health service providers in health literacy promotion is very important for improving doctor-patient communication effects, patient compliance and effective use of health services. Health services and medical personnel need to pay more attention to the health literacy issues, and improve communication awareness and communication skills. Medical services can adopt appropriate health-related materials, control the amount of information,less use of terminologies and evaluate the understanding effect of health-related information be based on the health literacy level of rural residents of our province.And these measures would be helpful for patients access to and understanding of health-related information. On the other hand, medical personnel should pay attention to the role of health literacy in the physician-patient communication, and take appropriate measures to guide patients with reducing use of terminologies, which would improve the doctor-patient communication effect, and ensure that patients can understand and correctly follow the doctors'advice to achieve the desired effect, and to ensure the effective use of health services.
Innovations and Limitations
1. The innovations of this research are as following:
(1) Presently,domestic definitions of health literacy dimensions are mostly from public health perspective.This study summarized the health literacy definition of World Health Organization and review the health literacy related literatures,and then defined the health literacy as four dimensions for the first time from the clinical perspective and taking into account the background and purpose of this study:health knowledge, reading and comprehension ability,numeracy and communication.
(2) At present, domestic assessment scales of health literacy are mostly from public health perspective. This study developed the health literacy assessment questionare in line with our language and cultural environment and suitable for the clinical environ-ment for the first time.
(3) This study, using binary Logistic regression analysis, and with introduction of resident individual characteristics, health status, social support and health service system as the control variables, explored the roles of health literacy on outpatient and hospitalization service use for the first time from clinical perspective. This will provide a scientific basis for chieving the basic goal of the "universal access to basic health care" proposed by the new health care reform by improving the utilization efficiency of resources from the individual aspects.
2. The limitations of the research:
(1) The investigation of this study was carried out only in rural area of Shandong Province, and analyzed the impact of health literacy on health services utilization of rural residents only in Shandong Province. Limited by the sample size, it is should be cautious to apply the conclusions of this study in other areas. Further research should investigate in a greater scope to further verify the impact of health literacy on health service utilization of rural residents.
(2) The study was cross-sectional, and analyzed the impact of health literacy on health services utilization just a particular point in time, and didn't take interventions on the residents'health literacy, therefore the conclusion might have some limitations.
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