城市公众健康素养快速评估与短信干预系统的构建与应用研究
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摘要
背景：
我国慢性病的患病和死亡呈不断上升趋势,己成为严重威胁公众健康的重要公共卫生问题。提升公众健康理念和健康素养水平、加强自我健康管理技能、转变不良生活和行为方式,是维护和促进公众健康的必要举措。健康素养己成为多个国家衡量公众健康素质高低的重要指标之一。国外开展健康素养研究较早,目前其内涵及评估研究亦比较成熟,已有12个健康素养模型、17个不同的健康素养概念、35种不同的健康素养评估方法。国外常用的评估工具主要有成人功能性健康素养测试(TOFHLA)、成人医学素养快速评估(REALM)和最新Newest Vital Sign测量工具(NVS),其中REALM、NVS因评估时间较短备受使用者欢迎。我国于2005年引入健康素养概念,2008年开展全国首次调查共79个条目,2012年的评估增至103项,所用评估时间超过20分钟。我国各地区开展的监测与评估研究多以国家问卷为参考,评估内容也较多,费时、费力。国内应借鉴国外的健康素养快速评估思路,结合我国健康教育与健康素养工作实际,研发适合我国实情的健康素养快速评估工具。科学的评估是为开展有效干预的重要前提,是选取适宜干预技术的主要依据。立足于城市公众健康管理,探索适宜全人群健康教育干预形式有着重要的意义。作为新媒体,短信有着受众面广、查看率高、管理灵活、成本较低、针对性强、再传播性好等特点,已在国内外被用于高血压、糖尿病、孕产妇、肾病等特殊人群的干预,用短信形式针对城市公众开展大规模的教育与干预尚未有相关报道。低健康素养与医疗卫生服务利用不足、疾病诊断延迟、对医疗状况和治疗理解不够、自我健康管理技能差不足、健康状况差、死亡率高有关,因此,立足于城市健康管理层面,将健康素养、健康管理和健康状况有机结合起来,构建健康素养快速评估,寻求切实有效的干预方法,对公众实施健康素养干预,提高其自我健康管理能力,促进其健康状况有着积极的意义
目的：
本研究拟探索出符合实际的、科学的、便于操作的公众健康素养快速评估与短信干预系统,将公众健康素养评估与其强化干预行为结合起来,将公众健康素养和自我健康管理联动起来,最终达到促进公众提升健康素养和健康状况的目的,为深化和完善城市公众健康素养教育干预以及实施公众健康管理工作提供重要决策依据。
方法：
本研究主要应用文献检索法、专题小组研讨、德尔菲法、现场横断面调查法、准实验研究等方法。
首先利用文献检索法对健康素养、健康管理以及健康状况的内涵、评估以及关联等状况进行课题背景研究,掌握国内外的进展状况以及存在的问题,并结合深圳健康教育工作的实际,提出创新的研究思路和研究内容,同时为下一步进行健康素养新内涵研究提供依据。
接着通过研究以入户调查方式所收集的深圳公众健康素养横断面调查数据(按照分阶段抽样方法调查了深圳32个社区6413位居民,问卷有效率为98.66%),深入分析公众健康素养、健康管理以及健康状况及其影响因素,为构建实际有效的健康素养快速评估系统提供现实性依据。
然后采用跨学科研究提出有利于健康教育工作发展的健康素养新内涵、新模型,并以德尔菲专家咨询法为主,咨询24位来自高校、医院、卫生行政、健康教育、疾控等机构的专家,在结合深圳现实依据的基础上构建健康素养快速评估系统的评价指标体系。
最后开展准实验研究,将原有的社区分为干预组和对照组,对干预组愿意参与短信干预的2863人实施短信干预,开展终期调查共回收干预组和对照组6400份问卷(问卷回收率为99.22%),利用新构建的健康素养快速评估系统进行评估,验证短信干预对提升公众健康素养和健康水平的有效性。
本研究使用SPSS21.0软件进行描述性统计、方差检验、卡方检验、t检验、Logistic回归、分层聚类分析、相关分析等统计分析,使用AMOS21.0进行验证性因子分析。
结果：
1、利用原健康素养评估系统和健康素养标准评估深圳公众的健康素养现状,为构建快速评估系统提供依据
(1)深圳公众健康素养水平不高。深圳具备健康素养的比例为6.28%,总体健康知识素养水平为59.86%、健康行为素养水平为66.94%、健康素养技能水平为59.32%。经Logistic回归分析,年龄组(OR=1.09)、性别(OR=1.79)、户籍(OR=0.67)、文化程度(OR=1.76)、家庭人口(OR=0.75)、健康管理(OR=1.67)等是深圳公众健康素养的影响因素。
(2)深圳公众健康意识不高。深圳公众只有30.91%的居民评价生活和行为方式因素是影响健康最主要的因素,远低于与WHO发布值60%,两者存在统计学差异(χ2=38.36,P<0.001)。经Logistic回归分析,深圳户籍(OR=1.23)、文化程度高(OR=1.23)、个人收入高(OR=1.12)、不吸烟(OR=1.16)、每年体检1次(OR=1.25)、每周锻炼2-3次以上(OR=1.25)、自我健康评价状况好(OR=1.18)、没有两周患病情况(OR=0.83)是正向影响因素,其评价生活和行为方式因素影响健康的比例偏高,而其他婚姻状况(离异和丧偶)(OR=0.78)、医疗花费高(OR=0.96)是负向影响因素。
(3)深圳公众自我健康管理比例不高。深圳公众仅有29.47%的居民进行了基本的自我健康管理。经二项分类Logistic回归分析显示,年龄高(OR=1.22)、性别(OR=1.20)、文化程度高(OR=1.24)、个人月收入高(OR=1.07)、家庭人口数多(OR=1.23)、深圳户籍(OR=)1.13、患有慢性病(OR=)1.22是自我健康管理的影响因素。深圳公众不同健康管理状况总健康素养(χ2=92.0,P<0.001)、健康知识(χ2=30.98,P<0.001)、健康行为素养比例(χ2=116.98,P<0.001)均有统计学意义。有健康管理的公众总健康素养、健康知识、健康行为素养比例相对较高。
(4)深圳公众自我健康评价况有待改善。深圳公众仅有62.42%的自我健康评价好。自我健康评价状况好的影响因素是年龄组(OR=0.75)、性别(OR=0.70)、婚姻(OR=0.87)、个人收入(OR=1.19)、饭前便后洗手(OR=1.25)、每天刷牙(OR=1.10)、每天睡眠7-8小时(OR=1.10)、按处方购买抗生素服用(OR=1.36)、很少有压力(OR=1.58)。
(5)深圳公众的两周患病、慢性病患病、住院等健康状况均与健康行为素养等存在关系。经Logistic回归分析,两周患病的影响因素是年龄(OR=0.81)、户籍(OR=1.41)、婚姻(OR=0.83)、文化程度(OR=0.92)、个人收入(OR=1.19)、家庭人口数(OR=0.93)、不吸烟(OR=1.34)、每天刷牙(OR=1.16)、每天睡眠7-8小时(OR=1.23)、按处方购买抗生素服用(OR=1.35)、每年1次体检(OR=1.21)、很少有压力(OR=1.48)；慢性病患病影响因素为年龄(OR=0.49)、户籍(OR=1.39)、个人收入(OR=1.17)、家庭人口数(OR=0.95)、不饮酒(OR=0.81)、经常开窗通风(OR=0.80)、每天刷牙(OR=1.39)、每天睡眠7-8小时(OR=1.14)、按处方购买抗生素服用(OR=1.26)、每年1次体检(OR=0.84)、很少有压力(OR=1.56)；住院的影响因素是性别(OR=0.61)、户籍(OR=1.36)、婚姻(OR=0.64)、文化程度(OR=1.15)、家庭人口数(OR=0.92)、不吸烟(OR=1.66)、饭前便后洗手(OR=1.40)、按处方购买抗生素服用(OR=1.34)、很少有压力(OR=1.24)。
2、健康素养新模型和健康素养快速评估系统指标体系构建
(1)健康素养新模型
综合国内外研究,结合深圳健康教育工作实际,本研究提出了健康素养新内涵：“一种获取健康知识信息,并用于优化自我健康管理,促进和形成一定的健康行为与健康技能水平,从而达到改善健康状况的能力和过程”,并提出狭义的三维度“健康知识-健康行为-健康技能模型”和广义的四维度“健康知识-健康行为-健康技能-健康水平”模型。为便于个体和群体健康素养水平的确定,本研究参照国外TOFHLA的健康素养界定标准,使用总分的60%和75%作为截位值将健康素养水平分成低健康素养、高健康素养和边际健康素养三个层面。
(2)健康素养快速评估系统构建
根据系统性、简明性、灵敏性和可持续性原则,本研究利用德尔菲法,结合分层聚类分析和健康素养影响因素状况构建健康素养快速评估系统。参与咨询的24位专家的权威程度为0.87,两次咨询的积极系数为100%,协调系数Kendall'sW为0.41,专家提供的意见可靠、可信。根据咨询结果和分层聚类分析以及基于各层健康素养水平的影响因素等实际依据,确定三维健康素养快速评估系统的核心评价指标包括20项,其中包括知识素养和行为素养各8项、技能素养4项,权重分别为40%、40%和20%；四维健康素养快速评估系统的核心评价指标包括20项,其中包括知识素养和行为素养各7项、技能素养4项、健康水平2项,权重分别为35%、35%、20%和10%。三维度和四维度健康素养快速评估系统与原健康素养评估系统的关联效度分别为0.89和0.86,三维度和四维度系统之间的相关系数为0.96。验证性因子分析证实其具有较好的适配度,GFI、AGFI、NFI、IFI、TLI和CFI的值都接近0.9。
(3)健康素养快速评估系统平均评估时间5.9分钟,比原评估系统13.2分钟快7.3分钟。
3、利用健康素养快速评估系统对短信干预效果进行评估
(1)健康素养水平变化
经过一年时间的短信干预,短信平台共针对干预组2863名对象人均发布60条,共160250条健康短信,干预组人群三维度健康素养均值干预后为64.67分,高于干预前的63.11分(t=24.95,P<0.001)四维度健康素养均值干预后为67.76分,高于干预前的66.42分(t=34.65,P<0.001)。三维度和四维度健康素养水平分别提升1.56和1.34。
(2)自我健康管理与健康状况的变化
干预组参与自我健康管理比例增加7.76%、慢性病患病率得到一定程度的控制,干预组与对照组的慢性病患病率有统计学差异(χ2=14.45,P<0.001)。短信干预对干预组的边际健康素养和高健康素养人群产生更为积极的效果。干预组边际健康素养人群自我健康管理的比例上升比例为10.92%,慢性病患病率由干预前的15.76%下降到干预后的12.39%；高健康素养人群自我健康评价好的比例由24.98%上升到31.16%,慢性病患病率由16.02%下降到9.49%；反之,低健康素养人群慢性病患病率由干预前的14.32%上升到18.32%。
(3)短信干预提升三维度和四维度健康素养水平每元的人均成本效果分别为0.54和0.38。
结论：
1、健康素养与健康管理及健康状况密切相关,深入开展健康素养研究意义重大。深圳公众健康素养水平不高,按照国内现有的评价标准具备健康素养的比例计算仅为6.28%,其健康素养水平受到多方面因素的影响,并与健康管理及健康状况都存在一定的关系。
2、健康素养新内涵和模型具有较好的创新价值,代表了国际健康素养内涵发展的方向。本研究所提出狭义的三维度“健康知识-健康行为-健康技能模型”和广义的四维度“健康知识-健康行为-健康技能-健康水平”模型,尤其是广义的模型将健康水平融入之中,具有更好的实用价值,更利于现实工作的指导。
3、健康素养快评评估系统具有一定实用性和稳定性,具有广泛的推广价值。构建的健康素养快速评估系统平均评估时间5.9分钟,比原评估系统13.2分钟快7.3分钟,采用百分制进行评价简单易行,在国内首次提出以60分和75分作为截值位点划分成低健康素养、边际健康素养和高健康素养三个水平,使用简捷、方便。
4、健康短信干预是较好的公众健康素养干预手段,具有一定的经济实用价值。利用短信方式开展公众健康教育干预,公众三维度和四维度健康素养水平分别提升1.56和1.34,产生一定的干预效果。短信干预提升健康素养的每元人均成本效果为0.54和0.38,这充分说明利用短信对城市公众开展健康教育干预可行、经济、有效,具有较好的推广应用价值。
Background
The prevalence and mortality of chronic diseases in China showed a rising trend, currently, which has become an important public health problem that threatens to public health. It is necessary to maintain and promote public health by enhancing the level of public health concept and health literacy, strengthening self-health management level, and transformation of the bad mode of life and behavior. Health literacy has become one of the important indexes to evaluate the public health quality in some countries. Health literacy study in abroad starts early, in which connotation and evaluation studies are relative mature. In Sorensen's research, there are12health literacy models and17different concepts of health literacy. In health literacy assessment researches, there are35different health literacy assessment methods, in which the Test of Functional Health Literacy in Adults(TOFHLA),the Rapid Estimate of Adult Literacy in Medicine (REALM) and the latest measurement tools of Newest Vital signs (NVS) are commonly used. It is because of short time for evaluation that the REALM and NVS are welcomed by users. It was in2005that our country introduced Health literacy concept and we did research since2007. The Health Administration Department of China carried out health literacy survey of public and evaluated66items in whole country in2008and2009,2012and2013respectively. The survey content in2008included health concept, basic health knowledge, healthy lifestyle and behavior, and basic skills, a total of79items, and we increased the proportion of tobacco control program after2012, in which cover103items totally, and the evaluation time was more than20minutes. The different regions of our country carry out monitoring and evaluation research based on national questionnaire for reference, which includes too much assessment content.The related research usually is a direct copy from foreign measurement method, without considering the China's culture and economy, so it's hard in the popularization and application. Therefore, we should draw lessons from the foreign thought of rapid assessment of health literacy, combining the reality of health education and health literacy in our country, and developing scientific and effective rapid assessment tool of health literacy in our country, which considerate public health and clinical medicine, individual and the group characteristics, and organic combination of health literacy and health status, health management together. It will become the common assessment tools, and facilitates comparison between different regions and different countries in different evaluation time for health literacy.
Scientific assessment is an important foundation for carrying out an effective intervention and the main basis to select the appropriate intervention techniques. There are important significances to explore the appropriate health education intervention ways which are suitable for whole population based on the urban public health management. We takes a lot of health literacy education at current, which was mainly comprehensive way to disseminate health literacy knowledge, such as TV, newspapers, radio, Internet, brochures, posters, billboards, speaking tour, tour, knowledge contests, and promotional activities in our country. However, the text massage form for large-scale population education intervention has not been reported now. It is widely accepted that short massage cover a large number of audience, high viewing rate, management flexibility, lower cost, highly targeted, and re-disseminated characteristics. Thus it has been used in Health education and behavioral interventions in special populations in domestic and abroad, such as High blood pressure, diabetes, maternal, kidney disease. The Low health literacy lead to the low health service utilization, delayed diagnosis, less understanding of the medical condition and treatment, self-health management skills shortage, poor health, and high mortality rate, so we should seek an more effective method of low health literacy intervention. The effective entry points of improving health are public intervention and improve self-management skills of health. As far as we know, there is no research about the combination of Health literacy, health management and health status in China.
In summary, it is necessary to carry out health literacy, health management, health status-related research and to build health literacy rapid assessment tool, which can be used to effectively carry out the scientific assessment of health literacy. In addition, targeted and effective intervention measures should be adopted to improve health literacy, health management and health status.
Objective
This study intends to explore a practical, scientific, and easy to operate for public rapid assessment of health literacy combined with short message intervention system, which can link the rapid assessment of health literacy with self-health management, eventually to promote the public health literacy and health status. It would provide an important decision basis for improving and completing the urban public health literacy education intervention and public health management.
Methods
Our research methods include literature retrieval, interdisciplinary method, panel discussion, Delphi expert consultation, cross-sectional survey, and quasi experimental research, etc.
First, we study the backgrounds by literature retrieval which covered the connotation, evaluation and correlation of the health literacy, health management and health status, then we grasp the progress and current problems in home and abroad. We should put forward the innovative research ideas and research content combined with existing problem of health education in Shenzhen city, which will provide the basis for the new connotation of health literacy research in the future.
Second, we analyze the data of public health literacy from cross-sectional survey in Shenzhen, which were collected by household surveys way (according to the stage sampling survey, we selected32communities with6,413residents in Shenzhen, effective rate of the questionnaire was98.66%). We did in-depth analysis of public health literacy, health management, health status, and their influencing factors, which provide the reality basis for constructing the practice and real effective rapid assessment system of health literacy.
Third, the new connotation and the new model of health literacy were proposed by interdisciplinary research which is helpful to the development of health education work. We construct health literacy evaluation index system of rapid assessment system mainly based on Delphi expert consultation method by consulting24experts, and combining the reality of Shenzhen city.
Finally, a quasi-experimental study was carried out and3205people participate in message intervention. The aim is to verify the stability and practicability of the health literacy evaluation index system, and also to verify the effectiveness of the intervention with short message to enhance public health literacy and healthy level.
The SPSS21.0software was used for descriptive statistics, test of variance, t test, chi-square test, Logistic regression, hierarchical cluster analysis, correlation analysis and other statistical analysis.
Results
1. Access the current situation of the public health literacy based on the original health literacy assessment system and the standards of health literacy in Shenzhen city
(1) The level of the public health literacy in Shenzhen city was not high. The percent of having health literacy was6.28%, with the level of overall health literacy knowledge59.86%, the level of health behavior66.94%, and the level of health literacy skills59.32%. After Logistic regression analysis,age(OR=1.09), gender(OR=1.79),household registration(OR=)0.67,the degree of culture(OR=1.76), family(OR=0.75), health management(OR=1.67) are considered as the influence factors of the public health literacy in Shenzhen.
(2) The public health consciousness in Shenzhen is not high. Only30.91percent of citizens in Shenzhen consider life and behavior factors as the most important affect factors of health, which is lower than60%reported by WHO, and there are statistical differences between our report and WHO (X2=38.36, P<0.001). By Logistic regression analysis, The household registration of Shenzhen(OR=1.23), high cultural degree(OR=0.78), high personal income(OR=1.12), no smoking(OR=1.16), check-up once per year(OR=1.25), exercise more2-3times per week(OR?=1.25), well status of self-reported health(OR=1.18), none prevalence in two weeks(OR=0.83) are positive influence factors. The evaluation of life and behavior factors account for high proportion to affect health, while marital status (divorced and widowed)(OR=0.78), high medical costs(OR=0.96) are negative factors.
(3) The proportion of public self-health-management in Shenzhen is not high. Only29.47%of the citizens of Shenzhen have the basic self-health-management. By the binomial Logistic regression analysis, age(OR=1.22), female(OR=1.20), high-education level(OR=1.24), high personal income(OR=1.07), large family population(OR=1.23), household registration of Shenzhen(OR=1.13), suffering from chronic diseases(OR=1.22) are the influence factors of self-health-management.
(4) The conditions of public health assessment in Shenzhen need to be improved. Only62.42%of the public have good self-health-evaluation, in which age(OR=0.75), gender(OR=0.70), marriage(OR=0.87), personal income(OR=1.19), washing your hands before eating and after toilet(OR=1.25), brushing your teeth every day(OR=1.10), sleep seven to eight hours per day(OR=1.10), using antibiotics by the prescription(OR=1.36), few pressure(OR=1.58) are the impact factors.
(5) The prevalence in two weeks, chronic diseases, and the hospitalization are related to health literacy and health behavior. By Logistic regression analysis, the influence factors of prevalence in two weeks are age(OR=0.81), household register(OR=1.41), marriage(OR=0.83), education level(OR=0.92), personal income(OR=1.19), family population(OR=0.93), no smoking(OR=1.34), brushing your teeth every day(OR=1.16), sleep seven to eight hours per day(OR=1.23), using antibiotics by the prescription(OR=1.35), A medical check-up every year(OR=1.21), few pressure(OR=1.48). The influence factors for chronic diseases are age(OR=0.49), household register(OR=1.39), personal income(OR=1.17), family population(OR=0.95), no drinking(OR=0.81), opening a window ventilated(OR=0.80), brushing your teeth every day(OR=1.39), sleep seven to eight hours per day(OR=1.14), using antibiotics by the prescription(OR=1.26), a medical check-up every year(OR=0.84), and few pressure(OR=1.56). The influence factors of hospitalization are gender(OR=0.61), household registration(OR=1.36), marriage(OR=0.64), culture degree(OR=1.15), the family population(OR=0.92), no smoking(OR=1.66), washing hand be for eating and after toilet(OR=1.40), use antibiotics according to the prescription(OR=1.34), and few pressure(OR=1.24).
2.Construction of the new health literacy model and the index system of the health literacy evaluation system
(1) The new health literacy model based on the comprehensive research in domestic and abroad, and combined with the reality of health education work in Shenzhen city, we put forward the new connotation of health literacy. That means " a kind of ability and process that can be used to obtain health knowledge, optimizing the self-health-management, promoting and forming some health behaviors and health skills, so as to improve the health situation". At the same time, we put forward the three-dimension model "health knowledge-health behavior-health skills" from the narrow view and a four-dimension model "health knowledge-health behavior-health skills-health level" from generalized view. To determine health literacy level, we refer to foreign health literacy standards S-TOFHLA, and use60%and75%values of the total score as cut off, so health literacy levels can be divided into three levels, such as low health literacy, high health literacy and marginal health literacy.
(2) Construction rapid evaluation system of health literacy.
According to the principle of systemic, conciseness, agility and sustainability, the Delphi method was used in this study, combined with hierarchical cluster analysis and the influencing factors of the health literacy to construct a rapid evaluation system of health literacy. The authority level of24experts who participated in the consultation is0.87, with the positive coefficient of two consultations100%, coordination coefficient Kendall's W0.41, so the experts' opinions were reliable and credible. According to the results of consultation, hierarchical clustering analysis,and the influence factors of health literacy, there are20items used to be the key evaluation index for three-dimensional rapid assessment system of health literacy, including the eight knowledge accomplishment and behavior literacy, four skills literacy, which weights are40%,40%and20%respectively. There are also20items in four-dimensional rapid assessment system of health literacy, including seven knowledge accomplishment and behavior literacy, four skills literacy, and two health levels, which weights are35%,35%,20%and10%respectively. The reliability between three-dimensional rapid assessment system and the old is0.89,and the four-dimensional rapid assessment system is0.86.
(3) The evaluation time for rapid assessment system of health literacy was5.9minutes on average, which is faster than the original assessment time (13.2minutes).
3.Evaluating of messages intervention effects with rapid evaluation system of health literacy
(1) Changes of the health literacy level
There are about60messages to every person used to publish for intervention in one year. The mean of three dimensions of health literacy in intervention group is64.67, which is higher than the value before intervention (mean=63.11,t=24.95, P <0.001).The mean of four dimensions of health literacy before intervention is66.42, which is lower than the value after intervention (mean=67.76, t=34.65, P<0.001) The health literacy levels of three dimensions four dimensions increase1.56and1.34respectively.
(2) The change of Self-health management and health status
There are statistical differences in the prevalence of chronic diseases between intervention group and control group. The prevalence of chronic diseases was under control and the proportion of self-health management in intervention group increased7.76%. Moreover, messages intervention had a great positive effects in marginal health literacy group and high health literacy group. The proportion of self-health management increased10.92percent and the prevalence of chronic diseases decreased from15.76percent to12.39percent in marginal health literacy group. Meanwhile, in high health literacy group, the proportion of self-health management increased from24.98percent to31.16percent. The prevalence of chronic diseases decreased from16.02percent to9.49percent in Marginal health literacy group, in contrast the prevalence of chronic diseases increased from14.32percent to18.32percent in low health literacy group.
(3) Per capita effectiveness of three-dimension and four-dimension health literacy were0.54and0.38by messages intervention respectively.
Conclusion
1.Health literacy was related to health management and health status closely and there is a great significance to do the further research on health literacy study. The level of public health literacy in Shenzhen was lower and according to the current evaluationcriteria in domestic, the proportion of Health literacy is only6.28percent. Our study suggested that the level of Public Health literacy was associated with health management and health status, and it was influenced by many factors.
2.We put forward the three-dimension model of health knowledge-health behaviors-health skills" model and the four-dimension model of health knowledge-health behaviors-health skills-health level based on the previous research all over the world and the practice of heath education, it will play an important role in the promotion of daily work, doing help in the screening of people with low level of health literacy, and doing comparison between different regions.
3.The rapid assessment system of health literacy has great potential practical value and reliability which is worthy of promotion and application.
The construction of rapid assessment system was simple and convenient with mean assessment time5.9minutes, which was7.3minutes faster than the old one which needs13.2minutes. It is simple and easy to assess the health literacy by the hundred percentage point system. The health literacy can be divided into three types: low level, marginal level and high level with the cut-off value of60and75, by which is appropriate for assessing the health literacy not only for individuals but also for populations.
4.Health messages are effective interventions not only for improving health literacy but also for economic and practical values. Compared with control group, the level of health literacy of public in intervention group improved1.56and1.34for three-dimension health literacy and four-dimension health literacy after the messages intervention. The cost-effectiveness of message intervention was0.54and0.38per person. So message intervention to improve the public health literacy is practical, economical and effective.
我国慢性病的患病和死亡呈不断上升趋势,己成为严重威胁公众健康的重要公共卫生问题。提升公众健康理念和健康素养水平、加强自我健康管理技能、转变不良生活和行为方式,是维护和促进公众健康的必要举措。健康素养己成为多个国家衡量公众健康素质高低的重要指标之一。国外开展健康素养研究较早,目前其内涵及评估研究亦比较成熟,已有12个健康素养模型、17个不同的健康素养概念、35种不同的健康素养评估方法。国外常用的评估工具主要有成人功能性健康素养测试(TOFHLA)、成人医学素养快速评估(REALM)和最新Newest Vital Sign测量工具(NVS),其中REALM、NVS因评估时间较短备受使用者欢迎。我国于2005年引入健康素养概念,2008年开展全国首次调查共79个条目,2012年的评估增至103项,所用评估时间超过20分钟。我国各地区开展的监测与评估研究多以国家问卷为参考,评估内容也较多,费时、费力。国内应借鉴国外的健康素养快速评估思路,结合我国健康教育与健康素养工作实际,研发适合我国实情的健康素养快速评估工具。科学的评估是为开展有效干预的重要前提,是选取适宜干预技术的主要依据。立足于城市公众健康管理,探索适宜全人群健康教育干预形式有着重要的意义。作为新媒体,短信有着受众面广、查看率高、管理灵活、成本较低、针对性强、再传播性好等特点,已在国内外被用于高血压、糖尿病、孕产妇、肾病等特殊人群的干预,用短信形式针对城市公众开展大规模的教育与干预尚未有相关报道。低健康素养与医疗卫生服务利用不足、疾病诊断延迟、对医疗状况和治疗理解不够、自我健康管理技能差不足、健康状况差、死亡率高有关,因此,立足于城市健康管理层面,将健康素养、健康管理和健康状况有机结合起来,构建健康素养快速评估,寻求切实有效的干预方法,对公众实施健康素养干预,提高其自我健康管理能力,促进其健康状况有着积极的意义
目的：
本研究拟探索出符合实际的、科学的、便于操作的公众健康素养快速评估与短信干预系统,将公众健康素养评估与其强化干预行为结合起来,将公众健康素养和自我健康管理联动起来,最终达到促进公众提升健康素养和健康状况的目的,为深化和完善城市公众健康素养教育干预以及实施公众健康管理工作提供重要决策依据。
方法：
本研究主要应用文献检索法、专题小组研讨、德尔菲法、现场横断面调查法、准实验研究等方法。
首先利用文献检索法对健康素养、健康管理以及健康状况的内涵、评估以及关联等状况进行课题背景研究,掌握国内外的进展状况以及存在的问题,并结合深圳健康教育工作的实际,提出创新的研究思路和研究内容,同时为下一步进行健康素养新内涵研究提供依据。
接着通过研究以入户调查方式所收集的深圳公众健康素养横断面调查数据(按照分阶段抽样方法调查了深圳32个社区6413位居民,问卷有效率为98.66%),深入分析公众健康素养、健康管理以及健康状况及其影响因素,为构建实际有效的健康素养快速评估系统提供现实性依据。
然后采用跨学科研究提出有利于健康教育工作发展的健康素养新内涵、新模型,并以德尔菲专家咨询法为主,咨询24位来自高校、医院、卫生行政、健康教育、疾控等机构的专家,在结合深圳现实依据的基础上构建健康素养快速评估系统的评价指标体系。
最后开展准实验研究,将原有的社区分为干预组和对照组,对干预组愿意参与短信干预的2863人实施短信干预,开展终期调查共回收干预组和对照组6400份问卷(问卷回收率为99.22%),利用新构建的健康素养快速评估系统进行评估,验证短信干预对提升公众健康素养和健康水平的有效性。
本研究使用SPSS21.0软件进行描述性统计、方差检验、卡方检验、t检验、Logistic回归、分层聚类分析、相关分析等统计分析,使用AMOS21.0进行验证性因子分析。
结果：
1、利用原健康素养评估系统和健康素养标准评估深圳公众的健康素养现状,为构建快速评估系统提供依据
(1)深圳公众健康素养水平不高。深圳具备健康素养的比例为6.28%,总体健康知识素养水平为59.86%、健康行为素养水平为66.94%、健康素养技能水平为59.32%。经Logistic回归分析,年龄组(OR=1.09)、性别(OR=1.79)、户籍(OR=0.67)、文化程度(OR=1.76)、家庭人口(OR=0.75)、健康管理(OR=1.67)等是深圳公众健康素养的影响因素。
(2)深圳公众健康意识不高。深圳公众只有30.91%的居民评价生活和行为方式因素是影响健康最主要的因素,远低于与WHO发布值60%,两者存在统计学差异(χ2=38.36,P<0.001)。经Logistic回归分析,深圳户籍(OR=1.23)、文化程度高(OR=1.23)、个人收入高(OR=1.12)、不吸烟(OR=1.16)、每年体检1次(OR=1.25)、每周锻炼2-3次以上(OR=1.25)、自我健康评价状况好(OR=1.18)、没有两周患病情况(OR=0.83)是正向影响因素,其评价生活和行为方式因素影响健康的比例偏高,而其他婚姻状况(离异和丧偶)(OR=0.78)、医疗花费高(OR=0.96)是负向影响因素。
(3)深圳公众自我健康管理比例不高。深圳公众仅有29.47%的居民进行了基本的自我健康管理。经二项分类Logistic回归分析显示,年龄高(OR=1.22)、性别(OR=1.20)、文化程度高(OR=1.24)、个人月收入高(OR=1.07)、家庭人口数多(OR=1.23)、深圳户籍(OR=)1.13、患有慢性病(OR=)1.22是自我健康管理的影响因素。深圳公众不同健康管理状况总健康素养(χ2=92.0,P<0.001)、健康知识(χ2=30.98,P<0.001)、健康行为素养比例(χ2=116.98,P<0.001)均有统计学意义。有健康管理的公众总健康素养、健康知识、健康行为素养比例相对较高。
(4)深圳公众自我健康评价况有待改善。深圳公众仅有62.42%的自我健康评价好。自我健康评价状况好的影响因素是年龄组(OR=0.75)、性别(OR=0.70)、婚姻(OR=0.87)、个人收入(OR=1.19)、饭前便后洗手(OR=1.25)、每天刷牙(OR=1.10)、每天睡眠7-8小时(OR=1.10)、按处方购买抗生素服用(OR=1.36)、很少有压力(OR=1.58)。
(5)深圳公众的两周患病、慢性病患病、住院等健康状况均与健康行为素养等存在关系。经Logistic回归分析,两周患病的影响因素是年龄(OR=0.81)、户籍(OR=1.41)、婚姻(OR=0.83)、文化程度(OR=0.92)、个人收入(OR=1.19)、家庭人口数(OR=0.93)、不吸烟(OR=1.34)、每天刷牙(OR=1.16)、每天睡眠7-8小时(OR=1.23)、按处方购买抗生素服用(OR=1.35)、每年1次体检(OR=1.21)、很少有压力(OR=1.48)；慢性病患病影响因素为年龄(OR=0.49)、户籍(OR=1.39)、个人收入(OR=1.17)、家庭人口数(OR=0.95)、不饮酒(OR=0.81)、经常开窗通风(OR=0.80)、每天刷牙(OR=1.39)、每天睡眠7-8小时(OR=1.14)、按处方购买抗生素服用(OR=1.26)、每年1次体检(OR=0.84)、很少有压力(OR=1.56)；住院的影响因素是性别(OR=0.61)、户籍(OR=1.36)、婚姻(OR=0.64)、文化程度(OR=1.15)、家庭人口数(OR=0.92)、不吸烟(OR=1.66)、饭前便后洗手(OR=1.40)、按处方购买抗生素服用(OR=1.34)、很少有压力(OR=1.24)。
2、健康素养新模型和健康素养快速评估系统指标体系构建
(1)健康素养新模型
综合国内外研究,结合深圳健康教育工作实际,本研究提出了健康素养新内涵：“一种获取健康知识信息,并用于优化自我健康管理,促进和形成一定的健康行为与健康技能水平,从而达到改善健康状况的能力和过程”,并提出狭义的三维度“健康知识-健康行为-健康技能模型”和广义的四维度“健康知识-健康行为-健康技能-健康水平”模型。为便于个体和群体健康素养水平的确定,本研究参照国外TOFHLA的健康素养界定标准,使用总分的60%和75%作为截位值将健康素养水平分成低健康素养、高健康素养和边际健康素养三个层面。
(2)健康素养快速评估系统构建
根据系统性、简明性、灵敏性和可持续性原则,本研究利用德尔菲法,结合分层聚类分析和健康素养影响因素状况构建健康素养快速评估系统。参与咨询的24位专家的权威程度为0.87,两次咨询的积极系数为100%,协调系数Kendall'sW为0.41,专家提供的意见可靠、可信。根据咨询结果和分层聚类分析以及基于各层健康素养水平的影响因素等实际依据,确定三维健康素养快速评估系统的核心评价指标包括20项,其中包括知识素养和行为素养各8项、技能素养4项,权重分别为40%、40%和20%；四维健康素养快速评估系统的核心评价指标包括20项,其中包括知识素养和行为素养各7项、技能素养4项、健康水平2项,权重分别为35%、35%、20%和10%。三维度和四维度健康素养快速评估系统与原健康素养评估系统的关联效度分别为0.89和0.86,三维度和四维度系统之间的相关系数为0.96。验证性因子分析证实其具有较好的适配度,GFI、AGFI、NFI、IFI、TLI和CFI的值都接近0.9。
(3)健康素养快速评估系统平均评估时间5.9分钟,比原评估系统13.2分钟快7.3分钟。
3、利用健康素养快速评估系统对短信干预效果进行评估
(1)健康素养水平变化
经过一年时间的短信干预,短信平台共针对干预组2863名对象人均发布60条,共160250条健康短信,干预组人群三维度健康素养均值干预后为64.67分,高于干预前的63.11分(t=24.95,P<0.001)四维度健康素养均值干预后为67.76分,高于干预前的66.42分(t=34.65,P<0.001)。三维度和四维度健康素养水平分别提升1.56和1.34。
(2)自我健康管理与健康状况的变化
干预组参与自我健康管理比例增加7.76%、慢性病患病率得到一定程度的控制,干预组与对照组的慢性病患病率有统计学差异(χ2=14.45,P<0.001)。短信干预对干预组的边际健康素养和高健康素养人群产生更为积极的效果。干预组边际健康素养人群自我健康管理的比例上升比例为10.92%,慢性病患病率由干预前的15.76%下降到干预后的12.39%；高健康素养人群自我健康评价好的比例由24.98%上升到31.16%,慢性病患病率由16.02%下降到9.49%；反之,低健康素养人群慢性病患病率由干预前的14.32%上升到18.32%。
(3)短信干预提升三维度和四维度健康素养水平每元的人均成本效果分别为0.54和0.38。
结论：
1、健康素养与健康管理及健康状况密切相关,深入开展健康素养研究意义重大。深圳公众健康素养水平不高,按照国内现有的评价标准具备健康素养的比例计算仅为6.28%,其健康素养水平受到多方面因素的影响,并与健康管理及健康状况都存在一定的关系。
2、健康素养新内涵和模型具有较好的创新价值,代表了国际健康素养内涵发展的方向。本研究所提出狭义的三维度“健康知识-健康行为-健康技能模型”和广义的四维度“健康知识-健康行为-健康技能-健康水平”模型,尤其是广义的模型将健康水平融入之中,具有更好的实用价值,更利于现实工作的指导。
3、健康素养快评评估系统具有一定实用性和稳定性,具有广泛的推广价值。构建的健康素养快速评估系统平均评估时间5.9分钟,比原评估系统13.2分钟快7.3分钟,采用百分制进行评价简单易行,在国内首次提出以60分和75分作为截值位点划分成低健康素养、边际健康素养和高健康素养三个水平,使用简捷、方便。
4、健康短信干预是较好的公众健康素养干预手段,具有一定的经济实用价值。利用短信方式开展公众健康教育干预,公众三维度和四维度健康素养水平分别提升1.56和1.34,产生一定的干预效果。短信干预提升健康素养的每元人均成本效果为0.54和0.38,这充分说明利用短信对城市公众开展健康教育干预可行、经济、有效,具有较好的推广应用价值。
Background
The prevalence and mortality of chronic diseases in China showed a rising trend, currently, which has become an important public health problem that threatens to public health. It is necessary to maintain and promote public health by enhancing the level of public health concept and health literacy, strengthening self-health management level, and transformation of the bad mode of life and behavior. Health literacy has become one of the important indexes to evaluate the public health quality in some countries. Health literacy study in abroad starts early, in which connotation and evaluation studies are relative mature. In Sorensen's research, there are12health literacy models and17different concepts of health literacy. In health literacy assessment researches, there are35different health literacy assessment methods, in which the Test of Functional Health Literacy in Adults(TOFHLA),the Rapid Estimate of Adult Literacy in Medicine (REALM) and the latest measurement tools of Newest Vital signs (NVS) are commonly used. It is because of short time for evaluation that the REALM and NVS are welcomed by users. It was in2005that our country introduced Health literacy concept and we did research since2007. The Health Administration Department of China carried out health literacy survey of public and evaluated66items in whole country in2008and2009,2012and2013respectively. The survey content in2008included health concept, basic health knowledge, healthy lifestyle and behavior, and basic skills, a total of79items, and we increased the proportion of tobacco control program after2012, in which cover103items totally, and the evaluation time was more than20minutes. The different regions of our country carry out monitoring and evaluation research based on national questionnaire for reference, which includes too much assessment content.The related research usually is a direct copy from foreign measurement method, without considering the China's culture and economy, so it's hard in the popularization and application. Therefore, we should draw lessons from the foreign thought of rapid assessment of health literacy, combining the reality of health education and health literacy in our country, and developing scientific and effective rapid assessment tool of health literacy in our country, which considerate public health and clinical medicine, individual and the group characteristics, and organic combination of health literacy and health status, health management together. It will become the common assessment tools, and facilitates comparison between different regions and different countries in different evaluation time for health literacy.
Scientific assessment is an important foundation for carrying out an effective intervention and the main basis to select the appropriate intervention techniques. There are important significances to explore the appropriate health education intervention ways which are suitable for whole population based on the urban public health management. We takes a lot of health literacy education at current, which was mainly comprehensive way to disseminate health literacy knowledge, such as TV, newspapers, radio, Internet, brochures, posters, billboards, speaking tour, tour, knowledge contests, and promotional activities in our country. However, the text massage form for large-scale population education intervention has not been reported now. It is widely accepted that short massage cover a large number of audience, high viewing rate, management flexibility, lower cost, highly targeted, and re-disseminated characteristics. Thus it has been used in Health education and behavioral interventions in special populations in domestic and abroad, such as High blood pressure, diabetes, maternal, kidney disease. The Low health literacy lead to the low health service utilization, delayed diagnosis, less understanding of the medical condition and treatment, self-health management skills shortage, poor health, and high mortality rate, so we should seek an more effective method of low health literacy intervention. The effective entry points of improving health are public intervention and improve self-management skills of health. As far as we know, there is no research about the combination of Health literacy, health management and health status in China.
In summary, it is necessary to carry out health literacy, health management, health status-related research and to build health literacy rapid assessment tool, which can be used to effectively carry out the scientific assessment of health literacy. In addition, targeted and effective intervention measures should be adopted to improve health literacy, health management and health status.
Objective
This study intends to explore a practical, scientific, and easy to operate for public rapid assessment of health literacy combined with short message intervention system, which can link the rapid assessment of health literacy with self-health management, eventually to promote the public health literacy and health status. It would provide an important decision basis for improving and completing the urban public health literacy education intervention and public health management.
Methods
Our research methods include literature retrieval, interdisciplinary method, panel discussion, Delphi expert consultation, cross-sectional survey, and quasi experimental research, etc.
First, we study the backgrounds by literature retrieval which covered the connotation, evaluation and correlation of the health literacy, health management and health status, then we grasp the progress and current problems in home and abroad. We should put forward the innovative research ideas and research content combined with existing problem of health education in Shenzhen city, which will provide the basis for the new connotation of health literacy research in the future.
Second, we analyze the data of public health literacy from cross-sectional survey in Shenzhen, which were collected by household surveys way (according to the stage sampling survey, we selected32communities with6,413residents in Shenzhen, effective rate of the questionnaire was98.66%). We did in-depth analysis of public health literacy, health management, health status, and their influencing factors, which provide the reality basis for constructing the practice and real effective rapid assessment system of health literacy.
Third, the new connotation and the new model of health literacy were proposed by interdisciplinary research which is helpful to the development of health education work. We construct health literacy evaluation index system of rapid assessment system mainly based on Delphi expert consultation method by consulting24experts, and combining the reality of Shenzhen city.
Finally, a quasi-experimental study was carried out and3205people participate in message intervention. The aim is to verify the stability and practicability of the health literacy evaluation index system, and also to verify the effectiveness of the intervention with short message to enhance public health literacy and healthy level.
The SPSS21.0software was used for descriptive statistics, test of variance, t test, chi-square test, Logistic regression, hierarchical cluster analysis, correlation analysis and other statistical analysis.
Results
1. Access the current situation of the public health literacy based on the original health literacy assessment system and the standards of health literacy in Shenzhen city
(1) The level of the public health literacy in Shenzhen city was not high. The percent of having health literacy was6.28%, with the level of overall health literacy knowledge59.86%, the level of health behavior66.94%, and the level of health literacy skills59.32%. After Logistic regression analysis,age(OR=1.09), gender(OR=1.79),household registration(OR=)0.67,the degree of culture(OR=1.76), family(OR=0.75), health management(OR=1.67) are considered as the influence factors of the public health literacy in Shenzhen.
(2) The public health consciousness in Shenzhen is not high. Only30.91percent of citizens in Shenzhen consider life and behavior factors as the most important affect factors of health, which is lower than60%reported by WHO, and there are statistical differences between our report and WHO (X2=38.36, P<0.001). By Logistic regression analysis, The household registration of Shenzhen(OR=1.23), high cultural degree(OR=0.78), high personal income(OR=1.12), no smoking(OR=1.16), check-up once per year(OR=1.25), exercise more2-3times per week(OR?=1.25), well status of self-reported health(OR=1.18), none prevalence in two weeks(OR=0.83) are positive influence factors. The evaluation of life and behavior factors account for high proportion to affect health, while marital status (divorced and widowed)(OR=0.78), high medical costs(OR=0.96) are negative factors.
(3) The proportion of public self-health-management in Shenzhen is not high. Only29.47%of the citizens of Shenzhen have the basic self-health-management. By the binomial Logistic regression analysis, age(OR=1.22), female(OR=1.20), high-education level(OR=1.24), high personal income(OR=1.07), large family population(OR=1.23), household registration of Shenzhen(OR=1.13), suffering from chronic diseases(OR=1.22) are the influence factors of self-health-management.
(4) The conditions of public health assessment in Shenzhen need to be improved. Only62.42%of the public have good self-health-evaluation, in which age(OR=0.75), gender(OR=0.70), marriage(OR=0.87), personal income(OR=1.19), washing your hands before eating and after toilet(OR=1.25), brushing your teeth every day(OR=1.10), sleep seven to eight hours per day(OR=1.10), using antibiotics by the prescription(OR=1.36), few pressure(OR=1.58) are the impact factors.
(5) The prevalence in two weeks, chronic diseases, and the hospitalization are related to health literacy and health behavior. By Logistic regression analysis, the influence factors of prevalence in two weeks are age(OR=0.81), household register(OR=1.41), marriage(OR=0.83), education level(OR=0.92), personal income(OR=1.19), family population(OR=0.93), no smoking(OR=1.34), brushing your teeth every day(OR=1.16), sleep seven to eight hours per day(OR=1.23), using antibiotics by the prescription(OR=1.35), A medical check-up every year(OR=1.21), few pressure(OR=1.48). The influence factors for chronic diseases are age(OR=0.49), household register(OR=1.39), personal income(OR=1.17), family population(OR=0.95), no drinking(OR=0.81), opening a window ventilated(OR=0.80), brushing your teeth every day(OR=1.39), sleep seven to eight hours per day(OR=1.14), using antibiotics by the prescription(OR=1.26), a medical check-up every year(OR=0.84), and few pressure(OR=1.56). The influence factors of hospitalization are gender(OR=0.61), household registration(OR=1.36), marriage(OR=0.64), culture degree(OR=1.15), the family population(OR=0.92), no smoking(OR=1.66), washing hand be for eating and after toilet(OR=1.40), use antibiotics according to the prescription(OR=1.34), and few pressure(OR=1.24).
2.Construction of the new health literacy model and the index system of the health literacy evaluation system
(1) The new health literacy model based on the comprehensive research in domestic and abroad, and combined with the reality of health education work in Shenzhen city, we put forward the new connotation of health literacy. That means " a kind of ability and process that can be used to obtain health knowledge, optimizing the self-health-management, promoting and forming some health behaviors and health skills, so as to improve the health situation". At the same time, we put forward the three-dimension model "health knowledge-health behavior-health skills" from the narrow view and a four-dimension model "health knowledge-health behavior-health skills-health level" from generalized view. To determine health literacy level, we refer to foreign health literacy standards S-TOFHLA, and use60%and75%values of the total score as cut off, so health literacy levels can be divided into three levels, such as low health literacy, high health literacy and marginal health literacy.
(2) Construction rapid evaluation system of health literacy.
According to the principle of systemic, conciseness, agility and sustainability, the Delphi method was used in this study, combined with hierarchical cluster analysis and the influencing factors of the health literacy to construct a rapid evaluation system of health literacy. The authority level of24experts who participated in the consultation is0.87, with the positive coefficient of two consultations100%, coordination coefficient Kendall's W0.41, so the experts' opinions were reliable and credible. According to the results of consultation, hierarchical clustering analysis,and the influence factors of health literacy, there are20items used to be the key evaluation index for three-dimensional rapid assessment system of health literacy, including the eight knowledge accomplishment and behavior literacy, four skills literacy, which weights are40%,40%and20%respectively. There are also20items in four-dimensional rapid assessment system of health literacy, including seven knowledge accomplishment and behavior literacy, four skills literacy, and two health levels, which weights are35%,35%,20%and10%respectively. The reliability between three-dimensional rapid assessment system and the old is0.89,and the four-dimensional rapid assessment system is0.86.
(3) The evaluation time for rapid assessment system of health literacy was5.9minutes on average, which is faster than the original assessment time (13.2minutes).
3.Evaluating of messages intervention effects with rapid evaluation system of health literacy
(1) Changes of the health literacy level
There are about60messages to every person used to publish for intervention in one year. The mean of three dimensions of health literacy in intervention group is64.67, which is higher than the value before intervention (mean=63.11,t=24.95, P <0.001).The mean of four dimensions of health literacy before intervention is66.42, which is lower than the value after intervention (mean=67.76, t=34.65, P<0.001) The health literacy levels of three dimensions four dimensions increase1.56and1.34respectively.
(2) The change of Self-health management and health status
There are statistical differences in the prevalence of chronic diseases between intervention group and control group. The prevalence of chronic diseases was under control and the proportion of self-health management in intervention group increased7.76%. Moreover, messages intervention had a great positive effects in marginal health literacy group and high health literacy group. The proportion of self-health management increased10.92percent and the prevalence of chronic diseases decreased from15.76percent to12.39percent in marginal health literacy group. Meanwhile, in high health literacy group, the proportion of self-health management increased from24.98percent to31.16percent. The prevalence of chronic diseases decreased from16.02percent to9.49percent in Marginal health literacy group, in contrast the prevalence of chronic diseases increased from14.32percent to18.32percent in low health literacy group.
(3) Per capita effectiveness of three-dimension and four-dimension health literacy were0.54and0.38by messages intervention respectively.
Conclusion
1.Health literacy was related to health management and health status closely and there is a great significance to do the further research on health literacy study. The level of public health literacy in Shenzhen was lower and according to the current evaluationcriteria in domestic, the proportion of Health literacy is only6.28percent. Our study suggested that the level of Public Health literacy was associated with health management and health status, and it was influenced by many factors.
2.We put forward the three-dimension model of health knowledge-health behaviors-health skills" model and the four-dimension model of health knowledge-health behaviors-health skills-health level based on the previous research all over the world and the practice of heath education, it will play an important role in the promotion of daily work, doing help in the screening of people with low level of health literacy, and doing comparison between different regions.
3.The rapid assessment system of health literacy has great potential practical value and reliability which is worthy of promotion and application.
The construction of rapid assessment system was simple and convenient with mean assessment time5.9minutes, which was7.3minutes faster than the old one which needs13.2minutes. It is simple and easy to assess the health literacy by the hundred percentage point system. The health literacy can be divided into three types: low level, marginal level and high level with the cut-off value of60and75, by which is appropriate for assessing the health literacy not only for individuals but also for populations.
4.Health messages are effective interventions not only for improving health literacy but also for economic and practical values. Compared with control group, the level of health literacy of public in intervention group improved1.56and1.34for three-dimension health literacy and four-dimension health literacy after the messages intervention. The cost-effectiveness of message intervention was0.54and0.38per person. So message intervention to improve the public health literacy is practical, economical and effective.
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