基于学校和家庭环境的深圳市中小学师生健康素养研究
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摘要
研究目的
从健康知识、健康行为和健康技能三个层次,描述中小学校师生的健康素养的分布特征；并从个体层次、家庭层次和学校环境等层次,分析中小学校师生的健康素养的影响因素,为中小学校健康促进策略提供基础数据和政策建议。
研究方法
本次调查对象为深圳市健康促进标杆工程试点的中小学师生,采用的是整群抽样的方式,共调查中小学师生1087例,其中小学生535例,中学生175例,教师377例。学生的调查内容包括人口学变量、家庭特征变量、学校特征变量以及健康素养；教师的调查内容包括人口学变量、学校工作环境与家庭经济状况以及健康素养。健康素养评估包括健康知识、健康行为和健康技能三个方面,是否具备健康素养按指标回答正确率在80%及以上计算。
研究结果
小学生的调查结果显示：男生多于女生(52.62%vs7.38%)；独生子女占28.65%；非深圳户籍占51.53%；没有与其父亲、母亲居住比例分别占5.46%和1.69%。健康素养的分布显示：具备健康行为的占82.06%,具备健康技能的占77.78%,具备健康知识的占69.48%,具备总体健康素养的占76.15%。多因素的分析结果显示：对健康知识影响有显著性意义的变量是年级和户籍特征；对健康行为影响有显著性意义的变量是学校环境卫生；对健康技能影响和总体健康素养有显著性意义的变量均是年级和学校环境卫生。
中学生的调查结果显示：男生多于女生(54.76%vs45.24%)；独生子女占36.31%；非深圳户籍占54.76%。健康素养的分布显示：具备健康知识的占47.62%；具备健康行为的占39.29%；具备健康技能的占75.00%；具备总体健康素养的占29.07%。多因素分析结果显示,对健康知识影响有显著性意义的变量是独生子女、学校教学质量和学校环境卫生；对健康行为和总体健康素养影响有显著性意义的变量均是年龄；对健康技能影响有显著性意义的变量是性别和年龄。
中小学教师的调查结果显示：非深圳户籍所占比例高(67.30%)；调查对象普遍感觉压力比较大(62.16%)。健康素养的分布显示：具备健康技能的占43.24%；具备健康知识的占34.05%；具备健康行为的占19.19%,具备总体健康素养的占6.76%。多因素的分析结果显示,对健康知识影响有显著性意义的变量是性别、户籍特征和领导认可；对健康行为影响有显著性意义的变量是文化程度、工作压力和领导认可；对健康技能影响有显著性意义的变量是婚姻状况和健康知识；对总体健康素养影响具有显著性意义的变量是性别、工作压力和领导认可。
研究结论
本研究提供了一个初始的中小学师生的健康素养及其家庭和学校影响因素的实证数据。中小学学生健康素养不同层次的影响因素分析结果均一致地显示,学校教学质量和环境卫生,特别是环境卫生对健康素养的影响具有重要作用,而家庭因素的影响,无论是对中学生还是对小学生,均没有显著性意义。教师健康素养多个层次的影响因素的分析结果显示,工作压力和领导认可,特别是领导认可对其健康素养的影响具有重要作用。
政策建议
在中小学生中,独生子女的健康素养值得关注和重视；由于在健康素养三个基本维度的影响因素中,学校环境卫生在很多层次上均具有显著性,而相比之下,家庭因素的影响并不具有显著性,因此,对中小学生而言,在工业化快速发展的社会经济背景下,基于学校的健康素养可能更为必要和重要。
本调查数据显示,中小学教师的总体健康素养并不高,而作为最具社会示范功能的职业群体,教师健康素养的提升是必要的和紧迫的,对此,需要强化学校的组织管理策略,其中重点是学校环境卫生和学校领导对教师工作的认可。
创新点与局限性
本研究提供了第一个关于中小学教师和学生两个视角的健康素养及其影响因素的实证数据。数据分析的结果显示,无论是中小学生还是教师,健康素养的影响因素中,学校因素均具有重要作用,特别是对中小学学生而言,学校因素的作用可能比其家庭因素更为重要,这为学校健康促进提供了重要信息。
本研究局限性主要是两个方面：一是样本来源及其样本量：本研究抽取学校比较少,虽然总体样本量为1000多例,但中学生样本量偏小,可能影响了研究结果；二是目前国内这一方面的研究比较少,使得讨论缺乏比较,不过,本文为后续的研究比较提供了前提和参考。
Objectives
To describe the distribution characteristics of health literacy among the primary and secondary school teachers and students from the three levels of health knowledge, health behavior and health skills; and to analysis influencing factors of health literacy of primary and secondary school teachers and students from the perspective of the individual level, family level and the school environment, and to provide basic data and policy recommendations for health promotion strategies of primary and secondary schools
Methods
The survey subject is Shenzhen health promotion benchmarking pilot project for primary and secondary teachers and students, using the cluster sampling method, and investigated a total of1087cases of primary and secondary school teachers and students, including535cases of primary school students,175cases of secondary school students, and377cases of teachers. The survey of students includes demographic variables, family characteristics variables, school characteristics variables and health literacy; the survey of teachers includes demographic variables, school environment and family economic status and health literacy. Health literacy assessment includes the assessment of health knowledge, health behavior and health skills, and the criterion of having the health literacy is that the correct answer rate of indicators is80%and above.
Results
The results of primary school students showed that boys is more than girls (52.62%vs7.38%); Only child accounted for28.65%; the primary school students of non-Shenzhen residence accounted for51.53%; and primary school students not living together with his father and mother accounted for5.46%and1.69%respectively. The distribution of health literacy showed that primary school students with health knowledge, behaviors, skills and overall accounted for69.48%,82.06%,77.78%,76.15%, respectively. The result of multivariate analysis showed that the influence factors of health knowledge were grade and household characteristics; those of health behaviors were school environment health; and those of health skills and overall health literacy were grade and school environment health.
Survey of middle school students showed that boys is more than girls(54.76%vs45.24%); Only child accounted for36.31%and the students of non-Shenzhen residence accounted for54.76%. The distribution of health literacy showed that primary school students with health knowledge, behaviors, skills and overall accounted for47.62%,39.29%,75.00%,29.07%, respectively. The result of multivariate analysis showed that the influence factors of health knowledge were only child, schools teaching quality and school health environment; those of health behavior as well as overall health literacy were age, and those of health skills were gender and age.
The results middle and primary school teachers showed that those without non-Shenzhen accounted67.30%. In general, the respondents felt with pressure (62.16%). The distribution of health literacy showed that teachers with health knowledge, behaviors, skills and overall accounted for34.05%,19.19%,43.24%,6.76%, respectively. The result of multivariate analysis showed that the influence factors of health knowledge were gender, household registry characteristics and leadership approval; those of health behavior were cultural degree, working pressure and leadership recognition; those of health skills were marital status and health knowledge and those of overall health literacy were gender, work pressure and leadership recognition.
Conclusions
This study provides empirical data for health literacy and impact factors about their families and school of a primary and secondary school teachers and students. Results of different levels analysis on health literacy showed that teaching quality and school environment status have a significant effect on health literacy of adolescents, especially school environment status. However, family factors had no significance, whether middle school students or pupils. Results of multiple levels analysis on teachers showed that the working pressure and leadership recognition play an important role on health literacy, especially leadership recognized.
Policy Suggestions
Among the primary and secondary students, it is worth concerning about the one-child health literacy. In three basic dimensions of health literacy of the influencing factors, school sanitation was significant on many levels; in contrast, family factors are not significant. Therefore, in the socio-economic background of the rapid development of industrialization, the school-based health literacy of the primary and secondary school students may be more necessary and important.
The survey data showed that overall health literacy of primary and secondary school teachers is not high, so upgrading of teachers'health literacy is necessary and urgent, because teachers are the most social demonstration occupational groups. In this regard, the school's organization and management strategies needed to strengthen, which focus on school sanitation and school leaders on the recognition of teachers'work.
Highlights and limitations
To our best of knowledge, the current study provided the first empirical data of health literacy of primary and secondary school teachers and students in China. Results of multiple levels analysis, whether on adolescents or on teachers, showed that school factors had significance on health literacy.
Two limitations of the current study must be addressed. First, the survey sample was not random, and its size was relatively small. Second, it was first study on this theme, and then it was difficult for us to compare and discuss the current results.
从健康知识、健康行为和健康技能三个层次,描述中小学校师生的健康素养的分布特征；并从个体层次、家庭层次和学校环境等层次,分析中小学校师生的健康素养的影响因素,为中小学校健康促进策略提供基础数据和政策建议。
研究方法
本次调查对象为深圳市健康促进标杆工程试点的中小学师生,采用的是整群抽样的方式,共调查中小学师生1087例,其中小学生535例,中学生175例,教师377例。学生的调查内容包括人口学变量、家庭特征变量、学校特征变量以及健康素养；教师的调查内容包括人口学变量、学校工作环境与家庭经济状况以及健康素养。健康素养评估包括健康知识、健康行为和健康技能三个方面,是否具备健康素养按指标回答正确率在80%及以上计算。
研究结果
小学生的调查结果显示：男生多于女生(52.62%vs7.38%)；独生子女占28.65%；非深圳户籍占51.53%；没有与其父亲、母亲居住比例分别占5.46%和1.69%。健康素养的分布显示：具备健康行为的占82.06%,具备健康技能的占77.78%,具备健康知识的占69.48%,具备总体健康素养的占76.15%。多因素的分析结果显示：对健康知识影响有显著性意义的变量是年级和户籍特征；对健康行为影响有显著性意义的变量是学校环境卫生；对健康技能影响和总体健康素养有显著性意义的变量均是年级和学校环境卫生。
中学生的调查结果显示：男生多于女生(54.76%vs45.24%)；独生子女占36.31%；非深圳户籍占54.76%。健康素养的分布显示：具备健康知识的占47.62%；具备健康行为的占39.29%；具备健康技能的占75.00%；具备总体健康素养的占29.07%。多因素分析结果显示,对健康知识影响有显著性意义的变量是独生子女、学校教学质量和学校环境卫生；对健康行为和总体健康素养影响有显著性意义的变量均是年龄；对健康技能影响有显著性意义的变量是性别和年龄。
中小学教师的调查结果显示：非深圳户籍所占比例高(67.30%)；调查对象普遍感觉压力比较大(62.16%)。健康素养的分布显示：具备健康技能的占43.24%；具备健康知识的占34.05%；具备健康行为的占19.19%,具备总体健康素养的占6.76%。多因素的分析结果显示,对健康知识影响有显著性意义的变量是性别、户籍特征和领导认可；对健康行为影响有显著性意义的变量是文化程度、工作压力和领导认可；对健康技能影响有显著性意义的变量是婚姻状况和健康知识；对总体健康素养影响具有显著性意义的变量是性别、工作压力和领导认可。
研究结论
本研究提供了一个初始的中小学师生的健康素养及其家庭和学校影响因素的实证数据。中小学学生健康素养不同层次的影响因素分析结果均一致地显示,学校教学质量和环境卫生,特别是环境卫生对健康素养的影响具有重要作用,而家庭因素的影响,无论是对中学生还是对小学生,均没有显著性意义。教师健康素养多个层次的影响因素的分析结果显示,工作压力和领导认可,特别是领导认可对其健康素养的影响具有重要作用。
政策建议
在中小学生中,独生子女的健康素养值得关注和重视；由于在健康素养三个基本维度的影响因素中,学校环境卫生在很多层次上均具有显著性,而相比之下,家庭因素的影响并不具有显著性,因此,对中小学生而言,在工业化快速发展的社会经济背景下,基于学校的健康素养可能更为必要和重要。
本调查数据显示,中小学教师的总体健康素养并不高,而作为最具社会示范功能的职业群体,教师健康素养的提升是必要的和紧迫的,对此,需要强化学校的组织管理策略,其中重点是学校环境卫生和学校领导对教师工作的认可。
创新点与局限性
本研究提供了第一个关于中小学教师和学生两个视角的健康素养及其影响因素的实证数据。数据分析的结果显示,无论是中小学生还是教师,健康素养的影响因素中,学校因素均具有重要作用,特别是对中小学学生而言,学校因素的作用可能比其家庭因素更为重要,这为学校健康促进提供了重要信息。
本研究局限性主要是两个方面：一是样本来源及其样本量：本研究抽取学校比较少,虽然总体样本量为1000多例,但中学生样本量偏小,可能影响了研究结果；二是目前国内这一方面的研究比较少,使得讨论缺乏比较,不过,本文为后续的研究比较提供了前提和参考。
Objectives
To describe the distribution characteristics of health literacy among the primary and secondary school teachers and students from the three levels of health knowledge, health behavior and health skills; and to analysis influencing factors of health literacy of primary and secondary school teachers and students from the perspective of the individual level, family level and the school environment, and to provide basic data and policy recommendations for health promotion strategies of primary and secondary schools
Methods
The survey subject is Shenzhen health promotion benchmarking pilot project for primary and secondary teachers and students, using the cluster sampling method, and investigated a total of1087cases of primary and secondary school teachers and students, including535cases of primary school students,175cases of secondary school students, and377cases of teachers. The survey of students includes demographic variables, family characteristics variables, school characteristics variables and health literacy; the survey of teachers includes demographic variables, school environment and family economic status and health literacy. Health literacy assessment includes the assessment of health knowledge, health behavior and health skills, and the criterion of having the health literacy is that the correct answer rate of indicators is80%and above.
Results
The results of primary school students showed that boys is more than girls (52.62%vs7.38%); Only child accounted for28.65%; the primary school students of non-Shenzhen residence accounted for51.53%; and primary school students not living together with his father and mother accounted for5.46%and1.69%respectively. The distribution of health literacy showed that primary school students with health knowledge, behaviors, skills and overall accounted for69.48%,82.06%,77.78%,76.15%, respectively. The result of multivariate analysis showed that the influence factors of health knowledge were grade and household characteristics; those of health behaviors were school environment health; and those of health skills and overall health literacy were grade and school environment health.
Survey of middle school students showed that boys is more than girls(54.76%vs45.24%); Only child accounted for36.31%and the students of non-Shenzhen residence accounted for54.76%. The distribution of health literacy showed that primary school students with health knowledge, behaviors, skills and overall accounted for47.62%,39.29%,75.00%,29.07%, respectively. The result of multivariate analysis showed that the influence factors of health knowledge were only child, schools teaching quality and school health environment; those of health behavior as well as overall health literacy were age, and those of health skills were gender and age.
The results middle and primary school teachers showed that those without non-Shenzhen accounted67.30%. In general, the respondents felt with pressure (62.16%). The distribution of health literacy showed that teachers with health knowledge, behaviors, skills and overall accounted for34.05%,19.19%,43.24%,6.76%, respectively. The result of multivariate analysis showed that the influence factors of health knowledge were gender, household registry characteristics and leadership approval; those of health behavior were cultural degree, working pressure and leadership recognition; those of health skills were marital status and health knowledge and those of overall health literacy were gender, work pressure and leadership recognition.
Conclusions
This study provides empirical data for health literacy and impact factors about their families and school of a primary and secondary school teachers and students. Results of different levels analysis on health literacy showed that teaching quality and school environment status have a significant effect on health literacy of adolescents, especially school environment status. However, family factors had no significance, whether middle school students or pupils. Results of multiple levels analysis on teachers showed that the working pressure and leadership recognition play an important role on health literacy, especially leadership recognized.
Policy Suggestions
Among the primary and secondary students, it is worth concerning about the one-child health literacy. In three basic dimensions of health literacy of the influencing factors, school sanitation was significant on many levels; in contrast, family factors are not significant. Therefore, in the socio-economic background of the rapid development of industrialization, the school-based health literacy of the primary and secondary school students may be more necessary and important.
The survey data showed that overall health literacy of primary and secondary school teachers is not high, so upgrading of teachers'health literacy is necessary and urgent, because teachers are the most social demonstration occupational groups. In this regard, the school's organization and management strategies needed to strengthen, which focus on school sanitation and school leaders on the recognition of teachers'work.
Highlights and limitations
To our best of knowledge, the current study provided the first empirical data of health literacy of primary and secondary school teachers and students in China. Results of multiple levels analysis, whether on adolescents or on teachers, showed that school factors had significance on health literacy.
Two limitations of the current study must be addressed. First, the survey sample was not random, and its size was relatively small. Second, it was first study on this theme, and then it was difficult for us to compare and discuss the current results.
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32. Fleming M, Madamala K. Improving medical practice:Understanding adolescent health literacy. Presented at the American Public Health Association. Philadelphia, PA.2005.
33. Ravert RD, Hancock MD, Ingersoll GM. Online forum messages posted by adolescents with type 1 diabetes. Diabetes Educator,2004,30(5):827-834.
34. Feldman SS, Elliott GR. At the Threshold:The Developing Adolescent. Cambridge, MA: Harvard University Press.1990.
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39. Levin-Zamir D:Health literacy in health systems:perspectives on patient self-management in Israel. Health Promot Int,2001,16(1):87-94.
40. Pleasant A, Kuruvilla SS. A tale of two health literacies:public health and clinical approaches to health literacy. Health Promot Int,2008,23(2):152-159.
41. Parker R. Health literacy:a challenge for American patients and their health care providers. Health Promot Int, 2000,15(4):277-283.
42. Lloyd LLJ, Ammary NJ, Epstein LG, et al. A transdisciplinary approach to improve health literacy and reduce disparities. Health Promot Pract,2006,7(3):331-335.
43. Ishikawa H, Yano E. Patient health literacy and participation in the health-care process. Health Expect,2008,11 (2):113-122.
44. McCray A. Promoting health literacy. J Am Med Inform Assoc,2004,12(2):152-163.
45. Robbins A. Public health literacy for lawyers:teaching population-based legal analysis. Environ Health Perspect,2003,111(14):744-745.
46. Paasche-Orlow MK. Bridging the international divide for health literacy research. Patient Educ Couns,2009,75:293-294.
47. Porr C, Drummond J, Richter S. Health Literacy as an Empowerment Tool for Low-Income Mothers. Family & Community Health,2006,29(4):328-335.
48. Paasche-Orlow M. Bridging the international divide for health literacy research. Patient Educ Couns,2009,75:293-294.
49. Barber MN, Staples M, Osborne RH, et al. Up to a quarter of the Australian population may have suboptimal health literacy depending upon the measurement tool:results from a population-based survey. Health Promot Int,2009,24(3):252-261.
50. Wadsworth LA, Thompson AM. Media literacy:a critical role for dietetic practice. Can J Diet Prac Res,2005,66:30-36.
51. Naito M, Nakayama T, Hamajima N. Health literacy education for children:acceptability of a school-based program in oral health. J Oral Sci,2007,49(1):53-59.
52. Neumark-Sztainer D, Sherwood NE, Coller T, et al. Primary prevention of disordered eating among preadolescent girls:feasibility and short-term effect of a community-based intervention. J Am Diet Assoc,2000,100:1466-1473.
53. Lavin AT, Shapiro GR, Weill KS. Creating an agenda for school-based health promotion:a review of 25 selected reports. Journal of School Health,1992,62:212-229.
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56.廖学舟,张娟,张隆明,等.鄂州市青少年亚健康现状及影响因素.中国社会医学杂志, 2010,1：8-10.
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62.张美娟,陈月枝,章淑娟.健康素养的概念分析.护理杂志,2009,56(5)：93-97.
63.邹思梅,方小衡,林德南,等.健康素养研究进展,中国健康教育,2010,26(7)：537-545.
64.张士靖,杜建.健康信息素养应成为中国公众健康素养促进的关键点.医学信息学杂志,2010,31(02)：45-49.
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66.肖王乐.中国公众健康素养调查及评价体系建立.中国疾病预防控制中心博士论文,2008.
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8. Ad Hoc Committee on Health Literacy for the Council on Scientific Affairs, American Medical Association. Health literacy:report of the Council on Scientific Affairs. JAMA, 1999,281 (6):552-557.
9. Adams RJ, Stocks NP, Wilson DH. et al. Health literacy A new concept for general practice. Australian Family Physician,2009,38:144-147.
10. Nutbeam D. The evolving concept of health literacy. Social Science& Medicine,2008,67: 2072-2078.
11. Kickbusch IS. Health literacy:addressing the health and education divide. Health Promotion International,2001,16:289-297.
12.郭欣,王克安.健康素养研究进展.中国健康教育,2005,21(08)：590-593.
13. Manganello JA. Health literacy and adolescents:a framework and agenda for future research. Health Educ Res.2008,23(5):840-847.
14. Institute of Medicine. Health literacy:a prescription to end confusion. Washington, DC: National Academies Press,2004.
15. Mayeaux EJ, Murphy PW, Arnold C, et al. Improving patient education for patients with low literacy skills. American Family Physician,1996,53:205-211.
16. Adams RJ, Stocks NP, Wilson DH, et al. Health literacy. A new concept for general practice? Aust Fam Physician,2009,38(3):144-147.
17. Levin-Zamir D. Health literacy in health systems:perspectives on patient self-management in Israel. Health Promot Int,2001,16(1):87-94.
18. Pleasant A, Kuruvilla SS:A tale of two health literacies:public health and clinical approaches to health literacy. Health Promot Int 2008,23(2):152-159.
19. Kutner M., Greenberg E, Jin Y, et al. The health literacy of America's adults:Results from the 2003 National Assessment of Adult Literacy.2006. Retrieved from http://nces.ed.gov/pubs2006/2006483.pdf
20. Ad Hoc Committee on Health Literacy for the Council on Scientific Affairs AMA. Health literacy, report of the Council on Scientific Affairs. J Am Med Assoc,1999,281:552-557.
21. Lee P. Why literacy matters:Links between reading ability and health. Archives of Ophthalmology,1999,117(1):100-103.
22. Baker DW, Parker RM, Williams MV, et al. The health care experience of patients with low literacy. Archives of Family Medicine,1996,5:329-334.
23. Weiss BD, Palmer R. Relationship between health care costs and very low literacy skills in a medically needy and indigent Medicaid population. Journal of the American Board of Family Practice,2004,17(1):44-47.
24. Williams M, Davis T, Parker R, et al. The role of health literacy in patient-physician communication. Family Medicine,2002,34(5):383-389.
25. Schillinger D, Bindman A, Wang F, et al. Functional health literacy and the quality of physician-patient communication among diabetes patients. Patient Education and Counseling, 2004,52(3):315-323.
26. Rudd R, Comings J, Hyde J. Leave no one behind:Improving health and risk communication through attention to literacy. Journal of Health Communication,2003,8(S1):104-115.
27. Agency for Healthcare Research and Quality. Literacy and health outcomes:Summary. Evidence Report/Technology Assessment,2004. Retrieved from http://www.ahrq.gov/clinic/epcsums/litsum.pdf
28. Baker DW, Parker RM, Williams MV, et al. The relationship of patient reading ability to self-reported health and use of health services. American Journal of Public Health,1997, 87(6):1027-1030.
29. Baker DW, Gazmararian JA, Williams MV, et al. Health literacy and use of outpatient physician services by Medicare Managed care enrollees. Journal of General Internal Medicine,2004,19:215-220.
30. Parker R. Health literacy:a challenge for American patients and their health care providers. Health Promot Int,2000,15(4):277-283.
31. Lloyd LLJ, Ammary NJ, Epstein LG, et al. A transdisciplinary approach to improve health literacy and reduce disparities. Health Promot Pract,2006,7(3):331-335.
32. Ishikawa H, Yano E. Patient health literacy and participation in the health-care process. Health Expect,2008,11 (2):113-122.
33. McCray A. Promoting health literacy. J Am Med Inform Assoc,2004,12(2):152-163.
34. Robbins A. Public health literacy for lawyers:teaching population-based legal analysis. Environ Health Perspect,2003,111(14):744-745.
35. DeWalt DA, Berkman ND, Sheridan S, et al. Literacy and health outcomes:A systematic review of the literature. Journal of General Internal Medicine,2004; 19(12):1228-1239.
36. Newacheck PW, Wong ST, Galbraith AA, et al. Adolescent health care expenditures:A descriptive profile. Journal of Adolescent Health,2003,32(S):3-11.
37. Paasche-Orlow MK:Bridging the international divide for health literacy research. Patient Educ Couns,2009,75:293-294.
38. Porr C, Drummond J, Richter S. Health Literacy as an Empowerment Tool for Low-Income Mothers. Family & Community Health,2006,29(4):328-335.
39. Paasche-Orlow MK. Bridging the international divide for health literacy research. Patient Educ Couns,2009,75:293-294.
40. Barber MN, Staples M, Osborne RH, et al. Up to a quarter of the Australian population may have suboptimal health literacy depending upon the measurement tool:results from a population-based survey. Health Promot Int,2009,24(3):252-261.
41. Wadsworth LA, Thompson AM. Media literacy:a critical role for dietetic practice. Can J Diet Prac Res,2005,66:30-36.
42. St Leger L. Schools, health literacy and public health:possibilities and challenges. Health Promot Int,2001; 16(2):197-205.
43. Naito M, Nakayama T, Hamajima N. Health literacy education for children:acceptability of a school-based program in oral health. J Oral Sci.2007,49(1):53-59.
44. Neumark-Sztainer D, Sherwood NE, Coller T, et al. Primary prevention of disordered eating among preadolescent girls:feasibility and short-term effect of a community-based intervention. J Am Diet Assoc,2000,100:1466-1473.
45. Lavin AT, Shapiro GR, Weill KS. Creating an agenda for school-based health promotion:a review of 25 selected reports. Journal of School Health,1992,62:212-229.
46. World Health Organization. The Status of School Health. Geneva,1996.
47.柳春红,孙秀发.青少年饮食行为及其心理影响因素.中国社会医学杂志,2011,3：182-184.
48.廖学舟,张娟,隆明,等.鄂州市青少年亚健康现状及影响因素.中国社会医学杂志,2010,1：8-10.
49. Tarlov A. Social determinants of health:the sociobiological translation. In:Blane D, Brunner E, Wilkinson R, eds. Health and social organization. London, Routledge,1996.
50. World Health Organization. Closing the gap in a generation:health equity through action on the social determinants of health,2008. Available: http://www.searo.who.int/LinkFiles/SDH_SDH_FinalReport.pdf.
51. Newacheck PW, Wong ST, Galbraith AA, et al. Adolescent health care expenditures:A descriptive profile. Journal of Adolescent Health,2003,32(S):3-11.
52. Kaiser Family Foundation. Key facts:Media literacy,2003. Retrieved from http://www.kff.org/entmedia/upload/Key-Facts-Media-Literacy.pdf
55. Entwisle DR. Schools and the adolescent. In S.S. Feldman & G.R. Elliott (Eds.), At the Threshold:The Developing Adolescent, (197-224). Cambridge, MA:Harvard University Press,1990.
54. Biancarosa G, Snow CE. Reading next:A vision for action and research in middle and high school literacy:A report to Carnegie Corporation of New York.2004. Retrieved from http://www.all4ed.org/publications/ReadingNext/ReadingNext.pdf
55. National Center for Education Statistics. NAEP Data Explorer,2008.Retrieved from http://nces.ed.gov/nationsreportcard/naepdata
56. Yin HS, Forbis SG, Dreyer BP. Health literacy and pediatric health. Current Problems in Pediatric and Adolescent Health Care,2007,37(7):258-286.
57. Gray NJ, Klein JD, Noyce PR, et al. Health information-seeking behaviour in adolescence: the place of the Internet. Social Science & Medicine,2005,60(7):1467-1478.
58. Kidshealth. KidsPoll:Health literacy poll:Summary of findings,2008. Retrieved from http://www.nahec.org/KidsPoll/health_literacy/HealthLiteracy_Summary_Of_Findings.pdf
59. Brown S, Teufel J, Birch D. Early adolescents'perceptions of health and health literacy. Journal of School Health,2007,77(1):7-15.
60. Fleming M, Madamala K. Improving medical practice:Understanding adolescent health literacy. Presented at the American Public Health Association. Philadelphia, PA.2005.
61. Ravert RD, Hancock MD, Ingersoll GM. Online forum messages posted by adolescents with type 1 diabetes. Diabetes Educator,2004,30(5):827-834.
62. Feldman SS, Elliott GR. At the Threshold:The Developing Adolescent. Cambridge, MA: Harvard University Press,1990.
63. Keating DP. Adolescent thinking. In S.S. Feldman and G.R. Elliott (Eds.), At the Threshold: The Developing Adolescent (54-92). Cambridge, MA:Harvard University Press,1990.
64. Steinberg L. Adolescence (7th ed.). New York, NY:McGraw-Hill,2005.
65.肖砾,陶茂萱.健康素养研究进展与展望.中国健康教育,2008,24(5)：361-363.
66.孙浩林,傅华.健康素养的涵义研究现状.中国慢性病预防与控制,2011,19(3)：323-326.
67.张美娟,陈月枝,章淑娟.健康素养的概念分析.护理杂志,2009,56(5)：93-97.
68.邹思梅,方小衡,林德南,等.健康素养研究进,中国健康教育,2010,26(7)：537-545.
69.张士靖,杜建.健康信息素养应成为中国公众健康素养促进的关键点.医学信息学杂志,2010,31(02)：45-49.
70.中华人民共和国卫生部公告第3号.中国公民健康素养——基本知识与技能(试行).2008.
71.肖王乐.中国公众健康素养调查及评价体系建立.中国疾病预防控制中心博士论文,2008.
72.卫生部妇幼保健与社区卫生司,中国健康教育中心,卫生部新闻宣传中心.首次中国居民健康素养调查报告,2009.
2. Adams RJ, Stocks NP, Wilson DH. et al. Health literacy A new concept for general practice. Australian Family Physician,2009,38:144-147.
3. Nutbeam D. The evolving concept of health literacy. Social Science& Medicine,2008,67: 2072-2078.
4. Kickbusch IS. Health literacy:addressing the health and education divide. Health Promotion International,2001,16:289-297.
5.郭欣,王克安.健康素养研究进展.中国健康教育,2005,21(08)：590-593.
6. Manganello JA. Health literacy and adolescents:a framework and agenda for future research. Health Educ Res.2008,23(5):840-847.
7. Institute of Medicine. Health literacy:a prescription to end confusion. Washington, DC: National Academies Press,2004.
8. Davis TC, Wolf MS. Health literacy:implications for family medicine. Fam Med, 2004,36(8):595-598.
9. Kutner M, Greenberg E, Jin Y, et al. The health literacy of America's adults:Results from the 2003 National Assessment of Adult Literacy. Retrieved from http://nces.ed.gov/pubs2006/2006483.pdf
10. Ad Hoc Committee on Health Literacy for the Council on Scientific Affairs AMA. Health literacy:report of the Council on Scientific Affairs. J Am Med Assoc,1999,281:552-557.
11. Lee P. Why literacy matters:Links between reading ability and health. Archives of Ophthalmology,1999,117(1):100-103.
12. Baker DW, Parker RM, Williams MV, et al. The health care experience of patients with low literacy. Archives of Family Medicine,1996,5:329-334.
13. Weiss BD, Palmer R. Relationship between health care costs and very low literacy skills in a medically needy and indigent Medicaid population. Journal of the American Board of Family Practice,2004,17(1):44-47.
14. Williams M, Davis T, Parker R, et al. The role of health literacy in patient-physician communication. Family Medicine,2002,34(5):383-389.
15. Schillinger D, Bindman A, Wang F, et al. Functional health literacy and the quality of physician-patient communication among diabetes patients. Patient Education and Counseling, 2004,52(3):315-323.
16. Rudd R, Comings J, Hyde J. Leave no one behind:Improving health and risk communication through attention to literacy. Journal of Health Communication,2003,8(S1):104-115.
17. Agency for Healthcare Research and Quality. Literacy and health outcomes:Summary. Evidence Report/Technology Assessment,2004. Retrieved from http://www.ahrq.gov/clinic/epcsums/litsum.pdf
18. Baker DW, Parker RM, Williams MV, et al. The relationship of patient reading ability to self-reported health and use of health services. American Journal of Public Health,1997, 87(6):1027-1030.
19. Baker DW, Gazmararian JA, Williams MV, et al. Health literacy and use of outpatient physician services by Medicare Managed care enrollees. Journal of General Internal Medicine,2004,19:215-220.
20. Lindau ST, Tomori C, Lyons T, et al. The association of health literacy with cervical cancer prevention knowledge and health behaviors in a multiethnic cohort of women. American Journal of Obstetrics and Gynecology,2002,186(5):938-943.
21. DeWalt DA, Berkman ND, Sheridan S, et al. Literacy and health outcomes:A systematic review of the literature. Journal of General Internal Medicine,2004,19(12):1228-1239.
22. Newacheck PW, Wong ST, Galbraith AA, et al. Adolescent health care expenditures:A descriptive profile. Journal of Adolescent Health,2003,32(S):3-11.
23. Kaiser Family Foundation. Key facts:Media literacy.2003. Retrieved from http://www.kff.org/entmedia/upload/Key-Facts-Media-Literacy.pdf
24. EntwisleDR. Schools and the adolescent. In S.S. Feldman& G.R. Elliott (Eds.), At the Threshold:The Developing Adolescent. Cambridge, MA:Harvard University Press.1990.
25. St Leger L. Schools, health literacy and public health:possibilities and challenges. Health Promot Int,2001,16(2):197-205.
26. Biancarosa G, Snow CE. Reading next:A vision for action and research in middle and high school literacy:A report to Carnegie Corporation of New York.2004. Retrieved from http://www.all4ed.org/publications/ReadingNext/ReadingNext.pdf
27. National Center for Education Statistics. NAEP Data Explorer.2011. Retrieved from http://nces.ed.gov/nationsreportcard/naepdata
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