| BackgroundAt 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?ObjectivesThe 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.MethodsFrom 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 results1. 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 RecommendationsThis 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 Limitations1. 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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