| Background and Research ObjectivesBased on the theory of the social determinants of health,Health in All Policies(Hi AP)was developed.The Hi AP is a collaborative approach that integrates and articulates health considerations into policy making across sectors to improve the health of all communities and people with active implementation and effective intervention.The theory specifies that health-related behaviors are the most influential health factors.Over half of deaths globally are due to unhealthy behaviors and lifestyles.A lot of relevant researches have shown that health-related behaviors are the most controllable factors among the social determinants of health,and are one of the priorities in the implementation of health intervention and management.Modifications in health behavior can successfully prevent more than 75% of non-communicable chronic diseases and contribute to the prevention of communicable diseases.The control in health risk behaviors can greatly improve public health,which is one of the best routes to maximize the “input-utility” in health,and one of the most cost-effective means of health management.On the other hand,in the context of the "China’s New Era",the major decision-making plan for implementing the Healthy China Initiative is to emphasize the need to adhere to prevention,advocate the healthy and civilized behavior and lifestyle,and accelerate the transition from treating diseases to focusing on people’s health.“Healthy China 2030”proposed to include “popularizing the healthy lifestyle” as a priority of five strategies to implement the Healthy China Initiative.In "China’s New Era",the implementation of Healthy China Initiative requires prevention as the first strategy,with promotion in healthy lifestyles and to change focus from medical treatment to people’s health.The Chinese government has issued a series of documents to fulfill the great goal in implementing the Healthy China Initiative,including “A Guideline to Implement the Country’s Healthy China Initiative”,“The Implementation and Assessment Program for Healthy China Acting Organization” and “The Healthy China Action Plan(2019-2030)”.Based on the theory of social determinants of health and the need to implement the Healthy China initiative,research on the influencing factors of health-related behaviors(which are the social determinants of health)is urgently needed,so as to effectively prevent the occurrence and the development of diseases,and to further improve the health status of individuals from source.Therefore,our study aimed to achieve the following four goals,including: 1)to understand the current status of health-related behaviors among the Chinese adults,including smoking,drinking,teeth-brushing,exercising and weight maintaining;2)to identify the socio-ecological factors associated with these health-related behaviors;3)to explore co-occurrence models of health-related behaviors and their properties;4)to put forward more effective intervention strategies of health-related behaviors and to provide relevant policy advice,so as to guide all citizens to live a healthy lifestyle and promote the implementation of Healthy China.Materials and MethodsThe data of the present study were obtained from the Sixth National Health Services Survey.Based on the theory of social determinants of health,our study selected five health-related behaviors,including smoking,drinking,teeth-brushing,exercising and weight maintaining,and collected the potential socio-ecological factors,including the general demographic characteristics,individuals’ health status,family status,community and geological location and the availability of health services.Therefore,we established a sub-database called “the Sixth National Health Service Survey on Health-related Behaviors”.Data were analyzed based on three dimensions.First,initial descriptive analysis for the specific health-related behavior and its potential socio-ecological factors was conducted,so as to understand the current status of health-related behaviors among the Chinese adults and its proportion within different populations.Second,the potential socio-ecological factors associated with health-related behaviors were analyzed,so as to identify the main socio-ecological factors that were most predictive of the health-related behaviors.Lastly,co-occurrence models of health-related behaviors were analyzed to explore the properties of the models.Based on the above logical idea of data analysis,each health-related behavior and its potential socio-ecological factors were descriptively analyzed,and frequencies and proportions were reported.Chi-square tests were used to explore the distribution and the differences of each health-related behavior on different potential socio-ecological factors.Then,we applied Back-Propagation(BP)neural network method to create neural network models of single and multiple dependent variables,by which all potential influencing factors of health-related behaviors were ranked and evaluated by importance.The most predictive socio-ecological factors of the health-related behaviors were selected to create tree model,which directly showed the specific effect of each factor on health-related behaviors.Lastly,we employed two-step cluster to group and identify the co-occurrence of multiple health-related behaviors,so as to explore the co-occurrence models and their properties.Data was managed by using the Statistical Analysis System(SAS)version 9.4 and the IBM Statistical Package for the Social Sciences(SPSS)version 22.0 at the very start.Descriptive analysis of health-related behaviors and their socio-ecological factors,chi-square tests and BP neural network method were applied by using IBM SPSS Statistics version 22.0.The tree model of the most predictive socio-ecological factors of the health-related behaviors and the co-occurrence models of two-step cluster were created by IBM SPSS Modeler version 14.1.A two-sided P-value of less than 5% were considered to be statistically significant.Main ResultsIn terms of the status quo of the health-related behaviors in the general Chinese adults,25.3% of the general Chinese adults smoked,21.9% drank,47.5% brushed teeth twice a day,47.3% exercised every week and 54.7% maintained a healthy weight.In terms of the most predictive socio-ecological factors of the health-related behaviors,the neural network model of current smoking and drinking showed that the importance values of sex and age were 30.0% and 12.0%,whose normalized importance values were100.0% and 40.0%,respectively.After adjusting for sex and age,the most important socio-ecological factor was the employment status,whose importance and normalized importance values were 17.3% and 100.0%,respectively.The education level ranked second in the importance of socio-ecological factors,whose importance and normalized importance values were 11.8% and 68.2%.The importance of geological location ranked third among all factors,which was 7.8% and its normalized importance value was 45.1%.In addition,VAS status,average annual household income,migrant population and the number of chronic diseases were all associated with current smoking and drinking,whose importance values were 33.0%,30.1%,28.9% and 27.2%,respectively.The initial neutral network model of brushing teeth twice a day,doing exercise every week and maintaining weight showed that the importance values of rural-urban differences and age differences were 14.9% and 10.1%,and their normalized importance values were100.0% and 67.8%,respectively.After adjusting for rural-urban difference and age factor,educational level was the most important socio-ecological factor,whose importance and normalized importance values were 16.9% and 100.0%,respectively.Employment status ranked second among the importance of socio-ecological factors,whose importance and normalized importance values were 8.7% and 51.5%,respectively.The importance value of household registration was 7.8%,which ranked third with its normalized importance value being 50.30%.The importance and normalized importance values of geological location were 7.8% and 46.2%,while the values of sex were 6.8% and 40.2%,respectively.In addition,the number of chronic diseases and if being the migrant population were also associated with the behaviors of brushing teeth twice a day,doing exercise every week and maintaining weight,whose normalized importance values were 33.7% and 27.8%.Based on the eight most predictive socio-ecological factors of the health-related behaviors obtained from the neural network models,tree models of specific health-related behavior were created.The results showed that there were 24 nodes in the tree model of smoking,34 nodes in the tree model of drinking,54 nodes in the tree model of brushing teeth twice a day,44 nodes in the tree model of exercising every week,and 30 nodes in the tree model of maintaining a healthy weight.In terms of co-occurrence models of the health-related behaviors,there were 6 possible health risk behaviors(having from 0 to 5 health risk behaviors)and 32 types of behavioral combinations,including 5 types combination of having 1 and 4 health risk behaviors,and 10 types combination of having 2 and 3 health risk behaviors,respectively.The analysis of two-step cluster showed that 32 types of behavioral combinations can be sorted into 5 groups.Among the 5 groups,the Chinese adults without any health risk behavior accounted for 12.1%.There were 22.3% of adults who did not brush teeth twice a day,or exercise every week,or maintain a healthy weight,while 9.2% had all of the three health risk behaviors.However,those who had two out of three health risk behaviors(did not brush teeth twice a day,exercise every week,or maintain a healthy weight)accounted for 22.0%.In addition,there were 34.4% of adults who current smoked and/ or drank,and along with any other health risk behavior(s),which accounted for the largest proportion of the 5 groups.Conclusion1.The improvement of the current status of health-related behaviors among the general Chinese adults is particularly needed.The percentage of people who brush twice a day or exercise every week has slightly increased.No significant improvement has been observed on the prevalence of smoking or drinking,which are still highly prevalent.However,people who maintain a healthy weight has decreased a bit.Therefore,in terms of specific health-related behavior,it shows the co-existence of various status,including slightly improvement,no improvement and deterioration.2.The most predictive socio-ecological factors of the health-related behaviors among the general Chinese adults include sex,age,educational level,employment status,the number of chronic diseases and geological location.Sex was significantly associated with health-related behaviors,which provides an explanation for the phenomenon of “The Male-Female Health-Survival Paradox”.However,instead of early prevention,the Chinese elderly usually showed better health-related behaviors only when they were already in poor health status.People with lower socio-economic status were associated with worse health-related behaviors,and they are more likely to be health-related behavioral nonfeasance.In terms of geological location,people in south and east areas showed a better health-related behavior,while people in west south and north areas showed a worse one.3.There are mainly five types of co-occurrence models of health-related behaviors among the Chinese adults.Drinking and smoking are the most significant health-related behaviors(or key behaviors).Smoking and/ or drinking tends to trigger other unhealthy behaviors,including teeth brushing less than twice a day,not exercising every week,and failure to maintain a healthy weight.Policy suggestionBased on the results and discussion,along with combination with theories on health-related behaviors and the implementation of Healthy China Initiative,the present study also put forward policy advice from macro,meso and micro levels.The present study suggests the need of encouraging involvement from multiple stakeholders,and the comprehensive and integrated packages,compiled and combined with multiple related intervention programs and/ or strategies across the full range of health-related behaviors,with particularly focus on smoking and drinking behaviors,should be designed and implemented immediately to generate substantially larger health benefits as a favorable and cost effective alternative.At a macro level,this study suggests the country to further establish a robust supporting system of health-related behaviors.China should further strengthen the legislation on health-related behaviors and to supervise its implementation.Related funds should be integrated to increase input in the interventions of health-related behaviors.Specialists in health intervention should be given higher importance.Personal supervision and community monitoring of health-related behaviors should be strengthened.At a meso level,the present study suggests the social organizations to widely implement interventions of health-related behaviors.Health education and interventions should be conducted to improve personal responsibility in health.Tertiary intervention network of health-related behaviors should be developed,and related technical environment should be supported as well.At a micro level,the study suggests that the both differences and properties in specific health-related behaviors and different subgroups should be addressed very seriously,so as to conduct targeted intervention strategies.Interventions on smoking and drinking should be regarded as priorities.It is also necessary to implement differentiated behavior intervention strategies for the specific groups with different sex,age and socio-economic status.In addition,urban-rural and regional imbalances in health-related behaviors should be emphasized. |
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