Objective: To systematically evaluate the impact of a school-based sodium reduction education program using mobile health (mHealth), known as EduSaltS, on salt-related knowledge, attitudes, practices (KAP) and sodium intake among adults and children during its real-world scaling-up and to examine geographic and population heterogeneity in its effects. Methods: A multi-center pragmatic pre-post study design was used. The EduSaltS program was implemented in three cities (Ganzhou in southern China, Zhenjiang in eastern China, and Qinhuangdao in northern China) between April 2022 and July 2024. Ten primary schools were selected from each city. Baseline and follow-up surveys were conducted approximately 12 months apart, aligned with the school calendar. Electronic questionnaires were used to collect baseline and post-intervention data on the primary outcome-salt-related KAP-from adults and children. In Ganzhou and Zhenjiang, 24 h urine collections were conducted to measure urinary sodium excretion. Results: A total of 721 adults and 770 children were included in the final analysis. After the intervention, the total KAP scores significantly increased in both adults and children across the three sites: by 8.7-10.0 points in adults and by 11.4-16.7 points in children (all p < 0.001). The changes in sodium intake showed significant heterogeneity. A significant decrease in urinary sodium was observed among adults in Ganzhou (-14.0 mmol/24 h, 95% CI: -26.1, -2.0, p = 0.022), corresponding to a reduction of 0.82 g in daily salt intake. No significant change was found among adults in Zhenjiang (adjusted difference: -0.7 mmol/24 h, 95% CI: -13.4 to 12.0, p = 0.912). In children, after the one-year intervention, urinary sodium excretion showed a significant increase from baseline to follow-up in both cities (Ganzhou: +12.9 mmol/24 h, p = 0.018; Zhenjiang: +14.0 mmol/24 h, p = 0.0002). Conclusions: The pre-post evaluation showed that the EduSaltS program was associated with significant improvements in salt-related knowledge across regions. Its effectiveness in reducing sodium intake, however, varied substantially by population and geographic location. The observed increase in children's urinary sodium excretion may partly reflect normal childhood growth and the limitations of a pre-post design without a control group. Pragmatic randomized controlled trials are warranted to verify the effectiveness of such interventions in reducing sodium intake and blood pressure across diverse populations and settings.

Background:While the mHealth and school-based scale-up intervention for salt reduction (EduSaltS) effectively reduced salt intake and blood pressure among adults living with participating schoolchildren, the sustainability of these effects remains uncertain. This study aimed to evaluate whether these effects persisted one year post intervention. Methods: A one-year follow-up of a cluster randomized controlled trial was conducted, involving 524 children and their 524 adult family members from 20 primary schools. At 24 months, 509 children (97.1%) and 486 adults (92.7%) completed the assessment. Mixed linear models were used to analyze the difference in changes in salt intake between the intervention and control groups at 24 months, compared to baseline and 12 months, as measured by consecutive 24 h urinary sodium excretions. Secondary outcomes included the differences in changes in blood pressure and salt-related knowledge, attitudes, and practices (KAP) scores. Results: The adjusted mean difference in changes in salt intake between groups was −0.34 g/24 h (95% CI: −0.94 to 0.26, p = 0.265) for children and −0.72 g/24 h (95% CI: −1.48 to 0.05, p = 0.065) for adults at 24 months versus baseline. The corresponding differences from 12 to 24 months were −0.09 g/24 h (95% CI: −0.69 to 0.51, p = 0.775) for children and 0.29 g/24 h (95% CI: −0.50 to 1.08, p = 0.468) for adults. The adjusted difference in changes in adult blood pressure showed a slight, nonsignificant rebound at 24 months. The intervention group maintained significantly higher KAP scores than the control group at both 12 and 24 months. Conclusions: The effects of EduSaltS on reducing salt intake and blood pressure in adults diminished slightly one year after the intervention ended. However, sustained improvements in salt-related KAP were observed in both children and adults. Ongoing support is vital to sustain long-term salt-reduction behaviors.

BackgroundGlobally, cardiovascular diseases are leading causes of mortality and disability, with hypertension being a major risk factor. Reducing salt intake and blood pressure are among the most cost-effective health promotion strategies. While mobile health (mHealth)– and school-based salt reduction interventions have proven effective in trials, their impact when scaled up in real-world contexts remains uncertain. ObjectiveWe evaluated the effectiveness of the real-world implementation of an mHealth- and school-based health education scale-up program to reduce salt intake (EduSaltS [mHealth and school-based education program to reduce salt intake scaling up in China]). MethodsA parallel cluster randomized controlled trial was conducted from April 2022 to July 2023 across 20 schools in 2 districts and 2 counties within Ganzhou City, Jiangxi Province, China. Schools were randomized 1:1 to intervention or control groups within each district or county. One third-grade class per school and 26 students per class were randomly sampled. One parent, or alternative family member (aged 18-75 years, residing with the student), of each student was invited to join. The EduSaltS intervention, spanning over 1 academic year, incorporated both app-based health education courses and offline salt reduction activities, with participation monitored through the backend management system. The intervention’s effectiveness was assessed by comparing changes in salt intake and blood pressure between groups from baseline to 1-year follow-up using surveys, physical examination, and 24-hour urine tests. ResultsOf 524 children (boys: n=288, 54.96%; age: mean 9.16, SD 0.35 years) and 524 adults (men: n=194, 37.02%; age: mean 40.99, SD 11.04 years) who completed the baseline assessments in 10 intervention and 10 control schools, 13 (2.48%) children and 47 (8.97%) adults were lost to follow-up. All schools and participants showed satisfactory intervention adherence. Measured differences in schoolchildren’s salt intake, systolic blood pressure, and diastolic blood pressure, between the intervention and control schools, were –0.24 g/day (95% CI –0.82 to 0.33), –0.68 mm Hg (95% CI –2.32 to 0.95), and –1.37 mm Hg (95% CI –2.79 to 0.06), respectively. For adults, the intervention group’s salt intake decreased from 9.0 (SE 0.2) g/day to 8.3 (SE 0.2) g/day post intervention. Adjusted changes in the intervention (vs control) group in salt intake, systolic blood pressure, and diastolic blood pressure were –1.06 g/day (95% CI –1.81 to –0.30), –2.26 mm Hg (95% CI –4.26 to –0.26), and –2.33 mm Hg (95% CI –3.84 to –0.82), respectively. ConclusionsThe EduSaltS program, delivered through primary schools with a child-to-parent approach, was effective in reducing salt intake and controlling blood pressure in adults, but its effects on children were not significant. While promising for nationwide scaling, further improvements are needed to ensure its effectiveness in reducing salt intake among schoolchildren. Trial RegistrationChinese Clinical Trial Registry ChiCTR2400079893; https://tinyurl.com/4maz7dyv (retrospectively registered); Chinese Clinical Trial Registry ChiCTR2000039767; https://tinyurl.com/5n6hc4s2

Objectives Global efforts to reduce sodium intake are slow, especially where discretionary salt use is the main source. Few structural approaches have been developed and evaluated for effectiveness and scalability. This study assesses an mHealth-based primary school health education program delivered via the school-student-family (SSF) route. Study design Pooled analysis of two trials plus one scaling-up cohort. Methods The evaluated SSF intervention is an mHealth-based school health education programme focused on salt reduction, featuring weekly cartoon-style lessons via parents' smartphones, abundant core/extended online/offline activities, and automated performance evaluation for schools, students and families. Guided by a framework for assessing health innovation scalability, data from two 1:1 cluster-randomized controlled trials (AppSalt and EduSaltS-Trial) collected at baseline, 12 months and 24 months (one-year post-intervention) were pooled to evaluate its effectiveness and sustained effects in reducing salt intake and blood pressure (BP). Linear mixed models were used to assess differences in salt intake (24-h urinary sodium) and systolic/diastolic blood pressure (SBP/DBP) between groups. Data from EduSaltS, a scaling-up initiative implemented across 308 schools with 72,498 children and parents, assessed its reach and acceptability. A random sample of 770 children and 721 adults from EduSaltS was assessed for pre-post improvements in knowledge, attitudes, and practices (KAP). Results The pooled trials (74 schools, 1114 students, 1708 parents) showed a 0.3 g/day (95 % CI: 0.0 to 0.7; 5 %) and 1.0 g/day (95 % CI: 0.6 to 1.3; 10 %) reduction in salt intake, with SBP/DBP decreases of 0.9/1.2 mmHg and 2.0/1.2 mmHg in children and adults, respectively. Sustainability analyses indicated halved salt intake reductions and maintained BP decreases in adults. EduSaltS improved salt-related KAP by 25.4 % in children and 14.3 % in adults, with high feasibility (100 % school participation, 98 % family registration, 84 % cloud-lesson completion). Conclusions The mHealth SSF strategy effectively reduces salt intake and BP, offering a scalable model for structurally implementing salt reduction initiatives, especially in regions with high discretionary salt use. Trial registration AppSalt: Chinese Clinical Trial Registry ChiCTR1800017553; EduSaltS: ChiCTR2000039767; EduSaltS-Trial: ChiCTR2400079893.

An mHealth-based school health education platform (EduSaltS) was promoted in real-world China to reduce salt intake among children and their families. This progress evaluation explores its implementation process and influencing factors using mixed methods. The mixed-methods process evaluation employed the RE-AIM framework. Quantitative data were collected from a management website monitoring 54,435 third-grade students across two cities. Questionnaire surveys (n = 27,542) assessed pre- and post-education effectiveness. Mixed-effects models were used to control cluster effects. Qualitative interviews (23 individuals and 8 focus groups) identified program performance, facilitators, and barriers. Findings were triangulated using the RE-AIM framework. The program achieved 100

Objective: To understand the awareness and influencing factors of core information on tuberculosis prevention and control in the elderly population in China. Methods: The study included all participants aged ≥60 from the "13th Five-Year" National Tuberculosis Control Plan end-term assessment in 2020, with 13 706 valid questionnaires obtained. Multivariate logistic regression was used to analyze the influencing factors of the awareness rate of core information on tuberculosis prevention and control in the elderly. Results: The total awareness rate of core information on tuberculosis prevention and control in the elderly aged ≥60 was 78.4%, with the highest for "suspicious symptoms of pulmonary tuberculosis" (85.4%) and the lowest for "whether pulmonary tuberculosis can be cured" (65.3%). The complete awareness rate of core information on tuberculosis prevention and control in the elderly was 41.3%, and the proportion of those who received tuberculosis health education is 67.6%. Multivariate logistic regression analysis results showed that factors associated with low awareness of core information included females (OR=0.93, 95%CI: 0.86-1.00), ages 70- (OR=0.91, 95%CI: 0.84-0.98) and ≥80 (OR=0.77, 95%CI: 0.68-0.87) and minority ethnicity (OR=0.85, 95%CI: 0.74-0.99). Factors associated with high awareness of core information included educational levels of junior high school (OR=1.46, 95%CI: 1.34-1.58), high school (OR=1.62, 95%CI: 1.45-1.81), junior college (OR=1.37, 95%CI: 1.11-1.68), and an undergraduate degree or higher (OR=1.52, 95%CI: 1.09-2.11), and receiving tuberculosis health education (OR=2.13, 95%CI: 1.97-2.27). Conclusions: In 2020, the awareness rate of core information on tuberculosis prevention and control in Chinese older adults aged ≥60 was lower than the national planning target. Therefore, there should be an increased focus on health education about tuberculosis for elderly females, those aged ≥70, ethnic minorities, and those with lower education levels.

Background:China is a country with a high burden of hepatitis B (Hep B) but a low treatment rate. One of the key reasons for the low treatment rate is the inadequate health literacy (HL) of the people, which may affect the awareness and knowledge of Hep B and its treatment, as well as the ability to actively and correctly seek medical resources. Objective:This study analyzed how HL contributed to the scale-up of antiviral treatment of Hep B in China. We expect that the findings of this study could be used to inform resource allocation for health education and other approaches intending to improve the HL of the Chinese population, thus facilitating the nationwide scale-up of Hep B treatment and contributing to the achievement of the 2030 goal of eliminating viral hepatitis as a major public health threat in China. Methods:We used the two-stage least squares regression method and adopted the mobile phone penetration rate as the instrumental variable to estimate the effect of improved HL on the number of 12-month standard Hep B antiviral treatments in China based on the panel data of 31 provinces from 2013 to 2020. Results:In the cross-sectional dimension, the higher the HL, the higher the number of treatments in the provinces in a specific year. In the time series dimension, the number of treatments in a specific province increased with the improvement of HL over time. After controlling the time-invariant inherent attributes of provinces, the instrumental variable estimation with two-stage least squares regression based on the province fixed effect model found that for every 1% increase of HL in each province, the number of treatments increased by 7.15% (0.0715 = e0.0691 - 1; P<.001). Such an increase turned to 5.19% (0.0519 = e0.0506 - 1; P<.001) for the analysis targeting the observation time from 2013 to 2019, as the data of 2020 were removed when the COVID-19 pandemic started. The study found no statistically significant effect of HL on the number of Hep B treatments in the provinces with higher newly reported Hep B incidence and lower gross domestic product per capita. Conclusions:Our findings suggest that improved HL of the population is an important favorable facilitator for the scale-up of Hep B treatment in China. Building awareness and knowledge of Hep B and its treatment can help individuals understand their health status, ensuring a healthier lifestyle and appropriate health care-seeking behaviors and health care service utilization, so that people can be diagnosed and treated timely and appropriately. Enhancing resource allocation to improve the overall HL of the population and sending Hep B-specific messages to the infected people would be a feasible and effective approach to scale-up the treatment of Hep B in low- and middle-income settings with limited resources, and contribute to achieving the 2030 global goal of eliminating viral hepatitis as a major public health threat.

To explore the association between health literacy and medical out-of-pocket (MOOP) expenses among Chinese residents based on the 2020 China Health Literacy Survey. Non-institutionalized residents aged 15–69 years were extracted from 31 provinces in China. Health literacy was assessed using the Chinese Health Literacy Scale. A total of 49,967 respondents were included in this study. Compared to participants with adequate health literacy, participants with intermediate, basic, and below basic health literacy were likely to create more MOOP, the unadjusted coefficients being 224.294 (p < 0.05), 316.676 (p < 0.01), and 458.883 (p < 0.01) respectively. After adjusting for demographic characteristics and socio-economic elements, health literacy was significantly associated with MOOP (β = −4.970, SE = 2.470, p < 0.05). Of six dimensions of health literacy, five were associated with MOOP in unadjusted models (p < 0.001 or p < 0.01). However, in adjusted models, only infectious disease literacy (β = −52.347, SE = 17.853, p < 0.01) and medical care literacy (β = −29.603, SE = 10.620, p < 0.01) remained associated with MOOP. This study suggests that health literacy is significantly associated with medical expenditure. The adoption of disease prevention measures and the utilization of public health services are important elements. Improving health literacy should be give more importance in health promotion and public education for the general public.

Objective To learn the health literacy condition and its influencing factors on 15～24 years old Chinese residents in 2021 in order to provide scientific reference for health education intervention and health policies formulation in the future.Methods The data of 15-24 years old Chinese residents in the National Health Literacy Monitoring in 2021 was analyzed.Results In the National Health Literacy Monitoring, a total of 2542 residents aged 15-24 years old were surveyed in 2021,including 682 residents aged 15-17 years old（26.83%） and 1860 residents aged 18-24 years old（73.17%）,1235 males（48.58%） and 1307 females（51.42%）.The level of health literacy among 15-24 years old Chinese residents in 2021 was 30.46%.According to the health literacy level of three aspects, 45.87% people had the basic knowledge and concept literacy, 34.50% had health lifestyle and behavior literacy, 27.88% had basic skill literacy.According to the literacy level of 6 kinds of health problems, 54.90% people had scientific view literacy, 32.21% had infectious diseases prevention and treatment literacy, 39.12% had chronic disease control and prevention literacy, 66.59% had safety and first aid literacy, 29.26% had basic medical care literacy, and 43.63% had health information literacy.Multivariate Logistic regression analysis showed that the health literacy level of 15-24 years old residents in eastern regions was higher than that in western regions, with OR value of 1.766（95%CI:1.324-2.357）;females were higher than males, with OR value of 1.510（95%CI:1.136-2.006）;senior high school/vocational high school/secondary school, college and above were higher than primary school and below, with OR value of 7.937（95%CI:2.080-30.285） and 19.291（95%CI:5.011-74.266）,respectively.Conclusion The health literacy level of Chinese residents aged 15-24 years old was low, basic skill literacy and basic medical care literacy were obviously insufficient, which need to be improved.

BackgroundHigh-salt diet is an important risk factor for several non-communicable diseases. School-based health education has been found effective in reducing salt intake among children and their families in China. However, no such interventions have been scaled up in the real world. For this purpose, a study was launched to support the development and scale-up of an mHealth-based system (EduSaltS) that integrated routine health education and salt reduction and was delivered through primary schools. This study aims to elaborate the framework, development process, features, and preliminary scaling-up of the EduSaltS system.MethodsThe EduSaltS system evolved from previously successfully tested interventions to reduce family salt intake by empowering schoolchildren through school health education. EduSaltS was designed by following the WHO’s conceptual framework for developing a scaling-up strategy which accounted for the nature of the innovation, the capacity of the implementing organizations, the characteristics of the environment, the resources available, and type of scaling up. The system was then developed step by step from determination of online platform architecture, definition of component interventions and activities, development of specific educational materials and tools, to the development of the online/offline hybridized system. The system was tested and refined by a pilot in two schools and a preliminary scale-up in two cities in China.ResultsEduSaltS was developed as an innovative health education system, including an online WeChat-based education platform, a set of offline activities, and an actual administrative website showing the progress and setting the system. The WeChat platform could be installed on users’ smartphones to automatically deliver 20 sessions of five-minute well-structured cartoon video classes, followed by other online interactive activities. It also helps support project implementation and real-time performance evaluation. As a first-stage roll-out, a one-year course has been successfully implemented among 54,538 children and their families from 209 schools in two cities, and the average course completion rate was 89.1%.ConclusionAs an innovative mHealth-based health education system, EduSaltS was developed based on successfully tested interventions and an appropriate framework for scaling up. The early-stage roll-out has shown its preliminary scalability, and further evaluation is ongoing.

Health literacy may constitute a modifiable determinant of smoking behavior and intention to quit. Little is known about the extent to which health literacy affects smoking or quitting smoking. We assessed the nationally representative cross-sectional datasets from the China Health Literacy Surveillance (CHLS) initiated in 2018. Using polytomous logistic regression models, the study investigated the association of health literacy with smoking behavior and the intention to quit smoking among men aged 15-69 in China. After confounding factors were controlled, compared with having below basic health literacy, having adequate health literacy appeared to be an independent protective factor from current smoking [current smoking vs never smoking: adjusted odds ratio [OR], 0.88; 95% confidence interval (CI), 0.81-0.96; p = 0.003; current smoking vs former smoking: adjusted OR, 0.77; 95% CI, 0.64-0.92; p = 0.003], while having intermediate health literacy was associated with current smoking vs never smoking (adjusted OR, 1.09; 95% CI, 1.02-1.17; p = 0.011) or former smoking vs never smoking (adjusted OR, 1.22; 95% CI, 1.06-1.40; p = 0.005). And having adequate health literacy was associated with intending to quit among current smokers (adjusted OR, 1.25; 95% CI, 1.10-1.42; p < 0.001). Findings provide evidence that health literacy may serve as a critical and independent protective factor for reducing poor smoking behavior or enhancing cessation intention among men. Efforts should focus on developing and evaluating intervention to control tobacco use among men with low health literacy level.

健康素养是健康的重要决定因素.党和政府高度重视健康素养促进工作,已出台一系列提升公众健康素养的政策和举措,并开展了全国健康素养监测.监测结果显示:我国居民健康素养水平从2012年的8.80％提升到2021年的25.40％,呈现持续增长的态势,但存在地区、人群间的不平衡.居民健康素养水平成为《"健康中国2030"规划纲要》的13个发展目标之一.本文对我国健康素养的研究历程、提升公众健康素养的重要举措、健康素养水平现状进行了介绍,并提出了对公众健康素养促进工作的思考.

The use of low-sodium salt substitute (LSSS) has the potential to reduce sodium and increase potassium intake. LSSS has been available in the Chinese market for years. However, its real-world use and impact on sodium/potassium intake is unclear. Baseline data of 4000 adult individuals who participated in three similarly designed randomized controlled trials were pooled together for this analysis. Self-reported awareness and use of LSSS were collected using a standardized questionnaire, and the participants’ 24-h urinary sodium and potassium excretion was used to estimate their dietary intake. Mixed-effects models were developed to assess the relationship between LSSS and 24-h urinary sodium and potassium excretion. 32.0% of the participants reported awareness of LSSS and 11.7% reported its current use. After adjusting for location, sex, age, and education, compared with the group of participants unaware of LSSS, participants who were aware of but not using LSSS and those who were using LSSS had a lower 24-h urinary sodium excretion by −356.1 (95% CI: −503.9, −205.9) mg/d and −490.6 (95% CI: −679.2, −293.7) mg/d, respectively (p < 0.001). No significant difference was found for 24-h urinary potassium excretion or sodium-to-potassium ratio among the three groups (p > 0.05). In conclusion, the findings of low usage of LSSS and the reduced urinary sodium excretion associated with the awareness and use of LSSS provide further support for the prometon of LSSS as a key salt reduction strategy in China.

Salt intake in China is very high, which increases the risk of hypertension and cardiovascular disease. This study aimed to assess the levels of salt-related knowledge, attitudes, and behaviors (KABs) and the factors that influence them and to explore the relationship between the scores of salt-related KAB and 24-h urinary sodium excretion. In 2018, we collected data from 5453 individuals aged 18–75 years from six provinces in China. A face-to-face survey was carried out, focusing on the KAB related to salt reduction. All participants were asked to collect one 24-h urine sample. Of the 5453 participants, 5352 completed urine collection. The mean score for overall KAB was 31.27 (SD = 9.18), which was composed of three elements: knowledge 4.80 (SD = 5.14), attitude 9.33 (SD = 3.93), and behavior 17.14 (SD = 4.43). The average 24-h urinary sodium excretion was 187.70 (SD = 77.48) mmol, which was equivalent to a urinary sodium excretion of 4.32 (SD = 1.78) g/d. We found that salt-related knowledge, attitude, behavior, and overall KAB scores were all inversely associated with 24-h urinary sodium excretion. For every one-point increase in the KAB score, the 24-h urinary sodium excretion decreased by 0.851 mmol (95% CI: −1.095, −0.602). We also found that location (rural/urban), sex, age, and education are associated with salt-related KAB scores. These results suggest that large-scale health education is needed to reduce salt intake in the Chinese population. In particular, efforts should be focused on reaching those who live in rural areas with low educational levels and older people.

目的 构建中国女性乳腺癌防治素养评价指标体系,为素养评估工具的开发和乳腺癌防治工作的开展提供理论基础.方法 通过文献研究、专家访谈及小组讨论拟定评价框架和候选指标集;采用德尔菲专家咨询法进行指标筛选,确定最终指标体系;采用百分权重法和乘积法确定指标权重.结果 25名专家参与德尔菲专家咨询,两轮咨询专家积极系数分别为92.59％、96.00％,专家权威系数为0.95,第2轮各项评分专家意见协调系数均>0.300(P均<0.001),专家意见趋向一致.最终构建了包括基本知识与理念、乳腺癌一、二、三级预防素养4个一级指标及12个二级指标和35个三级指标的中国女性乳腺癌防治素养评价指标体系.一级指标中,乳腺癌二级预防素养权重最高(0.261),乳腺癌三级预防素养权重最低(0.233).结论 构建的中国女性乳腺癌防治素养评价指标体系可为编制评估工具奠定基础,为乳腺癌防控和健康教育实践提供理论依据.

Objective: To develop a suitable scale for assessing the public health safety literacy in residents in China. Methods: The initial scale of Chinese public health safety literacy was developed through theoretical conceptualization, item pooling, field verifying and item inclusion and exclusion. Then the initial scale was converted into an electronic questionnaire. A total of 2 809 residents from 4 provinces were randomly selected for field testing. Classical test theory (CTT) and item response theory (IRT) were used for item reduction. SPSS 23.0 was used for exploratory factor analysis (EFA) and unidimensional testing. Package R 4.1.1 ltm and mirt were used for the analysis of the psychometric properties of items and generate the ICC, IIC and TIF. Results: The initial scale had 30 items (B1-B30), and the test took 9.8 s to complete one item averagely. According to the CTT, B2 was deleted due to coefficient of total correlation (CITC) <0.3 and the item-dimension correlation coefficient (IDCC) <0.4. B23 was deleted due to CITC<0.3, IDCC<0.4 and difficulty index (W) <0.2. B30 was deleted due to CITC<0.3 and W<0.2. The total Cronbach's α of the scale was 0.923 after deletion. EFA indicated that 14 items should be deleted due to lower factor loadings <0.7. EFA was conducted for remaining 13 items and 2 common factors were extracted, the factor loadings of all items were >0.7, the accumulated variance contribution of the 2 common factors was 63.361%, and the total Cronbach's α was 0.891, showing unidimensionality, IRT was used to test the remaining items. B14 and B20 were deleted due to discrimination coefficient (a) <0.3, difficulty threshold coefficient (b) ∉[-3,3], the small amount of information and the flat, crowded, non-monotonic ICC, and IIC. Finally, the Cronbach's α of the 11-itemed scale was 0.936 with TLI=0.97, CFI=0.99, and RMSEA=0.03. Conclusion: The final scale has good reliability, validity, discrimination, difficulty level and feasibility, and can be applied for the rapid assessment of public health safety literacy in China.

ObjectiveTo explore the status and influencing factors of public health safety literacy (PHSL) among residents in four provinces of China for providing references to the development of appropriate intervention strategies. MethodsWe recruited 2 809 urban and rural residents aged 15 – 69 years in three provinces (Hubei, Guangdong and Sichuan) and Beijing municipality using stratified multistage cluster sampling and conducted an on-site self-administered electronic questionnaire survey among the residents during April – June, 2021. A scale with three domains (each with a maximum score of 40) was designed to assess the PHSL of the residents. T-test, one-way analysis of variance (ANOVA), and χ2 test were adopted in univariate analysis and logistic regression in multivariate analysis. Results For all the participants, the mean overall PHSL score was 81.61 ± 13.71 and the mean domain scores were 29.21 ± 5.89 for PHS perception, 25.10 ± 5.10 for PHS knowledge, and 27.30 ± 4.87 for PHS skills. There were 80.85% of the participants being assessed with basic PHSL (with the overall scale score of ≥ 72) and there were 86.69%, 61.05%, and 78.96% of the participants being assessed with basic PHS perception, knowledge, and skills (with the domain scores of ≥ 24); also based on the scale of overall score of ≥ 96 and domain scores of ≥ 32, the proportion of the participants with good PHSL was 15.70% and the proportions of participants with good PHS perception, knowledge and skills were 35.32%, 14.03% and 20.15%, respectively. Multivariate logistic regression analysis showed that PHSL was associated with residential region, sex, education and household income. The participants residing in Hubei, Sichuan, and Guangdong province were less likely to have basic/good PHSL, with the odds ratios (OR) of 0.485/0.422, 0.488/0.699, and 0.389/0.566 in contrast to those residing in Beijing municipality. The participants being female (versus male: OR = 1.336/1.283), with the education of higher than primary school education or below (junior high school: OR = 1.786/1.205; senior high or vocational or technical secondary school: OR = 2.204/2.013; college and above: OR = 2.932/3.710), with the annual household income of more than 30 000 RMB yuan (30 000 – 60 000: OR = 1.660/1.648; ≥ 120 000: OR = 1.865/2.145) were more likely to have basic/good PHSL. ConclusionFor 15 – 69 years old residents in four provincial administrative regions of China, the PHSL still needs to be improved and the residents′ PHSL is influenced mainly by gender, education, annual household income and residential region.

目的 分析"中国公众公共卫生安全素养自制量表"的项目功能差异(DIF),检验量表题项质量,为开发公共卫生安全素养(PHSL)调查工具提供依据.方法 通过经典测试理论和项目反应理论相结合的方法编制了单维的中国公众公共卫生安全素养量表.使用自制的初始量表(30个题项),于2021年4—6月随机抽取湖北、广东、北京和四川省的2809名常住居民进行调查.利用SPSS 23.0进行PHSL得分分析,两组间比较采用t检验,多组间比较采用单因素方差分析.利用R4.1.2软件mirt和scDIF test包对量表题项进行不同人口学特征的DIF检验.结果 调查对象PHSL的平均得分为(34.44±7.59)(满分44分).不同性别、年龄、文化程度、职业、地区、城乡、家庭年均总收入的公众PHSL得分差异均有统计学意义(P<0.001).其中,女性高于男性,文化程度较高人群高于较低人群,农民低于其他职业人群,湖北地区高于其他地区,城镇居民高于农村居民.所有题项均不存在性别、收入和城乡的DIF(P>0.05);8个题项存在年龄的DIF(P<0.05);8个题项存在文化程度的DIF(P<0.05);6个题项存在职业的DIF(P<0.05);4个题项存在地区的DIF(P<0.05).结论 中国公众公共卫生安全素养自制量表题项稳定性较好,适合推广使用.

Background: In smokers seeking help with quitting, stopping smoking is typically accompanied by tobacco withdrawal symptoms such as craving and irritability. The prevalence and details of withdrawal symptoms in general population are less well mapped than in clinical samples. Here we report the patterns of tobacco withdrawal experience among a representative sample of smokers and ex-smokers in China.Methods: We used data from the nationally representative China Residents Health Literacy Survey (CRHLS) conducted in 2018-2019 . Among 87,028 participants, there were 22,115 ever-smokers (20,964 men and 1,151 women) aged 20~69 years who provided information on their smoking history and their experience of tobacco withdrawal symptoms. Multivariate logistic regressions were conducted to explore the association between withdrawal symptoms and smoking status and between withdrawal symptoms and participants’ characteristics.Findings: A total of 19,643 were current smokers and 2,472 were ex-smokers in this study. The mean age (SD) of current smokers was 49.7 (11.8) years, however, it was 53.6 (11.6) in ex-smokers (P<0.0001); 57.2% current smokers and 53.9% ex-smokers were resident in rural (P=0.0012); 61.3% current smokers have tried to quit smoking but failed. Among current smokers, 61.1% (11,993/19,643) have experienced at least one withdrawal symptom when unable to smoke, while among ex-smokers, the proportion was 46.3% (1,144/2472) (P<0.001). The most commonly reported withdrawal symptoms in both current smokers and ex-smokes, in the order of frequency, were craving, restlessness, anxiety, difficulty concentrating, and irritability. Among current smokers, presence of withdrawal symptoms was associated with higher nicotine dependence, heavier smoking (higher FTND, smoking pack-year, and smoking cigarettes per day), using manufactured cigarettes, starting smoking earlier, longer smoking duration, difficulty quitting, smoking a lot more than intended, being male, middle age and below, rural residents, lower income and poorer health, continued use of tobacco even following physical or mental health issues.Interpretation: Among general population in China, there are eight times as many smokers than ex-smokers. Among current smokers, two-third have tried to quit (or are motivated to quit) before. Less than half of ex-smokers have experienced tobacco withdrawal symptoms, while such experience is significantly more common among current smokers.Funding Information: National Key R&D Program of China (grant no 2017YFC1309400), Ministry of Finance of the People's Republic of China, and National Natural Science Foundation of China (grant no 81720108001). Declaration of Interests: The authors declared no conflicts of interest.Ethics Approval Statement: The study protocol was approved by the Ethics Review Committees of the China Health Education Center (Beijing, China). We informed each individual about the study's purpose and procedures, and all individuals signed informed consent before they were interviewed.