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Willingness to Receive Periodic Health Examination Based on the Health Belief Model Among the Elderly in Rural China: A CrossSectional Study
基于健康信念模型的中国农村老年人定期健康检查意愿：一项横断面研究

Zhuo Zhang, Ai-Tian Yin & Ying Bian

To cite this article: Zhuo Zhang, Ai-Tian Yin & Ying Bian (2021) Willingness to Receive Periodic Health Examination Based on the Health Belief Model Among the Elderly in Rural China: A Cross-Sectional Study, Patient Preference and Adherence, , 1347-1358, DOI: 10.2147/ PPA.S312806
引用本文：Zhuo Zhang, Ai-Tian Yin & Ying Bian (2021) 基于健康信念模型的中国农村老年人定期健康检查意愿：一项横断面研究，《患者偏好与依从性》，1347-1358，DOI: 10.2147/ PPA.S312806
To link to this article: https://doi.org/10.2147/PPA.S312806
要链接到这篇文章：https://doi.org/10.2147/PPA.S312806

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Published online: 21 Jun 2021.
在线发布：2021 年 6 月 21 日。
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Willingness to Receive Periodic Health Examination Based on the Health Belief Model Among the Elderly in Rural China: A Cross-Sectional Study
基于健康信念模型的中国农村老年人定期健康检查意愿：一项横断面研究

Zhuo Zhang ′ ′ ^('){ }^{\prime} Zhuo ZhangAi-Tian Yin 2 2 ^(2){ }^{2}Ying Bian ′ ′ ^('){ }^{\prime} Ying Bian'State Key Laboratory of Quality Research in Chinese Medicine, Institute of Chinese Medical Sciences, University of Macau, Taipa, Macau, People’s Republic of China; 2 2 ^(2){ }^{2} School of Health Care Management, Cheeloo College of Medicine, Shandong University, Jinan, People's Republic of China
中国澳门，澳门大学中国医学科学研究所中医药质量研究国家重点实验室；中国济南，山东大学齐鲁医学院健康管理学院

Correspondence: Ying Bian
通信：边颖

Institute of Chinese Medical Sciences, University of Macau, Avenida da Universidade, Room 2055, N22 Building, Taipa, Macau SAR, People’s Republic of China
澳门大学中国医学科学院，大学大道，2055 室，N22 大楼，氹仔，澳门特别行政区，中国人民共和国
Tel +853-66548926
Email bianyingum@163.com
电子邮件 bianyingum@163.com

Abstract 摘要

Purpose: This study aimed to explore factors affecting behavioral intention of receiving periodic health examinations (hereafter, BIE) among people aged 60 and over in rural China, namely, Shandong Province, using the extended health belief model (EHBM). Patients and Methods: Participants were selected using stratified multi-stage random sampling. Three cities were selected based on economic level. Subsequently, three counties and three villages were selected from each sample city and county. Finally, 30 respondents were selected from each sample village. Face-to-face surveys were conducted using a structured questionnaire between March and September 2017. Multiple linear regression was conducted to investigate the association between BIE and eight dimensions of EHBM: perceived susceptibility, perceived severity, perceived benefits, perceived barriers, perceived self-efficacy, cues to action, health knowledge, and social support. Results: Of the 509 rural respondents aged 60 years and older, the average score of behavioral intention was 4.43 ± 0.80 4.43 ± 0.80 4.43+-0.804.43 \pm 0.80. Multivariate linear regression analysis demonstrated poor BIE among participants who were men, were current smoker, were current drinker, were aged 70 years or over, had lower social support, and perceived lower self-efficacy, less benefits, and more barriers. Among them, barriers were found to have the strongest association with BIE ( B ′ = − 0.556 ; p < 0.001 B ′ = − 0.556 ; p < 0.001 B^(')=-0.556;p < 0.001\mathrm{B}^{\prime}=-0.556 ; \mathrm{p}<0.001 ). Qualitative interviews revealed that reasons for not receiving periodic health examinations (PHE) included pain, cost, difficulty in finding a health care provider, time and scheduling, potential lack of trust in the physician, and value of the PHE. Conclusion: This study highlighted the importance of psychological variables in the acceptance of PHE among the elderly in rural China and provided insights for further intervention designs targeting identified groups and performed by general practitioners. Addressing medical mistrust, strengthening, and enhancing one’s social support network and health communication channels, such as bulletin boards, may serve to facilitate BIE.
目的：本研究旨在探讨影响中国农村 60 岁及以上人群（以下简称 BIE）定期健康检查行为意图的因素，采用扩展健康信念模型（EHBM）。患者和方法：参与者采用分层多阶段随机抽样法选取。根据经济水平选择了三个城市。随后，从每个样本城市和县选择了三个县和三个村庄。最后，从每个样本村庄中选取了 30 名受访者。2017 年 3 月至 9 月期间，使用结构化问卷进行面对面调查。采用多元线性回归分析 BIE 与 EHBM 的八个维度之间的关联：感知易感性、感知严重性、感知益处、感知障碍、感知自我效能、行动线索、健康知识和社会支持。结果：在 509 名 60 岁及以上的农村受访者中，行为意图的平均分为 4.43 ± 0.80 4.43 ± 0.80 4.43+-0.804.43 \pm 0.80 。 多元线性回归分析显示，男性、当前吸烟者、当前饮酒者、年龄在 70 岁或以上、社会支持较低、感知自我效能较低、认为收益较少和障碍较多的参与者在 BIE 方面表现较差。其中，障碍与 BIE 的关联最强（ B ′ = − 0.556 ; p < 0.001 B ′ = − 0.556 ; p < 0.001 B^(')=-0.556;p < 0.001\mathrm{B}^{\prime}=-0.556 ; \mathrm{p}<0.001 ）。定性访谈揭示，不接受定期健康检查（PHE）的原因包括疼痛、费用、难以找到医疗服务提供者、时间和安排、对医生的潜在不信任以及对 PHE 的价值的看法。结论：本研究强调了心理变量在中国农村老年人接受 PHE 中的重要性，并为针对特定群体的进一步干预设计提供了见解，这些干预由全科医生实施。解决医疗不信任、加强和增强个人的社会支持网络以及健康沟通渠道（如公告栏）可能有助于促进 BIE。

Keywords: extended health belief model, periodic health examination, general practitioners, behavioral intention, elderly, rural China
关键词：扩展健康信念模型，定期健康检查，全科医生，行为意图，老年人，农村中国

Introduction 介绍

With increasing life expectancy and declining fertility due to China’s unique 36year one-child policy, China is experiencing rapid aging at a rate that is significantly faster than most countries. 1 1 ^(1){ }^{1} The increasing trend of population aging led to a dramatic increase in health and economic burdens. 2 2 ^(2){ }^{2} In addition, older adults with chronic disabling conditions not only have a reduced life expectancy but also significantly impact the mental health and quality of life of their caregivers. 3 3 ^(3){ }^{3}
随着寿命的延长和由于中国独特的 36 年独生子女政策导致的生育率下降，中国正以比大多数国家更快的速度经历快速老龄化。人口老龄化的趋势导致健康和经济负担的急剧增加。此外，患有慢性残疾的老年人不仅寿命缩短，还对照顾者的心理健康和生活质量产生显著影响。
This situation is considered alarming, as chronic diseases are generally preventable Through periodic health examinations (PHE), abnormal signs can be detected at an early stage, and correct diagnosis and effective treatment measures can be administered early. 4 4 ^(4){ }^{4}
这种情况被认为是令人担忧的，因为慢性疾病通常是可以预防的。通过定期健康检查（PHE），可以在早期发现异常迹象，并可以及早进行正确的诊断和有效的治疗措施。
PHE is a primary approach for general practitioners to perform clinical preventive services in China and delaying or avoiding unwanted outcomes through an organized PHE for people aged 60 years and older is a critical public health concern in China. 5 5 ^(5){ }^{5} The Chinese government officially approved the health management technical protocol for elderly people based on the principles of equitable access and use of clinical preventive services. This protocol, which was implemented formally on April 1, 2016, aimed to address the care needs of people aged 60 years and older and improve their quality of life. The protocol emphasized that people aged 60 years and older should be given periodic health assessments, where personal health records are updated, and an appointment is made for the next check. Notably, a dedicated approach to PHE and assessment was highlighted as a key priority.
PHE 是中国全科医生进行临床预防服务的主要方法，通过有组织的 PHE 延迟或避免 60 岁及以上人群的不良结果是中国一个重要的公共卫生问题。 5 5 ^(5){ }^{5} 中国政府正式批准了基于公平获取和使用临床预防服务原则的老年人健康管理技术规范。该规范于 2016 年 4 月 1 日正式实施，旨在满足 60 岁及以上人群的护理需求，提高他们的生活质量。该规范强调，60 岁及以上的人应定期进行健康评估，更新个人健康记录，并预约下次检查。值得注意的是，专门的 PHE 和评估方法被强调为关键优先事项。
The development of chronic diseases generally involves five stages: exposure, acquisition, advancement/ progression, complications, and death/disability. 6 6 ^(6){ }^{6} PHE helps to detect the impact factors of sub-health status at stage one, such as being overweight, obesity, smoking, alcohol use, and high blood pressure. A timely change in lifestyle or simple drug intervention can eliminate risk factors and reduce or avoid the occurrence of diseases. The second stage is the acquisition of early disease due to exposure. At this stage, PHE helps recognize asymptomatic but insidiously progressive diseases and postpone the development of subsequent adverse outcomes. PHE has been documented to be cost-saving or cost-effective. 7 7 ^(7){ }^{7} A study from Japan found a strong inverse association between older people’s medical expenditure and the use of PHE. 8 8 ^(8){ }^{8} Several community-based interventions involving health screening and primary care have found significant reductions in chronic diseases, such as stroke, 9 9 ^(9){ }^{9} ischemic heart disease, 10 10 ^(10){ }^{10} and chronic obstructive pulmonary disease. 11 11 ^(11){ }^{11} There is also convincing evidence that PHE is helpful in the early diagnosis of cancer and prevention of progression and potentially death. 12 12 ^(12){ }^{12}
慢性疾病的发展通常涉及五个阶段：暴露、获取、进展/发展、并发症和死亡/残疾。 6 6 ^(6){ }^{6} PHE 有助于在第一阶段检测亚健康状态的影响因素，例如超重、肥胖、吸烟、饮酒和高血压。及时改变生活方式或简单的药物干预可以消除风险因素，减少或避免疾病的发生。第二阶段是由于暴露而获得早期疾病。在这一阶段，PHE 有助于识别无症状但潜在进展的疾病，并推迟后续不良结果的发展。PHE 已被证明是节省成本或具有成本效益的。 7 7 ^(7){ }^{7} 一项来自日本的研究发现，老年人的医疗支出与 PHE 的使用之间存在强烈的负相关关系。 8 8 ^(8){ }^{8} 几项涉及健康筛查和初级保健的社区干预发现慢性疾病显著减少，例如中风， 9 9 ^(9){ }^{9} 缺血性心脏病， 10 10 ^(10){ }^{10} 和慢性阻塞性肺病。 还有令人信服的证据表明，PHE 有助于早期诊断癌症、预防病情进展和潜在的死亡。 12 12 ^(12){ }^{12}
The PHE participation rate in China is low. 13 13 ^(13){ }^{13} Moreover, surveys and focus groups found that rural residents were less likely to access recommended clinical preventive services than urban populations. 14 14 ^(14){ }^{14} However,
中国的公共卫生参与率较低。此外，调查和焦点小组发现，农村居民获取推荐的临床预防服务的可能性低于城市居民。
the total prevalence of individual chronic disease risk factors among rural residents was higher than that for urban residents. 15 15 ^(15){ }^{15} They tended to have more healthcare needs, while their underuse of primary care services was strikingly apparent compared to urban populations. 16 16 ^(16){ }^{16} Exploring the influencing factors of this utilization is crucial for PHE implementation.
农村居民的个体慢性疾病风险因素的总体流行率高于城市居民。 15 15 ^(15){ }^{15} 与城市人口相比，他们的医疗保健需求更高，而初级保健服务的使用不足显著。 16 16 ^(16){ }^{16} 探索这种利用的影响因素对公共卫生应急实施至关重要。
Health promotion programs based on theoretical frameworks were found to be more effective than programs that did not use theory. The Health Belief Model emphasizes how a person’s perceptions induce motivation and further produce behavior. 17 17 ^(17){ }^{17} To date, few studies examined psychosocial variables as a potentially influencing factor on BIE among people aged 60 years and older in rural China, underpinned by an extended health belief model (EHBM). Considering the utilization rate of PHE among the rural elderly population in China is extremely low while their health tends to be poor, analyzing factors that affect BIE is a vital health assessment approach for the aging Chinese society. Therefore, this study aimed to contribute timely direct policy suggestions. This study used representative data of Shandong Province to explore BIE systematically and clarify its influencing factors among elderly people in rural China, primarily based on EHBM in which factors were categorized into several groups.
基于理论框架的健康促进项目被发现比不使用理论的项目更有效。健康信念模型强调一个人的感知如何引发动机并进一步产生行为。迄今为止，只有少数研究考察了心理社会变量作为影响因素对中国农村 60 岁及以上人群的 BIE 的潜在影响，这些研究以扩展健康信念模型（EHBM）为基础。考虑到中国农村老年人群体的 PHE 利用率极低，而他们的健康状况往往较差，分析影响 BIE 的因素是对老龄化中国社会进行健康评估的重要方法。因此，本研究旨在提供及时的直接政策建议。本研究使用山东省的代表性数据系统地探讨 BIE，并阐明其在中国农村老年人中的影响因素，主要基于 EHBM，其中因素被分为几个组。

Patients and Methods
Design, Setting, and Participants
患者与方法 设计、环境和参与者

The target population of the present study was people in rural Shandong aged 60 years and older. The inclusion criteria were age of 60 years or older, permanent residence in Shandong, and ability to read and write Chinese. Utilizing stratified multi-stage sampling, a structured cross-sectional face-to-face questionnaire survey was conducted with 509 elderly people from 27 rural villages in 3 counties in Shandong Province between March to September 2017. The survey examined PHE behavior in the previous oneyear period. A sampling procedure was conducted, which contained county level, township level, and village level. First, all counties in Shandong Province were independently sorted in descending order by economic development ranking into 3 groups, and one county was selected at random from each group. Second, all townships in each of the sampled counties were divided into three groups based on their economic development level, and one township was selected from each group as a representative county ( 3 × 3 = ( 3 × 3 = (3xx3=(3 \times 3= 9 townships selected). Third, all villages in each sampled
本研究的目标人群是山东省 60 岁及以上的农村居民。纳入标准为 60 岁及以上、在山东省常住、能够读写中文。采用分层多阶段抽样方法，于 2017 年 3 月至 9 月对山东省 3 个县 27 个农村村庄的 509 名老年人进行了结构化的面对面问卷调查。调查考察了前一年内的公共卫生行为。抽样程序包括县级、乡级和村级。首先，山东省所有县按经济发展排名独立降序排序为 3 组，从每组中随机选择一个县。其次，抽样县的所有乡镇根据经济发展水平分为三组，从每组中选择一个乡镇作为代表县（共选择了 9 个乡镇）。第三，抽样的每个乡镇中的所有村庄。
township were grouped into three subgroups according to their regional economic status, and one village was randomly selected from each subgroup ( 3 × 3 × 3 = 27 3 × 3 × 3 = 27 3xx3xx3=273 \times 3 \times 3=27 villages). Finally, 30 individuals were randomly selected from each of the 27 villages. Thus, 810 rural residents were enrolled in the study and 805 completed the questionnaires with a response rate of 99.4 % 99.4 % 99.4%99.4 \%. In this study we only selected information from people aged 60 years and older for analysis. Among the respondents, 509 met the inclusion criteria. Additionally, 20 seniors were randomly obtained from the research subjects for qualitative research.
乡镇根据其区域经济状况被分为三个子组，并从每个子组中随机选择一个村庄（ 3 × 3 × 3 = 27 3 × 3 × 3 = 27 3xx3xx3=273 \times 3 \times 3=27 个村庄）。最后，从 27 个村庄中随机选择了 30 名个体。因此，共有 810 名农村居民参与了研究，805 人完成了问卷，响应率为 99.4 % 99.4 % 99.4%99.4 \% 。在本研究中，我们仅选择了 60 岁及以上人群的信息进行分析。在受访者中，509 人符合纳入标准。此外，从研究对象中随机选取了 20 名老年人进行定性研究。
Using the formula n = u 2 π ( 1 − π ) δ 2 n = u 2 π ( 1 − π ) δ 2 n=(u^(2)pi(1-pi))/(delta^(2))\mathrm{n}=\frac{\mathrm{u}^{2} \pi(1-\pi)}{\delta^{2}}, in which π π pi\pi referred to the percentage of elderly people in rural areas using PHE ( 53.6 % 53.6 % 53.6%53.6 \% ), δ = 0.1 π , α = 0.05 , u 0.05 = 1.96 δ = 0.1 π , α = 0.05 , u 0.05 = 1.96 delta=0.1 pi,alpha=0.05,u_(0.05)=1.96\delta=0.1 \pi, \alpha=0.05, u_{0.05}=1.96, the minimum sample size was calculated as n = 346 n = 346 n=346\mathrm{n}=346. Therefore, a sample size of 509 was sufficient.
使用公式 n = u 2 π ( 1 − π ) δ 2 n = u 2 π ( 1 − π ) δ 2 n=(u^(2)pi(1-pi))/(delta^(2))\mathrm{n}=\frac{\mathrm{u}^{2} \pi(1-\pi)}{\delta^{2}} ，其中 π π pi\pi 指的是使用 PHE 的农村地区老年人百分比 ( 53.6 % 53.6 % 53.6%53.6 \% )， δ = 0.1 π , α = 0.05 , u 0.05 = 1.96 δ = 0.1 π , α = 0.05 , u 0.05 = 1.96 delta=0.1 pi,alpha=0.05,u_(0.05)=1.96\delta=0.1 \pi, \alpha=0.05, u_{0.05}=1.96 ，最小样本量计算为 n = 346 n = 346 n=346\mathrm{n}=346 。因此，样本量为 509 是足够的。

Pilot Study 试点研究

A pilot study was conducted before the commencement of the study in February 2017 among 30 rural individuals aged 60 years and older in order to test the comprehensibility of the questionnaire items and establish the reliability of the questionnaire. Amendments were made to unfamiliar phrases that required clarification. In addition, experts from the School of Health Care Management at Shandong University assisted in revising the questionnaire. The pilot survey demonstrated a PHE usage rate of 53.6 % 53.6 % 53.6%53.6 \%.
在 2017 年 2 月研究开始之前，针对 30 名 60 岁及以上的农村个体进行了初步研究，以测试问卷项目的可理解性并建立问卷的可靠性。对需要澄清的不熟悉短语进行了修订。此外，来自山东大学健康管理学院的专家协助修订了问卷。初步调查显示 PHE 使用率为 53.6 % 53.6 % 53.6%53.6 \% 。

Data Collection 数据收集

Trained students from the School of Health Care Management at Shandong University were recruited to conduct individual face-to-face surveys in participants’ homes. The questionnaire items and response choices were read to
山东大学健康管理学院的受训学生被招募到参与者的家中进行个别面对面的调查。问卷项目和回答选项被读给
older participants in local languages in order to accommodate poor vision and other geriatric conditions. In addition, qualitative investigation was conducted using individual indepth interviews with 20 participants selected utilizing simple random sampling to explore reasons for low participation rate of PHE. To ensure data accuracy and completeness, the results were verified by quality controllers after finishing each questionnaire.
为了适应视力差和其他老年病状，针对当地语言的年长参与者进行了研究。此外，使用简单随机抽样选择了 20 名参与者，进行了个别深入访谈的定性调查，以探讨公共卫生教育参与率低的原因。为了确保数据的准确性和完整性，问卷完成后，质量控制人员对结果进行了验证。

Questionnaire 问卷

Structured self-designed questionnaires were used to assess PHE intention and each dimension of EHBM. The EHBM was adopted as a conceptual framework to predict healthrelated behavior, explain it, and further develop behavior change interventions (Figure 1). The EHBM is based on a hypothesis regarding the likelihood that individuals will take some preventive action and focus on adherence to preventive health behaviors. It has been commonly applied to address public health problems for risk reduction, prevention, and community health promotion. 18 18 ^(18){ }^{18} Behavioral intentions of receiving PHE (hereafter, BIE) and their determinants were measured using the eight domains of EHBM. According to this theory, individuals adopt certain preventive behaviors when they perceive themselves as susceptible to a disease or health problem (perceived susceptibility), perceive severity of the disease (perceived severity), perceive benefits of adopting a health behavior (perceived benefits), believe that the benefits of the behavior outweigh the costs (perceived barriers), have confidence in their ability to perform the action successfully (perceived self-efficacy), have health knowledge and social support, and there are factors that promote individuals to adopt such behaviors (cues to action).
使用结构化自设计问卷评估 PHE 意图及 EHBM 的各个维度。EHBM 被采用作为一个概念框架，以预测与健康相关的行为，解释这些行为，并进一步开发行为改变干预措施（图 1）。EHBM 基于一个假设，即个体采取某些预防行动的可能性，并专注于遵循预防健康行为。它通常被应用于解决公共卫生问题，以降低风险、预防和促进社区健康。 18 18 ^(18){ }^{18} 接受 PHE 的行为意图（以下简称 BIE）及其决定因素是通过 EHBM 的八个领域进行测量的。 根据这一理论，当个体感知到自己易受某种疾病或健康问题影响（感知易感性）、感知到疾病的严重性（感知严重性）、感知到采取健康行为的好处（感知好处）、相信行为的好处超过成本（感知障碍）、对自己成功执行该行为的能力有信心（感知自我效能）、具备健康知识和社会支持，并且存在促使个体采取这些行为的因素（行动提示）时，他们会采取某些预防行为。
Figure I Conceptual framework based on extended health belief model.
图 I 基于扩展健康信念模型的概念框架。
The questionnaire consisted of three parts. The first part included basic demographic information, such as sociodemographic data (gender, age, education level, marital status), economic status (per capita annual household income), health-related behavioral factor (tobacco use, alcohol use, exercise), and the need factor (number of noncommunicable chronic diseases). The second part was designed to explore BIE ( 1 item). The third part (49 items) targeted psychology, which was the major part based on selfdesigned eight-dimensional EHBM (Table 1). It contained statements regarding attitude and perceptions relating to PHE use behavior: perceived barriers ( 6 items), perceived benefits (3 items), perceived susceptibility ( 5 items), perceived severity ( 6 items), cues to action ( 5 items), self-efficacy ( 5 items), health knowledge ( 7 items), and social support ( 12 items). BIE, perceived barriers, perceived benefits, perceived susceptibility, perceived severity, cues to action, and selfefficacy were defined as an integrated view and these measurement items were revised from previous surveys. 19 − 21 19 − 21 ^(19-21){ }^{19-21} Furthermore, social support items were selected based previous research, 22 22 ^(22){ }^{22} which contained emotional support, tangible support, affectionate support, and positive interaction.
问卷由三个部分组成。第一部分包括基本的人口统计信息，如社会人口数据（性别、年龄、教育水平、婚姻状况）、经济状况（人均年家庭收入）、与健康相关的行为因素（吸烟、饮酒、锻炼）和需求因素（非传染性慢性疾病的数量）。第二部分旨在探讨 BIE（1 个项目）。第三部分（49 个项目）针对心理学，这是基于自设计的八维 EHBM（表 1）的主要部分。它包含与 PHE 使用行为相关的态度和感知的陈述：感知障碍（6 个项目）、感知收益（3 个项目）、感知易感性（5 个项目）、感知严重性（6 个项目）、行动线索（5 个项目）、自我效能（5 个项目）、健康知识（7 个项目）和社会支持（12 个项目）。BIE、感知障碍、感知收益、感知易感性、感知严重性、行动线索和自我效能被定义为一个综合视角，这些测量项目是从之前的调查中修订而来的。 此外，社会支持项目是根据之前的研究选择的，其中包括情感支持、实质支持、关爱支持和积极互动。
Table I Examples of the Questionnaire Items
表 I 问卷项目示例
Variables 变量 Items 物品 Range 范围 Item Example 项目示例
BIE I I~5

我打算定期进行 PHE。
I intend to perform PHE
regularly.
I intend to perform PHE regularly.| I intend to perform PHE | | :--- | | regularly. |
Self-efficacy 自我效能 5 5 ∼ 25 5 ∼ 25 5∼255 \sim 25

一般来说，我可以定期锻炼。
In general, I can exercise
regularly.
In general, I can exercise regularly.| In general, I can exercise | | :--- | | regularly. |

感知易感性
Perceived
susceptibility
Perceived susceptibility| Perceived | | :--- | | susceptibility |
 5 5 ∼ 25 5 ∼ 25 5∼255 \sim 25

我很担心如果我不进行公共卫生应急（PHE），会生病。
I worry a lot about becoming ill if
I do not perform PHE.
I worry a lot about becoming ill if I do not perform PHE.| I worry a lot about becoming ill if | | :--- | | I do not perform PHE. |
 感知的严重性
Perceived
severity
Perceived severity| Perceived | | :--- | | severity |
 6 6 ∼ 30 6 ∼ 30 6∼306 \sim 30

如果我生病了，我的职业将会受到威胁。
If I had an illness, my career
would be endangered.
If I had an illness, my career would be endangered.| If I had an illness, my career | | :--- | | would be endangered. |
 感知的好处
Perceived
benefits
Perceived benefits| Perceived | | :--- | | benefits |
 3 3 ∼ 15 3 ∼ 15 3∼153 \sim 15

当我进行 PHE 时，我不太担心疾病。
When I perform PHE, I do not
worry as much about illnesses.
When I perform PHE, I do not worry as much about illnesses.| When I perform PHE, I do not | | :--- | | worry as much about illnesses. |
 感知障碍
Perceived
barriers
Perceived barriers| Perceived | | :--- | | barriers |
 6 6 ∼ 30 6 ∼ 30 6∼306 \sim 30

进行 PHE 可能会耗费时间。
Performing PHE can be time-
consuming.
Performing PHE can be time- consuming.| Performing PHE can be time- | | :--- | | consuming. |
 行动提示
Cues to
action
Cues to action| Cues to | | :--- | | action |
 5 5 ∼ 25 5 ∼ 25 5∼255 \sim 25

村医的建议促使我进行公共卫生教育。
Village doctors'
recommendations prompted me
to perform PHE.
Village doctors' recommendations prompted me to perform PHE.| Village doctors' | | :--- | | recommendations prompted me | | to perform PHE. |
 健康知识
Health
knowledge
Health knowledge| Health | | :--- | | knowledge |
 7 7 ∼ 35 7 ∼ 35 7∼357 \sim 35

我熟悉临床预防服务。
I am familiar with the clinical
preventive services.
I am familiar with the clinical preventive services.| I am familiar with the clinical | | :--- | | preventive services. |
 社会支持
Social
support
Social support| Social | | :--- | | support |
 12 I2~60

我可以从我的家人那里获得必要的情感支持。
I can get the necessary emotional
support from my family.
I can get the necessary emotional support from my family.| I can get the necessary emotional | | :--- | | support from my family. |
Variables Items Range Item Example BIE I I~5 "I intend to perform PHE regularly." Self-efficacy 5 5∼25 "In general, I can exercise regularly." "Perceived susceptibility" 5 5∼25 "I worry a lot about becoming ill if I do not perform PHE." "Perceived severity" 6 6∼30 "If I had an illness, my career would be endangered." "Perceived benefits" 3 3∼15 "When I perform PHE, I do not worry as much about illnesses." "Perceived barriers" 6 6∼30 "Performing PHE can be time- consuming." "Cues to action" 5 5∼25 "Village doctors' recommendations prompted me to perform PHE." "Health knowledge" 7 7∼35 "I am familiar with the clinical preventive services." "Social support" 12 I2~60 "I can get the necessary emotional support from my family."| Variables | Items | Range | Item Example | | :--- | :--- | :--- | :--- | | BIE | I | I~5 | I intend to perform PHE <br> regularly. | | Self-efficacy | 5 | $5 \sim 25$ | In general, I can exercise <br> regularly. | | Perceived <br> susceptibility | 5 | $5 \sim 25$ | I worry a lot about becoming ill if <br> I do not perform PHE. | | Perceived <br> severity | 6 | $6 \sim 30$ | If I had an illness, my career <br> would be endangered. | | Perceived <br> benefits | 3 | $3 \sim 15$ | When I perform PHE, I do not <br> worry as much about illnesses. | | Perceived <br> barriers | 6 | $6 \sim 30$ | Performing PHE can be time- <br> consuming. | | Cues to <br> action | 5 | $5 \sim 25$ | Village doctors' <br> recommendations prompted me <br> to perform PHE. | | Health <br> knowledge | 7 | $7 \sim 35$ | I am familiar with the clinical <br> preventive services. | | Social <br> support | 12 | I2~60 | I can get the necessary emotional <br> support from my family. |
Abbreviations: BIE, behavioral intention of PHE; PHE, periodic health examination.
缩写：BIE，公共卫生行为意图；PHE，定期健康检查。
Health knowledge items were modified based on a previous study. 23 23 ^(23){ }^{23} The respondents were asked to indicate their agreement with statements on a five-point Likert-type scale (strongly disagree = 1 = 1 =1=1, disagree = 2 = 2 =2=2, neutral = 3 = 3 =3=3, agree = 4 = 4 =4=4, strongly agree = 5 = 5 =5=5 ).
健康知识项目根据之前的研究进行了修改。受访者被要求在五点李克特量表上表示他们对陈述的同意程度（强烈不同意 = 1 = 1 =1=1 ，不同意 = 2 = 2 =2=2 ，中立 = 3 = 3 =3=3 ，同意 = 4 = 4 =4=4 ，强烈同意 = 5 = 5 =5=5 ）。
The Cronbach’s α α alpha\alpha values for all the scales ranged from 0.72 to 0.94 . A panel of five experts, including family physicians, practitioner nurses, and public health experts, were invited to validate the questionnaire. Most items were evaluated by the experts to ensure appropriateness, with the Content Validity Index of 0.912 .
所有量表的 Cronbach's α α alpha\alpha 值范围为 0.72 到 0.94。邀请了包括家庭医生、执业护士和公共卫生专家在内的五位专家对问卷进行验证。大多数项目经过专家评估以确保适当性，内容效度指数为 0.912。

Statistics 统计数据

Data was processed using Microsoft Access and analyzed using STATA 15.1. The characteristics of subjects were described with number (percent). Mean (SD) was used to describe the scores of EHBM and BIE, and t t tt-tests or the oneway analysis of variance (ANOVA) were performed for groups comparisons. Pearson’s correlation analysis was conducted between EHBM constructs and BIE. In addition, a multiple linear regression analysis was used to identify the association between EHBM and BIE, with potential confounding factors adjusted. Standardized regression coefficient (B’) was used to explain the strength of the association. All P P PP values reported were two-sided, and P P PP values below 0.05 were considered statistically significant.
数据使用 Microsoft Access 处理，并使用 STATA 15.1 进行分析。用数字（百分比）描述受试者的特征。均值（标准差）用于描述 EHBM 和 BIE 的得分，并对组间比较进行了 t t tt -检验或单因素方差分析（ANOVA）。对 EHBM 构念和 BIE 之间进行了 Pearson 相关分析。此外，使用多元线性回归分析来识别 EHBM 与 BIE 之间的关联，并调整潜在的混杂因素。标准化回归系数（B'）用于解释关联的强度。所有报告的 P P PP 值均为双侧， P P PP 值低于 0.05 被认为具有统计学意义。

Results 结果

Participant Characteristics
参与者特征

Table 2 presents participant characteristics. The participants were predominantly male ( 65.6 % 65.6 % 65.6%65.6 \% ) and had an average age of 69.3 ± 7.1 69.3 ± 7.1 69.3+-7.169.3 \pm 7.1 years. The majority ( 78.2 % 78.2 % 78.2%78.2 \% ) had completed no more than junior school education. Approximately half of the families (56.6%) reported a per capita annual household income of less than 20,000 CNY (approximately 2950 USD). In addition, 75.6 % 75.6 % 75.6%75.6 \% of participants were married. Overall, 372 of the 509 respondents (73.1%) had one or more chronic diseases. Furthermore, health-related behavior information was collected, including tobacco use, alcohol use, and regular exercise. Overall, 34.4 % 34.4 % 34.4%34.4 \% of the respondents reported currently being a smoker, 37.5 % 37.5 % 37.5%37.5 \% reported currently being a drinker, and 66.8 % 66.8 % 66.8%66.8 \% reported regular exercise.
表 2 展示了参与者的特征。参与者主要为男性（ 65.6 % 65.6 % 65.6%65.6 \% ），平均年龄为 69.3 ± 7.1 69.3 ± 7.1 69.3+-7.169.3 \pm 7.1 岁。大多数（ 78.2 % 78.2 % 78.2%78.2 \% ）的教育水平不超过初中。约一半的家庭（56.6%）报告人均年收入低于 20,000 元人民币（约 2950 美元）。此外， 75.6 % 75.6 % 75.6%75.6 \% 的参与者已婚。总体而言，509 名受访者中有 372 人（73.1%）患有一种或多种慢性疾病。此外，还收集了与健康相关的行为信息，包括吸烟、饮酒和定期锻炼。总体而言， 34.4 % 34.4 % 34.4%34.4 \% 的受访者报告目前为吸烟者， 37.5 % 37.5 % 37.5%37.5 \% 报告目前为饮酒者， 66.8 % 66.8 % 66.8%66.8 \% 报告定期锻炼。

Scores of EHBM Variables EHBM 变量的分数

Table 3 shows the scores of the participants’ perceptions of PHE, and variables among respondents with different ages,
表 3 显示了参与者对 PHE 的感知得分，以及不同年龄受访者之间的变量
Table 2 Characteristics of Rural Elderly Aged 60 Years and Over
表 2 60 岁及以上农村老年人的特征
Characteristics 特征 Frequency  频率 ( n = 509 ) ( n = 509 ) (n=509)(n=509)
 百分比 (%)
Percentage
(%)
Percentage (%)| Percentage | | :--- | | (%) |
Socio-demographic characteristics
社会人口特征

年龄 < 70 < 70 < 70<70 70~80 ≥ 80 ≥ 80 >= 80\geq 80
Age
< 70 < 70 < 70<70
70~80
≥ 80 ≥ 80 >= 80\geq 80
Age < 70 70~80 >= 80| Age | | :--- | | $<70$ | | 70~80 | | $\geq 80$ |
 298 152 59 298 152 59 {:[298],[152],[59]:}\begin{aligned} & 298 \\ & 152 \\ & 59 \end{aligned} 58.5 29.9 I I. 6 58.5 29.9  I I.  6 {:[58.5],[29.9],[" I I. "6]:}\begin{aligned} & 58.5 \\ & 29.9 \\ & \text { I I. } 6 \end{aligned}

性别 男性 女性
Gender
Male
Female
Gender Male Female| Gender | | :--- | | Male | | Female |
 334 175 334 175 {:[334],[175]:}\begin{aligned} & 334 \\ & 175 \end{aligned} 65.6 34.3 65.6 34.3 {:[65.6],[34.3]:}\begin{aligned} & 65.6 \\ & 34.3 \end{aligned}

婚姻状况 单身 已婚
Marital status
Single
Married
Marital status Single Married| Marital status | | :--- | | Single | | Married |
 124 385 124 385 {:[124],[385]:}\begin{aligned} & 124 \\ & 385 \end{aligned} 24.4 75.6 24.4 75.6 {:[24.4],[75.6]:}\begin{aligned} & 24.4 \\ & 75.6 \end{aligned}

教育水平 小学或以下 初中或以上
Education level
Primary school or below Junior school or above
Education level Primary school or below Junior school or above| Education level | | :--- | | Primary school or below Junior school or above |
 398 111 398 111 {:[398],[111]:}\begin{aligned} & 398 \\ & 111 \end{aligned} 78.2 21.8 78.2 21.8 {:[78.2],[21.8]:}\begin{aligned} & 78.2 \\ & 21.8 \end{aligned}
Economic status 经济状况
Per capita annual household Income (yuan)
人均年家庭收入（元） < 10 , 000 10 , 000 ∼ 20 , 000 ≥ 20 , 000 < 10 , 000 10 , 000 ∼ 20 , 000 ≥ 20 , 000 {:[ < 10","000],[10","000∼20","000],[ >= 20","000]:}\begin{aligned} & <10,000 \\ & 10,000 \sim 20,000 \\ & \geq 20,000 \end{aligned}		 187 101 221 187 101 221 {:[187],[101],[221]:}\begin{aligned} & 187 \\ & 101 \\ & 221 \end{aligned} 36.7 19.8 43.4 36.7 19.8 43.4 {:[36.7],[19.8],[43.4]:}\begin{aligned} & 36.7 \\ & 19.8 \\ & 43.4 \end{aligned}
Health-related behavioral factor
健康相关行为因素

烟草使用 非吸烟者 前吸烟者 现吸烟者
Tobacco use
Nonsmoker
Ex-smoker
Current smoker
Tobacco use Nonsmoker Ex-smoker Current smoker| Tobacco use | | :--- | | Nonsmoker | | Ex-smoker | | Current smoker |
 263 71 175 263 71 175 {:[263],[71],[175]:}\begin{aligned} & 263 \\ & 71 \\ & 175 \end{aligned} 51.7 13.9 34.4 51.7 13.9 34.4 {:[51.7],[13.9],[34.4]:}\begin{aligned} & 51.7 \\ & 13.9 \\ & 34.4 \end{aligned}

酒精使用 不饮酒者 戒酒者 现饮者
Alcohol use
Nondrinker
Abstainer
Current drinker
Alcohol use Nondrinker Abstainer Current drinker| Alcohol use | | :--- | | Nondrinker | | Abstainer | | Current drinker |
 258 60 191 258 60 191 {:[258],[60],[191]:}\begin{aligned} & 258 \\ & 60 \\ & 191 \end{aligned} 50.7 11.8 37.5 50.7 11.8 37.5 {:[50.7],[11.8],[37.5]:}\begin{aligned} & 50.7 \\ & 11.8 \\ & 37.5 \end{aligned}

定期锻炼 不 < 45 min / d < 45 min / d < 45min//d<45 \mathrm{~min} / \mathrm{d} ≥ 45 min / d ≥ 45 min / d >= 45min//d\geq 45 \mathrm{~min} / \mathrm{d}
Exercise regularly
No
< 45 min / d < 45 min / d < 45min//d<45 \mathrm{~min} / \mathrm{d}
≥ 45 min / d ≥ 45 min / d >= 45min//d\geq 45 \mathrm{~min} / \mathrm{d}
Exercise regularly No < 45min//d >= 45min//d| Exercise regularly | | :--- | | No | | $<45 \mathrm{~min} / \mathrm{d}$ | | $\geq 45 \mathrm{~min} / \mathrm{d}$ |
 169 182 158 169 182 158 {:[169],[182],[158]:}\begin{aligned} & 169 \\ & 182 \\ & 158 \end{aligned} 33.2 35.8 31.0 33.2 35.8 31.0 {:[33.2],[35.8],[31.0]:}\begin{aligned} & 33.2 \\ & 35.8 \\ & 31.0 \end{aligned}
Need factor 需要因素

慢性病状态 否 是
Chronic disease status
No
Yes
Chronic disease status No Yes| Chronic disease status | | :--- | | No | | Yes |
 137 372 137 372 {:[137],[372]:}\begin{aligned} & 137 \\ & 372 \end{aligned} 26.9 73.1 26.9 73.1 {:[26.9],[73.1]:}\begin{aligned} & 26.9 \\ & 73.1 \end{aligned}
Characteristics Frequency (n=509) "Percentage (%)" Socio-demographic characteristics "Age < 70 70~80 >= 80" "298 152 59" "58.5 29.9 I I. 6" "Gender Male Female" "334 175" "65.6 34.3" "Marital status Single Married" "124 385" "24.4 75.6" "Education level Primary school or below Junior school or above" "398 111" "78.2 21.8" Economic status Per capita annual household Income (yuan) " < 10,000 10,000∼20,000 >= 20,000" "187 101 221" "36.7 19.8 43.4" Health-related behavioral factor "Tobacco use Nonsmoker Ex-smoker Current smoker" "263 71 175" "51.7 13.9 34.4" "Alcohol use Nondrinker Abstainer Current drinker" "258 60 191" "50.7 11.8 37.5" "Exercise regularly No < 45min//d >= 45min//d" "169 182 158" "33.2 35.8 31.0" Need factor "Chronic disease status No Yes" "137 372" "26.9 73.1"| Characteristics | Frequency $(n=509)$ | Percentage <br> (%) | | :---: | :---: | :---: | | Socio-demographic characteristics | | | | Age <br> $<70$ <br> 70~80 <br> $\geq 80$ | $\begin{aligned} & 298 \\ & 152 \\ & 59 \end{aligned}$ | $\begin{aligned} & 58.5 \\ & 29.9 \\ & \text { I I. } 6 \end{aligned}$ | | Gender <br> Male <br> Female | $\begin{aligned} & 334 \\ & 175 \end{aligned}$ | $\begin{aligned} & 65.6 \\ & 34.3 \end{aligned}$ | | Marital status <br> Single <br> Married | $\begin{aligned} & 124 \\ & 385 \end{aligned}$ | $\begin{aligned} & 24.4 \\ & 75.6 \end{aligned}$ | | Education level <br> Primary school or below Junior school or above | $\begin{aligned} & 398 \\ & 111 \end{aligned}$ | $\begin{aligned} & 78.2 \\ & 21.8 \end{aligned}$ | | Economic status | | | | Per capita annual household Income (yuan) $\begin{aligned} & <10,000 \\ & 10,000 \sim 20,000 \\ & \geq 20,000 \end{aligned}$ | $\begin{aligned} & 187 \\ & 101 \\ & 221 \end{aligned}$ | $\begin{aligned} & 36.7 \\ & 19.8 \\ & 43.4 \end{aligned}$ | | Health-related behavioral factor | | | | Tobacco use <br> Nonsmoker <br> Ex-smoker <br> Current smoker | $\begin{aligned} & 263 \\ & 71 \\ & 175 \end{aligned}$ | $\begin{aligned} & 51.7 \\ & 13.9 \\ & 34.4 \end{aligned}$ | | Alcohol use <br> Nondrinker <br> Abstainer <br> Current drinker | $\begin{aligned} & 258 \\ & 60 \\ & 191 \end{aligned}$ | $\begin{aligned} & 50.7 \\ & 11.8 \\ & 37.5 \end{aligned}$ | | Exercise regularly <br> No <br> $<45 \mathrm{~min} / \mathrm{d}$ <br> $\geq 45 \mathrm{~min} / \mathrm{d}$ | $\begin{aligned} & 169 \\ & 182 \\ & 158 \end{aligned}$ | $\begin{aligned} & 33.2 \\ & 35.8 \\ & 31.0 \end{aligned}$ | | Need factor | | | | Chronic disease status <br> No <br> Yes | $\begin{aligned} & 137 \\ & 372 \end{aligned}$ | $\begin{aligned} & 26.9 \\ & 73.1 \end{aligned}$ |
gender, education levels, per capita annual household income, marital status, health-related behavioral factors, and chronic disease status. Of the 509 respondents, the average score of behavioral intention was 4.43 ( 0.80 : behavioral intention), and scores of the eight dimensions of
性别、教育水平、人均年家庭收入、婚姻状况、与健康相关的行为因素和慢性疾病状态。在 509 名受访者中，行为意图的平均分为 4.43（0.80：行为意图），八个维度的分数为
EHBM were 21.33 (3.18: self-efficacy), 21.32 (5.51: health knowledge), 46.72 (13.08: social support), 17.87 (5.12: perceived susceptibility), 11.22 (3.68: perceived severity), 12.12 (2.90: perceived benefits), 10.91 (5.28: perceived barriers), 19.83 (4.73: cues to action), respectively.
EHBM 的得分分别为 21.33（3.18：自我效能），21.32（5.51：健康知识），46.72（13.08：社会支持），17.87（5.12：感知易感性），11.22（3.68：感知严重性），12.12（2.90：感知益处），10.91（5.28：感知障碍），19.83（4.73：行动提示）。
As depicted in Table 3, participants who had higher BIE were more likely to be 60-69 years old, female, exsmoker, abstainer, had per capita annual household income ranging from 10,000 to 20,000 CNY (1473-2950 USD). Participants who were male ( P < 0.05 P < 0.05 P < 0.05\mathrm{P}<0.05 ), were ex-smoker ( P < 0.05 P < 0.05 P < 0.05\mathrm{P}<0.05 ), were abstainer ( P < 0.05 ) ( P < 0.05 ) (P < 0.05)(\mathrm{P}<0.05) and exercised regularly ( P < 0.05 ) ( P < 0.05 ) (P < 0.05)(\mathrm{P}<0.05) perceived more self-efficacy. Participants who were aged 60-69 ( P < 0.05 P < 0.05 P < 0.05\mathrm{P}<0.05 ), were ex-smoker ( P < 0.05 ) ( P < 0.05 ) (P < 0.05)(\mathrm{P}<0.05) and were abstainer ( P < 0.05 P < 0.05 P < 0.05\mathrm{P}<0.05 ) perceived more social support. Participants who were female ( P < 0.05 P < 0.05 P < 0.05\mathrm{P}<0.05 ), were ex-smoker ( P < 0.05 ) ( P < 0.05 ) (P < 0.05)(\mathrm{P}<0.05), were abstainer ( P < 0.05 ) ( P < 0.05 ) (P < 0.05)(\mathrm{P}<0.05) and exercised regularly ( P < 0.05 P < 0.05 P < 0.05\mathrm{P}<0.05 ) perceived more susceptibility. Participants who had lower education level ( P < 0.05 P < 0.05 P < 0.05\mathrm{P}<0.05 ), were female ( P < 0.05 P < 0.05 P < 0.05\mathrm{P}<0.05 ), and had no habit of smoking and drinking ( P < 0.05 P < 0.05 P < 0.05\mathrm{P}<0.05 ) perceived more severity. Participants who were aged 60-69 ( P < 0.05 P < 0.05 P < 0.05\mathrm{P}<0.05 ), were female ( P < 0.05 ) ( P < 0.05 ) (P < 0.05)(\mathrm{P}<0.05), were ex-smoker ( P < 0.05 P < 0.05 P < 0.05\mathrm{P}<0.05 ), were abstainer ( P < 0.05 ) ( P < 0.05 ) (P < 0.05)(\mathrm{P}<0.05) and had an per capita annual household income ranging from 10,000 to 20,000 CNY (1473-2950 USD; P < 0.05 P < 0.05 P < 0.05\mathrm{P}<0.05