The Current Status of Health Promotion Lifestyle and Its Related Factors in Chinese Residents


 Objectives: This study aimed to explore the current status of Chinese residents' health promotion lifestyle and its influencing factors, especially explore how health attitudes affect health promotion lifestyle, thus can make targeted recommendations for health promotion in China and similar areas.Study design: This study was based on a household survey of 1769 adults aged 18 and over from Shandong Province of China conducted in 2018.Methods: A cross-sectional, face-to-face survey design was used. The between-group measured data were compared by One-way ANOVA or t-tests. The correlation between the health attitude and health promotion lifestyle was examined by Pearson correlation. Logistic regression model was used to examine the related factors influencing Chinese residents’ health promotion lifestyle.Results: The health promotion lifestyle of residents in Chinese residents was not good. Significant differences existed in health promotion lifestyle among different genders, education levels, income levels, marital status, and health attitude (Ps <0.001). Multivariable Logistic regression model found that gender, education level, annual family per capita income, affection and behavioral intention in health attitude were key factors influencing Chinese residents’ health promotion lifestyle (Ps<0.001). Conclusions: Individual health responsibilities need to be further strengthened. More affective factors and operable measures should be added to enhance health affection and health behavioral intention, so as to enhance health promotion lifestyle.

Introduction adjusted to make it easy to be understood. Adjusted Cronbach's alpha for the total pro le is 0.88, with subscales ranging from 0.71 to 0.85. The total score ranges between 30-120, in which 30-52 represents poor, 53-75 represents average, 76-98 represents good, and 99-120 represents excellent.

Health Attitude Questionnaire
A self-designed Health Attitude Questionnaire was used in the study, which using a 5-point Likert scale with choices ranging from totally disagree = 0 to totally agree = 4 [19,20]. The original questionnaire was designed according to health promotion lifestyle, contained 30 items. The nal questionnaire contains 23 items and, the Cronbach's α is 0.81. We extracted three factors-Health Cognition (8 items), Health Affection (8 items), and Health Behavioral Tendency (7 items), which respectively explained 12.71%, 15.37%, and 23.80% of the total variance. The con rmatory factor analysis of the three-factor model resulted in an acceptable model t (Tucker-Lewis Index = 0.90, Comparative Fit Index = 0.92, Normed Fit Index = 0.93, Expected Cross-Validation Index = 0.35, Root-Mean-Square Error of Approximation = 0.068). The item loadings range from 0.72 to 0.83, and correlation coe cients among the three factors range from 0.54 to 0.70. The total score is between 0-92, in which 0-30 represents poor, 31-61 represents average, and 62-92 represents good.

Data Analysis
In this study, the database was built using Access 2010 software; the data was recorded two times and compared to ensure data integrity and accuracy. The statistical analysis was performed using the Statistical Package for the Social Sciences version 24.0 (SPSS, Inc., Chicago, IL, USA). The independent variables of this study are individual-level factors (e.g., gender, age, education level, and so on.), which were summarized using descriptive statistics. The statistical description of the measurement data was expressed by mean and standard deviation (SD). Besides, the analysis of variance or t-test was used to compare the between-group measured data. All tests were bilateral, and the test level was set at α = 0.05. The Pearson correlation coe cient was used to analyze the correlation between the health attitude and health promotion lifestyle. Multivariate logistic regression model was used to explore the related factors affecting Chinese residents' health promotion lifestyle. The results were exhibited as adjusted odds ratios (ORs) with their 95% con dence intervals (CIs).

Basic Sociodemographic Characteristics
In this study, 1800 questionnaires were distributed, of which 1784 were collected, with 1769 valid responses (effective rate, 98.28%). Among the 1769 respondents, 790 (44.66%) are male and 979 (55.34%) are female; the mean age is 45.6 (SD = 9.12). Table 1 presents the sociodemographic data of study participants.

Status of Health Promotion Lifestyle
The mean (SD) of HPLP-IICR total score of 1769 was 82.12 (16.63  Correlation Analysis of Health Attitude and Health Promotion Lifestyle As shown in Table 3, the three aspects of health attitude are correlated with multiple aspects of health promotion lifestyle, suggesting that health attitude is a signi cant predictor of health promotion lifestyle. With health promotion lifestyle (0 = excellent and good, 1 = average and poor) as the dependent variable, signi cant factors in single-factor analysis were selected as independent variables for multivariate logistic regression analysis, which include gender, education level, annual family per capita income, marital status, and three factors of health attitude: health cognition, health affection, and health behavioral intention.
Results indicated that the independent factors in uencing health promotion lifestyle include gender, education level, annual family per capita income, health affection, and health behavioral intention. As shown in

Discussion
This study has con rmed that mean score for health promotion lifestyle reaches (82.12±16.63), but 54.50% of the participants are in the status of average or poor, so the overall conditions of Chinese adults' health promotion lifestyle is not good. That is consistent with previous studies of Chinese [21,22], and is lower than studies of Xia, Chen et al. [23,24]. The score of Nutrition is the highest (3.08±0.74), which is the same as the research results of Chen, Zhao and other scholars [22,25]. With the increasing improvement of living standards and the popularization of nutrition knowledge, Chinese residents have higher requirements on diet, not only to satisfy their appetite, but also to pay more attention to nutrition ingredients and dietary collocation. The score of Physical Activity is the second highest (2.97±0.79), which is different from previous studies [23,24]. The reason may be due to the differences between the scales used in this survey and those used in other surveys. After revision, the items that do not conform to Chinese culture had been deleted, so that they were easier to be understood [16]. It was worth noting that Chinese women showed better physical activity than men, which was different from studies of South Koreans [26] and Americans [27]. Perhaps this is because several Chinese women went square dancing as a way of exercise. Square dancing refers to dancing in an open and public space in China, usually on a at patch such as a public square [28]. This group exercise has become popular in both urban and rural regions across China in recent 15 years [29,30] and has been popular, mainly among women [28]. Thanks to its convenience, low cost and social function, square dancing has enabled Chinese women to get physical activity and spiritual satisfaction after work and housework [31]. It is interesting to note that unlike previous studies [32] reporting that living with a partner exerts positive in uence on physical activity, this study found that married people's Physical Activity is worse than that of unmarried people. That may be because in Chinese tradition, married people should take more family-oriented economic responsibilities and the responsibility of raising children, which makes them more inclined to spend their spare time and energy on work and raising children. The score of Health Responsibility got the lowest (2.42±0.89), similar results had been reported by Zhang [33], whose study also based on residents of northern China. This may be due to the lack of emphasis on self-responsibility for health in northern Chinese culture.
A signi cant and novel work of this study is to discover whether health attitude can in uence health promotion lifestyle. Our main nding is that three aspects of health attitude have certain in uence on health behavior, among which health cognition has the least in uence, followed by health affection, and health behavioral intention has the greatest in uence. The in uence of health cognition on health promotion lifestyle has been discussed in many previous studies [34]. This study has found that health affection plays a more important role in the initiation of health promotion lifestyle than health cognition, that was not presented in other studies. The impact of health behavior intention on health behavior has been con rmed by several studies [35], some of which focus on promoting health promotion lifestyle in people without health motivation [36]. However, based on this study, if people can have health related knowledge and health affective experience at the same time and further develop corresponding behavioral intention, it is more likely to have health promotion lifestyle.
In addition to attitude, this study found that female residents may adopt more health promotion lifestyle, corroborating several studies [37,38]. The effects of education and family income on health behavior are similar to previous studies [39,40]. Prior studies suggested that poorly educated adults may have di culty in understanding medical statistics, drug dose requirements, and basic health concepts such as daily nutritional value [41][42][43]. People with a high school diploma or above, tend to seek and use health information, regardless of their educational level and other sociodemographic factors [44,45].
In China, as in other countries, inconsistencies in health behavior due to differences in gender, wealth, and education still persist; thus, decreasing the gap should be a top issue of particular urgency to both public and private sectors [46]. Due to the important in uence of health attitude on health promotion lifestyle, affection and behavioral intention should be fully considered in the process of health promotion. For example, health promotion programs should be designed with elements that evoke affection in the residents, health-relevant motor manipulations can facilitate health behavior change and higher intentionbehavior consistency [47]. Based on the characteristics of Chinese residents' greater emphasis on family responsibilities, more health promotion projects aimed at adolescents and requiring family participation could be designed. In order to compensate for the lack of health responsibility, while improving the accessibility and quality of health services, the propaganda of "everyone is the rst person responsible for his/her own health" should be strengthened.

Limitations
The ndings of this study should be considered in light of some limitations. Health attitudes and health promotion lifestyle are self-reported variables, so that report bias may exist. In the study, only Shandong Province residents have been conducted the survey, so that the representativeness may be limited.
However, despite these limitations, this study can re ect the current health promotion lifestyle of Chinese residents and, reveal the in uence of health attitude on health promotion lifestyle. It also provides relevant suggestions for the formulation of relevant health policies.

Conclusions
This study found that the general health promotion lifestyle in Chinese residents is not good. Of note, gender, education level, annual family per capita income, health affection, and health behavioral intention are signi cant factors in uencing residents' health promotion lifestyle. Furthermore, this study suggests that more affective factors and operable measures should be added to enhance health affection and health behavioral intention. Individual health responsibilities should be emphasized and health promotion projects involving all family members should be designed, so as to enhance health promotion lifestyle.

Conflicts of Interest
The authors declare no conflict of interest.

Availability of data and materials
The datasets used during the current study are available from the corresponding authors on reasonable request.

Ethics approval and consent to participate
The study was conducted and approved by Ethics Committee of Centre for Health Management and Policy Research, School of Public Health, Cheeloo College of Medicine, Shandong University, and all the participants had given their informed consent.

Consent for publication
Not applicable.