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Abstract Background Adherence to antiparkinsonian drugs (APDs) is critical for patients with Parkinson’s disease (PD), for which medication is the main therapeutic strategy. Previous studies have focused on specific disorders in a single system when assessing clinical factors affecting adherence to PD treatment, and no international comparative data are available on the medical costs for Chinese patients with PD. The present study aimed to evaluate medication adherence and its associated factors among Chinese patients with PD using a systematic approach and to explore the impact of adequate medication adherence on direct medical costs. Methods A retrospective analysis was conducted using the electronic medical records of patients with PD from a medical center in China. Patients with a minimum of two APD prescriptions from January 1, 2016 to August 15, 2018 were included. Medication possession ratio (MPR) and proportion of days covered were used to measure APD adherence. Multiple linear regression analysis was used to identify factors affecting APD adherence. Gamma regression analysis was used to explore the impact of APD adherence on direct medical costs. Results In total, 1,712 patients were included in the study, and the mean MPR was 0.68 (± 0.25). Increased number of APDs and all medications, and higher daily levodopa-equivalent doses resulted in higher MPR (mean difference [MD] = 0.04 [0.03–0.05]; MD = 0.02 [0.01–0.03]; MD = 0.03 [0.01–0.04], respectively); combined digestive system diseases, epilepsy, or older age resulted in lower MPR (MD = -0.06 [-0.09 to -0.03]; MD = -0.07 [-0.14 to -0.01]; MD = -0.02 [-0.03 to -0.01], respectively). Higher APD adherence resulted in higher direct medical costs, including APD and other outpatient costs. For a 0.3 increase in MPR, the two costs increased by $34.42 ($25.43–$43.41) and $14.63 ($4.86–$24.39) per year, respectively. Conclusions APD adherence rate among Chinese patients with PD was moderate and related primarily to age, comorbidities, and healthcare costs. The factors should be considered when prescribing APDs.

With the expansion of vaccination programs, the policy of terminating nonpharmaceutical interventions for preventing the SARS-CoV-2 pandemic should become more flexible. The current study investigated the clinical and economic outcomes of intervention policies combining nonpharmaceutical interventions and vaccination programs for dealing with the SARS-CoV-2 pandemic. An agent-based transmission model was adopted that describes how a SARS-CoV-2 virus spreads in the populations of China. The model inputs were derived from the literature and expert opinion. The following intervention policies were simulated: no intervention, strict nonpharmaceutical interventions, and nonpharmaceutical interventions for workplace, community, school and home gradually terminated by combining vaccination programs for specified age groups (vaccination age in years: 20–60, 20–70, 20–80, ≥ 20, ≥ 10 and whole population). Cumulative infections and deaths in one calendar year, costs and quality-adjusted life years (QALYs) were measured. When the vaccination program was taken up in at least the ≥ 20 years age group in all populations, nonpharmaceutical interventions for workplace and community settings could be gradually terminated because the cumulative number of infections was < 100 per 100,000 persons. Further ending nonpharmaceutical interventions in school and home settings could not meet the target even when the vaccination program had been taken up in all populations. When cumulative deaths were used as the endpoint, nonpharmaceutical interventions in workplace, community and school settings could be gradually terminated. Vaccine efficacy and coverage have substantial impacts. Terminating nonpharmaceutical interventions in workplace settings could produce the lowest cost when vaccination programs are taken up at least in the ≥ 10 years age group; this method dominates most intervention strategies due to its lower costs and higher QALYs. According to our findings, nonpharmaceutical interventions might be gradually terminated in Chinese settings.

Abstract Leveraging substantial data from China’s Weibo and datasets from Reddit and X (previously Twitter) in the United States, this research explores the disparities and complex dynamics of emotions and social connections among social media users in China and the United States during the COVID-19 pandemic. The findings indicate that the expression of three negative emotions (anxiety, sadness, and anger) and positive emotions exhibited distinctive dynamics under the impact of the pandemic, with China individuals expressing more anxiety but less sadness and anger than those in the US. Moreover, Chinese social media experienced a surge in positive emotional expressions under lockdown, whereas the US witnessed a conspicuous decline in positive emotions. Also, the expression of three types of social connections - “family”, “collective”, and “country”-exhibited significant differences under the impact of the pandemic, with Chinese individuals establishing deeper connections with their country and American individuals leaning towards familial connections. Further analysis on the moderating effects of social connections substantiated that the “country” connection in China and the “family” connection in the US mitigated the negative emotions affected by the pandemic. These findings facilitate a deeper understanding of how cultural contexts shape social and psychological responses in crises. Based on topic analysis and forward-looking orientation analysis, this study dissects the aforementioned findings through the dichotomy of collectivist and individualist cultures, providing new insights for social psychological support and emotional guidance in the development of public health communication strategies in the future.

Abstract This study aims to assess clinical outcomes following switching from originator to generic amlodipine. This population‐based, matched, cohort study included users of originator amlodipine using claims data during 2018–2020 from a health system in Tianjin, China, in which usage of generic amlodipine was promoted by a drug procurement policy, the national volume‐based procurement. Non‐switchers refer to those remained on originator after the policy, while pure‐switchers were those who switched to and continued using generic amlodipine, and back‐switchers were those switched to generic amlodipine but then back to the originator. Propensity score matching generates comparable non‐switchers and pure‐switchers pairs, and non‐switchers and back‐switchers pairs. The primary outcome was major adverse cardiovascular events (MACEs), defined as all‐cause mortality, stroke, and myocardial infarction during follow‐up (April 1, 2019 to December 30, 2020). Secondary outcomes included heart failure, atrial fibrillation, and adherence to amlodipine. The hazard ratio (HR) for each clinical outcome was assessed through Cox proportional hazard regression. In total, 5943 non‐switchers, 2949 pure‐switchers, and 3061 back‐switchers were included (mean age: 62.9 years; 55.5% men). For the matched pairs, pure‐switchers (N = 2180) presented no additional risks of clinical outcomes compared to non‐switchers (N = 4360) (e.g., MACEs: 2.86 vs. 2.95 events per 100 person‐years; HR = 0.97 [95%CI: 0.70–1.33]). Back‐switchers (N = 1998) also presented no additional risk compared to non‐switchers (N = 3996) for most outcomes except for stroke (HR = 1.55 [95%CI: 1.03–2.34]). Pure‐switchers and back‐switchers all had better amlodipine adherence than non‐switchers. Generic substitution of amlodipine is not associated with increased risk of cardiovascular events or all‐cause mortality, but improves medicine adherence.

This cohort study used the China Health and Retirement Longitudinal Study (CHARLS, 2015–2018) to investigate the effects of socioeconomic status and social capital to the incidence of depressive symptoms among middle-aged and older individuals in China, incorporating a sample size of 9949 participants. Socioeconomic status, social capital and other explanatory variables were collected in 2015, while depressive symptoms were assessed in 2018. Basic characteristics and social capital measures were compared between urban and rural residents using the chi-square test. Logistic regression was used to explore the relationship between socioeconomic status, social capital and depressive symptoms, and the Karlson, Holm, and Breen (KHB) method was employed to verify the mediating role of social capital. We reported persistent socioeconomic inequalities in depressive symptoms, with rural residents and the illiterate having 1.45 times and 1.34 times higher odds of depression. We ascertained social capital from both the cognitive and structural constructs, where we enriched the measurement of structural social capital from three specific dimensions, i.e., informal interaction, altruism, and formal social participation. We found that both cognitive and structural social capital were associated with lower incidence of depressive symptoms, where informal interaction had the largest effect. The mediation analysis further illustrated that informal interaction contributed most to explain 6 %–12 % of the socioeconomic inequalities in depressive symptoms. These results highlighted the unsatisfied mental wellbeing of the vulnerable older people living in rural areas. The finding suggested that older people may benefit more from personal interactions than formal participations. To fulfill the Health in All vision, government and social organizations should consider how to create opportunities to better integrate the older people into the community.

Abstract Background This study was conducted to investigate the prevalence and determinants of breastfeeding in 2008 and 2018, respectively, in Northeast China, where health service efficiency is at the lowest national level and regional data on breastfeeding are lacking. The influence of early initiation of breastfeeding on later feeding practices was specifically explored. Methods Data from the China National Health Service Survey in Jilin Province in 2008 (n = 490) and 2018 (n = 491) were analysed. Multistage stratified random cluster sampling procedures were used to recruit the participants. Data collection was conducted in the selected villages and communities in Jilin. Early initiation of breastfeeding was defined as the proportion of children born in the last 24 months who were put to the breast within one hour after birth in both the 2008 and 2018 surveys. Exclusive breastfeeding was defined as the proportion of infants 0–5 months of age who were fed exclusively with breast milk in the 2008 survey; while defined as the proportion of infants 6–60 months of age who had been fed exclusively with breast milk within the first six months of life in the 2018 survey. Results The prevalence of early initiation of breastfeeding (27.6% in 2008 and 26.1% in 2018) and exclusive breastfeeding during the first six months (

BackgroundThis study aimed to explore the relationship between air pollution and hospital admissions for asthma in older adults, and to further assess the health and economic burden of asthma admissions attributable to air pollution.MethodsWe collected information on asthma cases in people over 65 years of age from nine cities in Sichuan province, as well as air pollution and meteorological data. The relationship between short-term air pollutant exposure and daily asthma hospitalizations was analyzed using the generalized additive model (GAM), and stratified by gender, age, and season. In addition, we assessed the economic burden of hospitalization for air pollution-related asthma in older adults using the cost of disease approach.ResultsThe single pollutant model showed that every 1 mg/m3 increase in CO was linked with an increase in daily hospitalizations for older adults with asthma, with relative risk values of 1.327 (95% CI: 1.116–1.577) at lag7. Each 10 μg/m3 increase in NO2, O3, PM10, PM2.5 and SO2, on asthma hospitalization, with relative risk values of 1.044 (95% CI: 1.011–1.078), 1.018 (95% CI: 1.002–1.034), 1.013 (95% CI: 1.004–1.022), 1.015 (95% CI: 1.003–1.028) and 1.13 (95% CI: 1.041–1.227), respectively. Stratified analysis shows that stronger associations between air pollution and asthma HAs among older adult in females, those aged 65–69 years, and in the warm season, although all of the differences between subgroups did not reach statistical significance. During the study period, the number of asthma hospitalizations attributable to PM2.5, PM10, and NO2 pollution was 764, 581 and 95, respectively, which resulted in a total economic cost of 6.222 million CNY, 4.73 million CNY and 0.776 million CNY, respectively.ConclusionThis study suggests that short-term exposure to air pollutants is positively associated with an increase in numbers of asthma of people over 65 years of age in Sichuan province, and short-term exposure to excessive PM and NO2 brings health and economic burden to individuals and society.

Abstract To explore the effects of UNICEF‐suggested modifiable factors, that is, water, sanitation and hygiene (WASH), early adequate feeding and health care on child malnutrition, and to examine the extent to which each factor contributes to urban–rural disparities of child malnutrition in China. Pooling two waves of regionally representative survey data from Jilin, China, in 2013 and 2018, we report on urban–rural relative risks (RRs) in the prevalence of child stunting, wasting and overweight. We employ Poisson regression to examine the effects of urban–rural setting and the three modifiable factors on the prevalence of each malnutrition outcome, that is, stunting, wasting and overweight. We perform mediation analyses to estimate the extent to which each modifiable factor could explain the urban–rural disparities in each malnutrition outcome. The prevalence of stunting, wasting and overweight were 10.9%, 6.3% and 24.7% in urban, and 27.9%, 8.2% and 35.9% in rural Jilin, respectively. The rural to urban crude RR was 2.55 (95% confidence interval [CI]: 1.92–3.39) for stunting, while the corresponding RRs for wasting and overweight were 1.31 (95% CI: 0.84–2.03) and 1.45 (95% CI: 1.20–1.76), respectively. The rural to urban RR for stunting reduced to 2.01 (95% CI: 1.44–2.79) after adjusting for WASH. The mediation analyses show that WASH could mediate 23.96% (95% CI: 4.34–43.58%) of the urban–rural disparities for stunting, while early adequate feeding and health care had no effects. To close the persistent urban–rural gap in child malnutrition, the specific context of rural China suggests that a multi‐sectoral approach is warranted that focuses on the sanitation environment and other wider social determinants of health.

Abstract Background Consultation length, the time a health provider spend with the patient during a consultation, is a crucial aspect of patient-physician interaction. Prior studies that assessed the relationship between consultation length and quality of care were mainly based on offline visits. Research was lacking in E-consults settings, an emerging modality for primary health care. This study aims to examine the association between consultation length and the quality of E-consults services. Methods We defined as standardized patient script to present classic urticaria symptoms in asynchronous E-consults at tertiary public hospitals in Beijing and Hangzhou, China. We appraised consultation length using six indicators, time waiting for first response, time waiting for each response, time for consultation, total times of provider’s responses, total words of provider’s all responses, and average words of provider’s each response. We appraised E-consults services quality using five indicators building on China’s clinical guidelines (adherence to checklist; accurate diagnosis; appropriate prescription; providing lifestyle modification advice; and patient satisfaction). We performed ordinary least squares (OLS) regressions and logistic regressions to investigate the association between each indictor of consultation length and E-consults services quality. Results Providers who responded more quickly were more likely to provide lifestyle modification advice and achieve better patient satisfaction, without compromising process, diagnosis, and prescribing quality; Providers who spent more time with patients were likely to adhere to clinical checklists; Providers with more times and words of responses were significantly more likely to adhere to the clinical checklist, provide an accurate diagnosis, appropriate prescription, and lifestyle modification advice, which achieved better satisfaction rate from the patient as well. Conclusions The times and words that health providers provide in E-consult can serve as a proxy measure for quality of care. It is essential and urgent to establish rules to regulate the consultation length for Direct-to-consumer telemedicine to ensure adequate patient-provider interaction and improve service quality to promote digital health better.

Objective Direct-to-consumer telemedicine is rapidly changing the way that patients seek medical care. This study provided the first report on access, cost and quality of text- and image-based tele-dermatology e-consults, in China. Methods We adopted the Standardized Patients approach to evaluate the services of tele-dermatology e-consults in two metropolitan cities, that is, Beijing and Hangzhou, in China. We measured quality from four dimensions: service process, diagnosis accuracy, prescription and treatment comprehensiveness, based on China's national clinical guidelines. We performed logistic regressions to investigate factors that were associated with high-quality care. Results For 114 physicians eligible for inclusion, we succeeded in 87 (76%) validated visits. The median waiting time was 100 minutes (IQR 19–243 minutes) and the median length of consultation was 636 minutes (about 10 hours, IQR 188–1528 minutes). Per visit costs varied from $0 to $38, with a median of $8 (IQR 4–9). Among all, 15% of visits showed high quality in service process, 84% arrived in the correct diagnosis, 24% provided high-quality prescriptions and 71% provided comprehensive treatment. Providing images was associated with high quality in service process (OR 7.22, 95% CI 1.49–34.88). Visits in metropolitan Beijing and on non-work days had better prescription quality than that in metropolitan Hangzhou (OR 6.05, 95% CI 1.75–20.95) and that on workdays (OR 3.75, 95%CI 1.27–11.04), respectively. Conclusions Tele-dermatology e-consults seem to be easy to access and less expensive in China. However, great efforts are warranted to ensure that service processes and prescriptions adhere to clinical guidelines.

Introduction We comprehensively evaluate whether the Chinese Government’s goal of ensuring Universal Health Coverage for essential health services has been achieved.Methods We used data from the 2008, 2013 and 2018 National Health Services Survey to report on the coverage of a range of Sustainable Development Goals (SDG) indicator 3.8.1. We created per capita household income deciles for urban and rural samples separately. We report time trends in coverage and the slope index (SII) and relative index (RII).Results Despite much lower levels of income and education, rural populations made as much progress as their urban counterparts for most interventions. Coverage of maternal and child health interventions increased substantially in urban and rural areas, with decreasing rich-poor inequalities except for antenatal care. In rural China, one-fifth women could not access 5 or more antenatal visits. Coverage of 8 or more visits were 34% and 68%, respectively in decile D1 (the poorest) and decile D10 (the richest) (SII 35% (95% CI 22% to 48%)). More than 90% households had access to clean water, but basic sanitation was poor for rural households and the urban poorest, presenting bottom inequality. Effective coverage for non-communicable diseases was low. Medication for hypertension and diabetes were relatively high (>70%). But adequate management, counting in preventive interventions, were much lower and decreased overtime, although inequalities were small in size. Screening of cervical and breast cancer was low in both urban and rural areas, seeing no progress overtime. Cervical cancer screening was only 29% (urban) and 24% (rural) in 2018, presenting persisted top inequalities (SII 25% urban, 14% rural).Conclusion China has made commendable progress in protecting the poorest for basic care. However, the ‘leaving no one behind’ agenda needs a strategy targeting the entire population rather than only the poorest. Blunt investing in primary healthcare facilities seems neither effective nor efficient.

Abstract Backgrounds Non-communicable diseases (NCDs) have become a priority public health issue. The aim of this study was to examine whether socio-economic inequalities exist in chronic disease management among Chinese adults, and whether the relationship between SES and chronic disease management mediated by social capital. Methods We used combined data from China Health and Retirement Longitudinal Study (CHARLS). A total of 19,291 subjects, including 14,905 subjects from 2011 survey, 2036 subjects from 2013, and 2350 subjects from 2015 was included in this study. Results Subjects living in urban setting, with higher education attainment and economic status were more likely to have annual health checks, and to be diagnosed for those with hypertension, diabetes and dyslipidemia (all P

ObjectiveCervical cancer, the fourth leading cancer diagnosed in women, has brought great attention to cervical cancer screening to eliminate cervical cancer. In this study, we analyzed two waves of provincially representative data from northeastern China's National Health Services Survey (NHSS) in 2013 and 2018, to investigate the temporal changes and socioeconomic inequalities in the cervical cancer screening rate in northeastern China.MethodsData from two waves (2013 and 2018) of the NHSS deployed in Jilin Province were analyzed. We included women aged 15–64 years old and considered the occurrence of any cervical screening in the past 12 months to measure the cervical cancer screening rate in correlation with the annual per-capita household income, educational attainment, health insurance, and other socioeconomic characteristics.ResultsA total of 11,616 women aged 15–64 years were eligible for inclusion. Among all participants, 7,069 participants (61.11%) were from rural areas. The rate of cervical cancer screening increased from 2013 to 2018 [odds ratio (OR): 1.06; 95% confidence interval (CI): 1.04–1.09, p < 0.001]. In total, the cervical cancer screening rate was higher among participants who lived in urban areas than rural areas (OR: 1.20; 95% CI: 1.03–1.39, p = 0.020). The rate was also higher among those with the highest household income per capita (OR: 1.30; 95% CI: 1.07–1.56, p = 0.007), with higher educational attainment (p < 0.001), and with health insurance (p < 0.05), respectively. The rate of cervical cancer screening was also significantly associated with parity (OR: 1.62; 95% CI: 1.23–2.41, p = 0.001) and marital status (OR: 1.45; 95% CI: 1.15–1.81, p = 0.001) but not ethnicity (OR: 1.41; 95% CI: 0.95–1.36, p = 0.164).ConclusionCervical cancer screening coverage improved from 2013 to 2018 in northeastern China but remains far below the target 70% screening rate proposed by the World Health Organization. Although rural-urban inequality disappeared over time, other socioeconomic inequalities remained.

BackgroundThe WeChat platform has become a primary source for medical information in China. However, no study has been conducted to explore the quality of information on WeChat for the treatment of hypertension, the leading chronic condition. ObjectiveThis study aimed to explore the quality of information in articles on WeChat that are related to hypertension treatment from the aspects of credibility, concreteness, accuracy, and completeness. MethodsWe searched for all information related to hypertension treatment on WeChat based on several inclusion and exclusion criteria. We used 2 tools to evaluate information quality, and 2 independent reviewers performed the assessment with the 2 tools separately. First, we adopted the DISCERN instrument to assess the credibility and concreteness of the treatment information, with the outcomes classified into five grades: excellent, good, fair, poor, and very poor. Second, we applied the Chinese Guidelines for Prevention and Treatment of Hypertension (2018 edition) to evaluate the accuracy and completeness of the article information with regard to specific medical content. Third, we combined the results from the 2 assessments to arrive at the overall quality of the articles and explored the differences between, and associations of, the 2 independent assessments. ResultsOf the 223 articles that were retrieved, 130 (58.3%) full texts were included. Of these 130 articles, 81 (62.3%) described therapeutic measures for hypertension. The assessment based on the DISCERN instrument reported a mean score of 31.22 (SD 8.46). There were no articles rated excellent (mean score >63); most (111/130, 85.4%) of the articles did not refer to the consequences—in particular, quality of life—of no treatment. For specific medical content, adherence to the Chinese Guidelines for Prevention and Treatment of Hypertension was generally low in terms of accuracy and completeness, and there was much erroneous information. The overall mean quality score was 10.18 (SD 2.22) for the 130 articles, and the scores differed significantly across the 3 types (P=.03) and 5 sources (P=.02). Articles with references achieved higher scores for quality than those reporting none (P

Inadequate feeding is one of the most critical underlying determinants of child malnutrition. In this study, we explore infant young child feeding (IYCF) and deconstruct breastfeeding barriers in mothers of severely malnourished children in one of the most marginalized districts of Punjab province of Pakistan. Using purposive sampling, 20 lactating mothers are recruited for open-ended semi-structured interviews. Results reveal that barriers to immediate and exclusive breastfeeding include the introduction of pre-lacteal, butter, and cow or formula milk by mothers and grandmothers. Birthing difficulties and ritualizing prelacteal to transfer religion and culture cause the delay of early initiation of breastmilk. The colostrum is also discarded based on its weird physical look. Moreover, household circumstances, limited diet, extra workload, and mental stress associated with marital relationships are other significant barriers. Mothers perceive their breastmilk as thin, impotent, and of bad quality and often complain against breastmilk insufficiency due to general weakness. Furthermore, poor mothers reduce breastfeeding when the fertility burden is high, especially if a female baby is in their womb. Alternatively, outer milk is recommended but washing bottles with detergents often becomes frequent. In conclusion, immediacy, exclusivity, frequency, and duration of breastfeeding are circumscribed owing to multiple social, cultural, and economic causes. Therefore, a holistic approach combining cultural and structural causes might be more relevant for successful IYCF practices in marginalized communities of Pakistan.

The Coronavirus Disease 2019 (COVID-19) pandemic has caused numerous unexpected changes for families and societies, which have likely contributed to higher amounts of stress for most parents. This study aimed to examine the relationship between burnout and mental health among parents during the COVID-19. Pandemic exposure and household factors (e.g., family structure, family function) were examined as moderators. An online cross-sectional survey recruiting 1,209 adults was conducted from April 21st to April 28th, 2020 during the COVID-19 lockdown in China. The multivariable linear regression analysis was employed to test the association between burnout, household factors, and mental health among parents. Findings suggested that for parents with a young child, poorer mental health was related to a higher level of burnout (β = 0.220, P < 0.001) and greater exposure to the pandemic. Mothers of a single and/or young child had considerably poorer mental health. Moreover, the relationship between mental health and burnout among parents was significantly moderated by epidemic exposure (β = 2.561, P < 0.001), family structure (number of children: β = −1.257, P < 0.001; first child age: β=-1.116, P < 0.001) and family function (β = −0.574, P < 0.05). This study indicated that burnout symptoms were significantly associated with worse mental health among parents in China. Besides, exposure to the pandemic, family structure, and family function was found to moderate the association between burnout and mental health among parents. Therefore, the present study stressed enhanced access to mental health resources and emotional supports for parents during a public crisis to reduce the deleterious effects of burnout.

BackgroundDetection of depression gained prominence soon after this troublesome disease emerged as a serious public health concern worldwide. ObjectiveThis systematic review aims to summarize the findings of previous studies concerning applying machine learning (ML) methods to text data from social media to detect depressive symptoms and to suggest directions for future research in this area. MethodsA bibliographic search was conducted for the period of January 1990 to December 2020 in Google Scholar, PubMed, Medline, ERIC, PsycINFO, and BioMed. Two reviewers retrieved and independently assessed the 418 studies consisting of 322 articles identified through database searching and 96 articles identified through other sources; 17 of the studies met the criteria for inclusion. ResultsOf the 17 studies, 10 had identified depression based on researcher-inferred mental status, 5 had identified it based on users’ own descriptions of their mental status, and 2 were identified based on community membership. The ML approaches of 13 of the 17 studies were supervised learning approaches, while 3 used unsupervised learning approaches; the remaining 1 study did not describe its ML approach. Challenges in areas such as sampling, optimization of approaches to prediction and their features, generalizability, privacy, and other ethical issues call for further research. ConclusionsML approaches applied to text data from users on social media can work effectively in depression detection and could serve as complementary tools in public mental health practice.

Background: Globally, diabetes has brought an enormous burden to public health resources, and the situation of disease burden caused by diabetes in China is especially severe. China is currently facing the dual threat of aging and diabetes, and wearable activity trackers could promote elderly diabetic patients' physical activity levels and help them to manage blood glucose control. Therefore, examining the influencing factors of elderly patients' adoption intention is critical as wearing adoption determines actual wearing behaviors.Objective: This study aims to explore the predicting factors of Chinese elderly type 2 diabetic patients' adoption intention to wearable activity trackers and their actual wearing behavior, using diffusion of innovation theory as the theoretical framework. We hope to provide insights into future interventions using wearable activity trackers as tools to improve the outcome of patients.Methods: Wearable activity trackers were freely distributed to type 2 diabetic patients in Beijing, China. A questionnaire survey was conducted to examine predicting factors of adoption intention after a week's try-on. Actual wearing behavior for 3-month was obtained from the exclusive cloud. Data were analyzed with structural equation modeling.Results: A total of 725 patients completed the questionnaire. Patients had a mean age of 60.3 ± 7.6 years old and the educational level was generally lower. The results indicated that observability was the primary influencing factor of patients' adoption intention (β = 0.775, P < 0.001). Relative advantage (β = 0.182, P = 0.014) and perceived social image (β = 0.080, P = 0.039) also had a positive influence while perceived risk (β = −0.148, P < 0.001) exerted a negative influence. In addition, results showed that the more intention led to the better actual wearing behavior (β = 0.127, P = 0.003). Observability (β = 0.103, P = 0.005), perceived ease (β = 0.085, P = 0.004), and relative advantage (β = 0.041, P = 0.009) also indirectly influenced the wearing behavior.Conclusion: The intentions of Chinese elderly type 2 diabetic patients to wearable activity trackers directly influenced the actual wearing behavior. In addition, their adoption intention to wearable activity trackers was mainly influenced by observability, perceived ease to use, relative advantage, perceived risk, and social image.

Background: Ambient air pollution is leading risk factor for health burden in China. Few studies in China have investigated the economic loss related to short-term exposure to ambient PM2.5, which could trigger acute onset of cardiorespiratory diseases within a few days. Methods: Daily ambient air pollutants data are obtained for each city from the National Air Quality Monitoring System and daily hospitalization data are obtained from the urban employee-based basic medical insurance scheme database in 74 Chinese cities with an average coverage of 88.5 million urban employees during 2016-2017. A three-stage time-series analytic approach is used in this study to investigate the impact of short-term exposure to ambient fine particulate (PM2.5) air pollution on hospital admissions, expenses and hospital stays of three cause-specific cardiorespiratory diseases, including lower respiratory infections (LRI), coronary heart disease (CHD) and stroke in the included cities. Findings: Based on the time-series analysis using daily hospitalization data, 28,560 LRI cases, 54,600 CHD cases, and 23,989 stroke cases are attributable to ambient PM2.5 in the 74 cities during the study period, and the related attributable expenses are 220 million CNY (US$ 32.9 million) for LRI, 458 million CNY (US$ 68.5 million) for CHD, and 410 million CNY (US$ 65.8 million) for stroke, respectively. These attributable numbers account for 1.45% to 2.05% of total hospital admissions and 1.10% to 1.51% of total expenses for the three diseases during 2016-2017, respectively. The attributable numbers for the three cause-specific cardiorespiratory diseases would increase to 362,007 hospital admission cases and 3.68 billion CNY expenses ($US550 million) in the entire urban employee population (299 million) in China during 2016-2017, and the related direct economic loss of absence from work would be 798 million CNY (US$ 119.3 million). Interpretation: Our results support that short-term exposure to ambient PM2.5 pollution could lead to significant health and economic impacts in China. Reducing levels of ambient PM2.5 can avoid substantial health damage and expenditures, and generate appreciable economic benefits from decreasing absence from work. Funding: Natural Science Foundation of China (82073509, 71903010, 71903011), and the National Key Research and Development Program of China (2017YFC0211600, 2017YFC0211601).

Background China set out the vision to establishing a hierarchical medical system, with primary health care (PHC) facilities serving health care users’ first contact. Common ailments were listed, supported by a series of auxiliary policy measures. We aim to assess whether these policies were effective to prompt users’ preference to PHCs within these contexts.Methods Using data from three waves of National Health Service Survey, we examined trends in care users’ first contact with PHC facilities in Jilin, a north eastern province, during 2008–2018. We analysed trends and factors affecting care users’ choices, stratified by type of diseases and urban–rural settings.Results From 38 823 respondents, the survey identified 3302 health care users who sought outpatient care. 54.92% and 82.49% with diseases recommended to PHC, in urban and rural Jilin, respectively, contacted PHC facilities first. While 33.51% and 61.19% with diseases not recommended to PHC did so. Care users’ first contact with PHC facilities followed an inverse U shape during 2008–2018. Such trends were more profound among care users with hypertension and/or diabetes. Neither social health insurance coverage nor contracting with family doctors was associated with care users’ first contacts. Only 1.25% care users had referral experiences. Low perceived quality was the main barrier to choose PHC facilities.Conclusion Health care users sought PHC in a chaotic manner in Jilin. None of the recent efforts seemed effective in prompting their preference to PHC facilities. Without levering quality of PHC, an effective hierarchical medical system could be hardly forged in China.

Background: We evaluated a large-scale pilot program in Shaanxi Province, western rural China, which integrated prenatal screening interventions for congenital abnormalities into routine antenatal programs. Methods: We surveyed 1,597 mothers who gave birth between 2009 and 2016. Adopting the interrupted time-series design, we evaluated the program's impact on awareness, coverage, and cost, by comparing two counties with only supply-side policies, and two counties from the neighbouring province with no policies; and among the two counties with both supply- and demand-side policies and the two counties with only supply-side policies. We adjusted the sampling procedure and women's background characteristics. We conducted subgroup analyses by women's education. Findings: After one year of implementation, the coverage of prenatal foetal aneuploidies and B-ultrasound screening rose by 25.0% and 23.5%. The program's supply-side policies attributed to 17.2 percentage points (90%CI 7.8–26.6%) and 27.3 percentage points (90%CI 16.2–38.5%) in coverage, and contributed to a higher median cost of 796.5RMB (90%CI 595.5–997.5). These significantly affected women with secondary education and above. However, the program's demand-side measures, that is, vouchers, seemed to be effective only in the mountainous regions, which raised awareness, and increased coverage of prenatal foetal aneuploidies screening by 28.6 percentage points (90%CI 13.4–43.8%), while not increasing costs. These significantly affected women with primary education and below. Education-related inequalities widened post-program in counties with only supply-side policies, but no inequalities existed in counties with demand-side policies. Interpretation: Shaanxi's program made a pilot study to other provinces of China to integrate antenatal services. Government subsidies might be more effective in targeting specific geographic locations and people with primary education and lower.

Objectives: We aim to analyze equity in maternal, newborn, and child health (MNCH) interventions in Jilin, a northeastern province of China, 2008–2018.Study design: Cross-sectional study.Methods: We used provincially representative survey data from 2008, 2013, and 2018. We included 18 essential MNCH interventions, analyzed equity, and calculated the composite coverage score. We used logistic and multiple linear regressions to adjust sampling clusters and covariates.Results: Coverage of hospital-based interventions, such as hospital delivery and antenatal B-ultrasound tests, was nearly universal in Jilin province. Cesarean sections persisted at alarmingly high rates (57.6%). Enormous unmet needs and rural–urban inequalities existed for community-based interventions, such as improved drinking water sources (85.4 vs. 97.9%, p < 0.01), improved sanitation facilities (52.5 vs. 94.2%, p < 0.01), four government-funded antenatal care services (55.8 vs. 84.1%, p < 0.01), and at least eight antenatal care sessions (26.8 vs. 46.3%, p < 0.05). Compared to rural–urban inequity, individual-level disparities across income and education were either small in scale or statistically insignificant. The inequity in coverage of maternal and newborn care shrank during 2008–2018.Conclusions: Despite its success in reducing mortality, China's unique obstetrician-led safe motherhood strategy may come at the cost of over-medicalization and health inequity. Jilin province's recent efforts to revitalize primary health care show the potential to make a change. An integrated system that links families, communities, and all levels of health care organizations seems to be the most effective and efficient model to offer continuing MNCH care.

Abstract Background China has made remarkable progress in scaling up essential services during the last six decades, making health care increasingly available in rural areas. This was partly achieved through the building of a three-tier health system in the 1950s, established as a linked network with health service facilities at county, township and village level, to extend services to the whole population. Methods We developed a Theory of Change to chart the policy context, contents and mechanisms that may have facilitated the establishment of the three-tier health service delivery system in rural China. We systematically synthesized the best available evidence on how China achieved universal access to essential services in resource-scarce rural settings, with a particular emphasis on the experiences learned before the 1980s, when the country suffered a particularly acute lack of resources. Results The search identified only three peered-reviewed articles that fit our criteria for scientific rigor. We therefore drew extensively on government policy documents, and triangulated them with other publications and key informant interviews. We found that China’s three-tier health service delivery system was established in response to acute health challenges, including high fertility and mortality rates. Health system resources were extremely low in view of the needs and insufficient to extend access to even basic care. With strong political commitment to rural health and a “health-for-all” policy vision underlying implementation, a three-tier health service delivery model connecting villages, townships and counties was quickly established. We identified several factors that contributed to the success of the three-tier system in China: a realistic health human resource development strategy, use of mass campaigns as a vehicle to increase demand, an innovative financing mechanisms, public-private partnership models in the early stages of scale up, and an integrated approach to service delivery. An implementation process involving gradual adaptation and incorporation of the lessons learnt was also essential. Conclusions China’s 60 year experience in establishing a de-professionalized, community-based, health service delivery model that is economically feasible, institutionally and culturally appropriate mechanism can be useful to other low- and middle-income countries (LMICs) seeking to extend essential services. Lessons can be drawn from both reform content and from its implementation pathway, identifying the political, institutional and contextual factors shaping the three-tier delivery model over time.

Objective To monitor hypertension prevalence, awareness, treatment and control in China two to three years after major reform of the health system. Methods Data from a national survey conducted in 2011–2012 among Chinese people aged 45 years or older – which included detailed anthropometric measurements – were used to estimate the prevalence of hypertension and the percentages of hypertensive individuals who were unaware of, receiving no treatment for, and/or not controlling their hypertension well. Modified Poisson regressions were used to estimate relative risks (RRs). Findings At the time of the survey, nearly 40% of Chinese people aged 45 years or older had a hypertensive disorder. Of the individuals with hypertension, more than 40% were unaware of their condition, about 50% were receiving no medication for it and about 80% were not controlling it well. Compared with the other hypertensive individuals, those who were members of insurance schemes that covered the costs of outpatient care were more likely to be aware of their hypertension (adjusted RR, aRR: 0.737; 95% confidence interval, CI: 0.619–0.878) to be receiving treatment for it (aRR: 0.795; 95% CI: 0.680–0.929) and to be controlling it effectively (aRR: 0.903; 95% CI: 0.817–0.996). Conclusion In China many cases of hypertension are going undetected and untreated, even though the health system appears to deliver effective care to individuals who are aware of their hypertension. A reduction in the costs of outpatient care to patients would probably improve the management of hypertension in China.

Between 1990 and 2006, China reduced its under-five mortality rate (U5MR) from 64.6 to 20.6 per 1000 live births and achieved the fourth United Nation’s Millennium Development Goal nine years ahead of target. This study explores the contribution of social, economic and political determinants, health system and policy determinants, and health programmes and interventions to this success.

OBJECTIVE: To assess trends in hospital births in China during 1988-2008 in an effort to determine if efforts to overcome financial barriers to giving birth in hospital have reduced the access gap between the rich and the poor. METHODS: Cross-sectional data obtained from four National Health Service Surveys were used to determine trends in hospital births during 1988-2008. Crude and adjusted annual rates were calculated by means of Poisson regression and were used to define trends across socioeconomic regions and households in different income quintiles. FINDINGS: In 2008 women throughout China were giving birth in hospital almost universally except in region IV, the most remote rural region, where the percentage of hospital births was only 60.8. Hospital births in this region had increased steadily before 2002, but after that year the upward trend slowed down. During 1988-2001 the average yearly increase had been 21%, but in 2002-2008 it dropped to 10% (P=0.0031). Inequalities between socioeconomic regions were greater than among individual households belonging to different income strata. By 2008 the difference between low- and high-income households in the proportion of hospital births had become very small (96.1% and 87.7% of high- and low-income households, respectively, gave birth in hospital that year). CONCLUSION: Most Chinese women now give birth in hospital, but the poorest rural region is still lagging behind. A more active and comprehensive approach will be needed to increase hospital births in these remote, hard-to-reach populations.

OBJECTIVE: To identify factors driving the rapid increase in caesarean section in China between 1988 and 2008. METHODS: Data from four national cross-sectional surveys (1993, 1998, 2003 and 2008) and modified Poisson regression were used to determine whether changes in household income, access to health insurance or women's education accounted for the rise in caesarean sections in urban and rural areas. FINDINGS: In 2008, 64.1% of urban women and 11.3% of women in the poorest rural region reported giving birth by caesarean section. A fast rise was occurring in all socioeconomic groups. Between 1993 and 2008, the risk of caesarean section had increased more than threefold in urban areas (relative risk, RR: 3.63; 95% confidence interval, CI: 2.61-5.04) and more than 15-fold in rural areas (RR: 15.46; 95% CI: 10.46-22.86). After adjustment for improvements in income, education and access to health insurance over the study period, the RR dropped minimally in urban areas (RR: 3.07; 95% CI: 2.32-4.07), which suggests that these factors do not explain the rise; in rural areas, the adjusted RR dropped to 7.18 (95% CI: 4.82-10.69), which shows that socioeconomic change is only partly responsible for the rise. Socioeconomic region of residence was a more important driver of the caesarean section rate than individual socioeconomic status. CONCLUSION: The large variation in caesarean section rate by socioeconomic region - independent of individual income, health insurance or education - suggests that structural factors related to service supply have influenced the increasing rate more than a woman's ability to pay.