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In this paper, we aim to establish a mathematical model to design a maximizing social welfare intervention mechanism of healthcare service goods in China. The intervention mechanism is helpful to facilitate the adoption of the healthcare service goods. We consider a research problem that regulates the supply chain system for healthcare service goods by an intervention mechanism, and two intervention strategies composed of demand-growth strategy and subsidy strategy are used to the combination of intervention mechanism. Then this paper presents a new method based on fuzzy set and bilevel programming to design the intervention mechanism. To demonstrate the effectiveness of the proposed model, we conduct a case study for Wudang personalized health package and verify our model by the specific result analysis, the result indicates that our joint intervention mechanism is helpful to achieve the target and increase social welfare. [ABSTRACT FROM AUTHOR]

Much of the literature on recovery focuses on the economy, the physical environment and infrastructure at a macro level, which may ignore the personal experiences of affected individuals during recovery. This paper combines internal factors at a micro level and external factors at a macro level to model for understanding perception of recovery (PoR). This study focuses on areas devastated by the 2008 Wenchuan earthquake in China. With respect to three recovery-related aspects (house recovery condition (HRC), family recovery power (FRP) and reconstruction investment (RI)), structural equation modeling (SEM) was applied. It was found that the three aspects (FRP, HRC and RI) effectively explain how earthquake affected households perceive recovery. Internal factors associated with FRP contributed the most to favourable PoR, followed by external factors associated with HRC. Findings identified that for PoR the importance of active recovery within households outweighed an advantageous house recovery condition. At the same time, households trapped in unfavourable external conditions would invest more in housing recovery, which result in wealth accumulation and improved quality of life leading to a high level of PoR. In addition, schooling in households showed a negative effect on improving PoR. This research contributes to current debates around post-disaster permanent housing policy. It is implied that a one-size-fits-all policy in disaster recovery may not be effective and more specific assistance should be provided to those people in need. [ABSTRACT FROM AUTHOR]

This paper aimed to investigate the role of parental education in child disability in China. We used nationally representative data from China’s National Sample Survey on Disability, iterated twice, in 1987 and 2006, with data of 764,718 children aged 0–14 years. Logit models were used for statistical analysis. Results showed that the prevalence of child disability was significantly associated with each parent’s education. Maternal education was more important than paternal education in child disability in both surveys. The analysis of marginal effect indicated a one-year increase in maternal and paternal schooling led to an average decrease of 0.121% and 0.091% in the probability of child disability in 1987, and 19 years later, these figures had dwindled to 0.091% and 0.072%, respectively. [ABSTRACT FROM AUTHOR]

Introduction: Inconsistency in the time trade-off (TTO) task in EQ-5D-5L occurs when a respondent gives a higher value to a logically worse health state, the occurrence of inconsistency compromises the quality of the data. It is not yet clear which factors are associated with individual level inconsistency. Relating inconsistency to the characteristics of the respondent, interviewer, and the interview process could be helpful in understanding the causes of inconsistency. The objective of this paper is to discover the factors associated with individual level inconsistencies. Methods: Twenty interviewers interviewed 1,296 respondents and each respondent valued 10 health states using the EQ-VT platform in 5 cities in China. At the respondent level, inconsistency was identified in terms of severity and quantity and related to the respondent’s background characteristics, the time and iterations spent on the wheelchair example task, and the formal TTO tasks, using multilevel multinomial regression analyses. Interviewers’ impact on inconsistencies was analyzed using single level multinomial regression analyses. Results: In the full dataset, slight inconsistency was more related to the interview process (Time spent on TTO task: RRR = 1.246 with 95%CI: 1.076,1.441; time spent on Wheelchair example: RRR = 0.815 with 95%CI:0.699,0.952) while severe inconsistency was more related to respondent’s gender (Gender: RRR = 2.347 with 95%CI:1.429,3.855). One Interviewer (Interviewer 7: RRR = 7.335 with 95%CI:1.908,28.195) and interviewer’s experience (Sequence: RRR = 0.511 with 95%CI:0.385,0.678) in general showed strong influence over inconsistency in the TTO task. Conclusion: In conclusion, logical inconsistency in the valuation of EQ-5D-5L health states is associated not only with respondents’ characteristics but also with interviewers’ performance and the interview process. The role of interviewers and the importance of interviewer training may be more crucial than hitherto believed. This finding could be generalizable to other interviewer-administered health-state valuation study. [ABSTRACT FROM AUTHOR]

Background: Around the world, regulatory bodies have taken the lead in determining the competencies required to become a physician. As a first step in addressing this project, it was decided to develop a set of core competencies that were unique to China and that might serve as a basis for medical education. The purpose of this paper was to construct a competency model for clinical physicians in China. Methods: Data was collected using a cross-sectional survey of 6247 clinicians from seven administrative regions (31 provinces, autonomous regions and municipalities directly under the central government) in China. The total sample was randomly divided into two sub-samples, an initial sample (Sample 1) and a replication sample (Sample 2). Independent exploratory factor analysis was conducted in each sample and the results were compared to determine the stability. After that the confirmatory factor analysis was used to ascertain the competency model for physicians. The reliability, convergent and discriminant validity of competency-based instrument were also examined. Results: 76 items with 8 dimensions were identified, accounting for 68.41% of the construct’s total variance in the initial sample and 67.47% in the replication sample. For the two samples, the overall scale reliability (Cronbach’s alpha) was both 0.985 with dimensions from 0.905 to 0.954 for the initial sample and from 0.902 to 0.955 for the replication sample after deleting the items. In confirmatory factor analysis, the result showed that all items had acceptable goodness of fit index. RMSEA and SRMR were less than 0.08 (RMSEA = 0.046, SRMR = 0.040), while GFI, NFI, IFI, and CFI were higher than 0.9 (GFI = 0.905, NFI = 0.903, IFI = 0.909, CFI = 0.909), leading to acceptable construct validity. All construct reliability values of the factors were higher than 0.70, and all average variance extracted values exceeded 0.50. Thus, we considered the reliability and validity of the 8 dimensions were acceptable. Conclusions: The instrument was shown to be both valid and reliable for measuring clinical physicians’ competency in China. The results of the competency-based instrument can be used by ministry of health and administrators of hospitals to assess physicians’ competencies, encourage and guide them to modify their behaviors according to the evaluation criteria, and also cultivate physicians with strong clinical practice, innovation and independent scientific research ability. Through these measurements and understandings, the overall level of clinical physicians will be increased in China. [ABSTRACT FROM AUTHOR]

Background: In this paper, we report findings regarding the prevalence of expressed distress and depressive conditions among women living in a rural region of Sichuan Province. As well, we know of no data among women in rural China that examine whether “depression,” as categorically defined in classifications such as the DSM, adequately captures the expressed distress and symptomatic complaints of women in rural China. Methods: A multistage sampling method was employed to recruit the target population. The Center for Epidemiologic Studies Depression Scale (CES-D) was used to measure distress symptoms, and MINI International Neuropsychiatric Interview (MINI) was employed to determine the prevalence of diagnosable depression and other disorders. Results: Among 1898 rural women, 12.4% (236) scored ≥16 on the CES-D, indicative of distress, and a subset of 7.7% (146) had scores ≥21, highly suggestive of a clinically significant disorder. We found that 49.8% women with ≥16 CES-D score were identified as showing features consistent with a current major depressive episode (MDE) vs. 1.9% in a sample of randomly selected women with <16 CES-D score. Among respondents, 30 of 84 (35.7%) scoring 16–20 and 83 of 143 (58.0%) scoring ≥21 reported symptoms consistent with MDE. 25.1% of women with a positive CES-D score did not describe symptoms consistent with any DSM-IV disorder. Conclusions: We found a higher portion of women reporting significant distress than previously described. Among them, there was a clear gradient, such that 41.7% of women with moderate distress did not have a psychiatric diagnosis, and even among those with more severe symptoms, 15.4% did not manifest a DSM-specific psychiatric condition. [ABSTRACT FROM AUTHOR]

While internal migration is widely occurring in countries across the world and older people are more likely to be left behind by family members who out-migrated to other locations, little attention has been paid to the cognitive health of those people who have been left behind (PLB). Understanding how these demographic patterns relate to older persons’ cognitive health may inform efforts to reduce the disease burden due to cognitive decline. Data came from the China Health and Nutrition Survey in 1997, 2000 and 2004. Participants aged 55 to 93 who participated in a cognitive function screening test (score range: 0–31) in two or more waves and provided information on family members’ migration (n = 1,267) were included in the analysis. A mixed linear model was used to investigate the association between being left behind by any members who had not resided in the household for at least 6 months at baseline and cognitive function. Approximately 10% of the participants had been left behind by family members who migrated out of their communities. A significant interaction was observed in relation to cognitive function between being left behind and the number of years from the first test. Specifically, there was a less steep decline in cognitive function of PLB compared to people not left behind. This longitudinal study showed that PLB tended to have a higher cognitive function compared to those not left behind due to their relatively stable transition in cognitive function during the study period. [ABSTRACT FROM AUTHOR]

Background: Migration of physicians has been a cause for global concern. In China, reforms of the higher education and healthcare systems have led to a shortage of postgraduate training positions relative to the number of medical graduates. Medical graduates opt for non-clinical roles or move abroad to pursue further training and practice opportunities. The impact of this physician migration is not known. This study quantifies where Chinese migrant physicians to the U.S. were educated, where they went to practice, and how these trends have changed over time. Methods: We combined data on physician characteristics from the 2008 and 2017 American Medical Association Physician Masterfiles with demographic information from the Educational Commission for Foreign Medical Graduates. Using a repeated cross-sectional approach, we reviewed the available data, including citizenship at entry to medical school, medical school attended, practice specialty, and practice location. Results: The number of Chinese-educated physicians (CEPs) to the United States (US) has increased over the past 10 years, from 3,878 in 2008 to 5,355 in 2017 (+38.1%). The majority held Chinese citizenship at entry to medical school (98.4% vs 97.1%) with the remainder being citizens of other East Asian nations. Of the Chinese citizens identified in 2008, 913 (19.3%) attended medical school outside of China; in 2017, 376 (6.7%) attended medical school outside of China, representing a decrease of 58.8%. Overall, in 2017, four Chinese medical schools provided 32.1% of all Chinese-educated physicians in the US. Over 50% of the CEPs were practicing in Internal Medicine, Anatomic/ Clinical Pathology, Anesthesiology, Family Medicine or Neurology. Compared with all IMGs, CEPs are more likely to be Anatomic/ Clinical Pathologists and Anesthesiologists. CEPs were concentrated in several states, including New York, California and Massachusetts. In 2017, a lower proportion of CEPs in the US healthcare workforce were in residency training, compared to 2008 (13.2% vs 22.8%). Conclusions: Unlike trends from some other South Asian countries, the number of CEPs in the US has increased over the past 10 years. Migration trends may vary depending on citizenship and country of medical school training. The majority of Chinese-educated graduates come to the US from relatively few medical schools. Fewer CEPs currently in residency training might indicate lower success rates in securing GME training in the US. [ABSTRACT FROM AUTHOR]

Objective: Medical students in China are currently facing a dilemma of whether to clarify their identity as students to patients. Further investigation is needed to support policy-making. The aim was to identify factors influencing medical students’ decision on whether or not to clarify their identity to patients and to examine the effects of their decision. Methods: The study was a cross-sectional nationwide multicenter survey consisting of 947 medical students. A self-designed questionnaire was composed of 19 structured questions investigating the present situation and participants’ perception of the ethical dilemma surrounding medical student identity. The questionnaires were distributed randomly in teaching hospitals affiliated with 13 medical schools across China from June 2015 to January 2016. Results: A total of 947 valid questionnaires were retrieved with a valid response rate of 83.7%. Most medical students (71.4%) tended to be ambiguous about their student identity in front of patients. The frequency of encountering distrust and patients’ or patient relatives’ refusal to allow students to perform procedures was significantly lower for students who explicitly stated their identity than for those who were ambiguous about their identity (p<0.001). Less experience in clinical rotations (<0.5 y/0.5–1 y, OR 2.7, 95% CI 1.7–4.3; <0.5 y/>1 y, OR 3.6, 95% CI 2.0–6.5), preceptors’ straightforward introduction of the students (OR 8.7, 95% CI 5.4–13.8) and students’ acknowledgment of patients’ right to know (OR 2.3, 95% CI 1.2–4.5) were related to students’ clear self-introduction to patients. Conclusion: It is beneficial for medical students to clearly explain their identity to patients in order to decrease patient distrust and prevent the refusal to have certain appropriate procedures performed. Several methods, including emphasizing the role of mentors, developing curriculum for medical students, and creating clear regulations and guidelines for revealing the identity of medical students on the healthcare team can help address and ideally resolve this ethical dilemma of identity disclosure. [ABSTRACT FROM AUTHOR]

Background: Postpartum Family Visits (PFVs) have been advocated as a way to improve health outcomes for puerperal women and their newborns. This study aimed to identify individual factors associated with the utilization of PFVs in rural Jiangsu Province, China. Methods: We employed responses of the household survey in Jiangsu province, part of the National Health Service Survey (NHSS), a nationally representative survey in China. The data analysis framework was designed based on Andersen’s behavioral model. The outcome variables included nonuse and deficient use of PFVs, and the explanatory variables were organized into three hierarchical levels: predisposing, enabling and need factors. Univariate analysis and multivariate logistic regression analysis were conducted to examine the impact of the three hierarchical levels on PFVs utilization. Results: A total of 884 rural women who had a childbearing history in the prior five years answered PFVs questions. About 23.4% of them had never received any PFVs, and 40.4% received <3 visits. In the results of multivariate logistic regression, educational level (OR = 0.43, 95% CI: 0.24–0.77), income (OR = 0.62, 95% CI: 0.43–0.88), the distance from the nearest hospital (OR = 1.49, 95% CI: 1.07–2.07) and parity (OR = 2.17, 95% CI: 1.54–3.05) had significant relationship with nonuse. Factors significantly associated with deficient use of PFVs included employment (OR = 0.62, 95% CI: 0.39–0.98), the distance from the nearest hospital (OR = 1.73, 95% CI: 1.26–2.36), level of delivery institution (OR = 1.57, 95% CI: 1.14–2.17), and parity (OR = 1.45, 95% CI: 1.03–2.05). Conclusion: The study found lower Social Economic Status (SES), long distance with primary health institutions, and the increased need for services stemming from multi-parity reduced the likelihood of nonuse or deficient use of PFVs in rural areas. Multiparous, low SES women and those living far away from primary health institutions should be paid more attention to assure the coverage of postpartum care. [ABSTRACT FROM AUTHOR]

Objective: The School-based Education Program to Reduce Salt Intake in Children and Their Families study was a cluster randomized control trial among grade five students in 28 primary schools and their families in Changzhi, China. It achieved a significant effect in lowering systolic blood pressure (SBP) in all family adults by 2.3 mmHg and in elderlies (aged > = 60 years) by 9.5 mmHg. The aim of this study was to assess the cost-effectiveness of this salt reduction program. Methods: Costs of the intervention were assessed using an ingredients approach to identify resource use. A trial-based incremental cost-effectiveness ratio (ICER) was estimated based on the observed effectiveness in lowering SBP. A Markov model was used to estimate the long-term cost-effectiveness of the intervention, and then based on population data, extrapolated to a scenario where the program is scaled up nationwide. Findings were presented in terms of an incremental cost per quality-adjusted life year (QALY). The perspective was that of the health sector. Results: The intervention cost Int$19.04 per family and yielded an ICER of Int$2.74 (90% CI: 1.17–12.30) per mmHg reduction of SBP in all participants (combining children and adult participants together) compared with control group. If scaled up nationwide for 10 years and assumed deterioration in treatment effect of 50% over this period, it would reach 165 million families and estimated to avert 42,720 acute myocardial infarction deaths and 107,512 stroke deaths in China. This would represent a gain of 635,816 QALYs over 10-year time frame, translating into Int$1,358 per QALY gained. Conclusion: Based on WHO-CHOICE criteria, our analysis demonstrated that the proposed salt reduction strategy is highly cost-effective, and if scaled up nationwide, the benefits could be substantial. Trial registration: ClinicalTrials.gov [ABSTRACT FROM AUTHOR]

Background: Currently, there are many studies focusing on the influencing factors of the elderly people’s living arrangements or health status, but little is known about the relationship between living arrangements or health status and long-term care models for the old-age, especially the joint effects. Objective: We aimed to assess the effects of health status and living arrangements on long-term care models (LTCM) among the elderly of Xiamen, China, especially their cumulative joint effects. Methods: A total of 14,373 participants aged ≥ 60 years by multistage sampling in Xiamen of China were enrolled. Multinomial logistic regression was used to estimate the Odds ratios (ORs) regressing LTCM on health status and living arrangements using the Anderson model as theoretical framework. Results: Totally, 14,292 valid questionnaires were obtained, of which 86.37% selected home care. With the increase of disability degree, older people are more likely to choose institutional care, compared to living alone (ORs = 1.75, 2.06, 4.00, 4.01 for the “relatively independent’, “mild disability’, “moderate disability’, and “total disability’, respectively, in comparison with “completely independent’). The elderly living with children and other family members preferred to choose home care. (ORs = 0.50, 0.39, 0.40, and 0.43 for the “living with children’, “living with spouse’, “living with children and spouse’, and “living with others’, respectively, in comparison with “alone’). Additionally, residence, number of children, education level, and feelings of loneliness were the determinants of the choice of social pension. Conclusion: A multitude of older people are trended to choose home care in Xiamen of China. There was an interaction and joint effect between the degree of disability and the living arrangements on LTCM. Therefore, policymakers should pay close attention to care for those living alone, childless, and disabled elders to meet their care needs, especially in home care. In addition, the social construction of facilities for elders in rural areas should be strengthened. [ABSTRACT FROM AUTHOR]

Purpose of the study: Populations in Latin America, Asia and sub-Saharan Africa are rapidly ageing. The extent to which traditional systems of family support and security can manage the care of increased numbers of older people with chronic health problems is unclear. Our aim was to explore the social and economic effects of caring for an older dependent person, including insight into pathways to economic vulnerability. Design & methods: We carried out a series of household case studies across urban and rural sites in Peru, Mexico, China and Nigeria (n = 24), as part of a cross-sectional study, nested within the 10/66 Dementia Research Group cohort. Case studies consisted of in-depth narrative style interviews (n = 60) with multiple family members, including the older dependent person. Results: Governments were largely uninvolved in the care and support of older dependent people, leaving families to negotiate a ‘journey without maps’. Women were de facto caregivers but the traditional role of female relative as caregiver was beginning to be contested. Household composition was flexible and responsive to changing needs of multiple generations but family finances were stretched. Implications: Governments are lagging behind sociodemographic and social change. There is an urgent need for policy frameworks to support and supplement inputs from families. These should include community-based and residential care services, disability benefits and carers allowances. Further enhancement of health insurance schemes and scale-up of social pensions are an important component of bolstering the security of dependent older people and supporting their continued social and economic participation. [ABSTRACT FROM AUTHOR]

Objective: Living arrangements are important to the elderly. However, it is common for elderly parents in urban China to not have a living situation that they consider ideal. An understanding of their preferences assists us in responding to the needs of the elderly as well as in anticipating future long-term care demands. The aim of this study is to provide a clear understanding of preferences for future living arrangements and their associated factors among middle-aged and older people in urban China. Methods: Data were extracted from the CHARLS 2011–2012 national baseline survey of middle-aged and elderly people. In the 2011 wave of the CHARLS, a total of 17,708 individual participants (10,069 main respondents and 7,638 spouses) were interviewed; 2509 of the main respondents lived in urban areas. In this group, 41 people who were younger than 45 years old and 162 who had missing data in the variable “living arrangement preference” were excluded. Additionally, 42 people were excluded because they chose “other” for the variable “living arrangement preference” (which was a choice with no specific answer). Finally, a total of 2264 participants were included in our study. Results: The most popular preference for future living arrangements was living close to their children in the same community/neighborhoods, followed by living with adult children. The degree of community handicapped access, number of surviving children, age, marital status, access to community-based elderly care centers and number of years lived in the same community were significantly associated with the preferences for future living arrangements among the respondents. Conclusion: There is a trend towards preference for living near adult children in urban China. Additionally, age has a positive effect on preference for living close to their children. Considerations should be made in housing design and urban community development plans to fulfill older adults’ expectations. In addition, increasing the accessibility of public facilities in the residential area was important to the elderly, especially for those who preferred living in proximity to their children rather than co-residing with their children. We found that more surviving children were associated with a lower likelihood of choosing “institutionalization”, and it positively contributed to preference for intergenerational living arrangements in our study. As expected, compared with their married counterparts, people who were separated/divorced/widowed preferred living with adult children rather than living independently. A relatively shorter length of residence in the same community was an important indicator of preference for independent living; this finding might require further research. [ABSTRACT FROM AUTHOR]

Health literacy (HL) has become an important public health issue and is receiving growing attention. However, the HL levels of military college students in China have never been analyzed. This study aimed to investigate the HL and related associate factors in military college students in Chongqing, China. Data was obtained with the “Chinese Citizen Health Literacy Questionnaire (2012 edition)” from 3183 military college students aged 16–28 years at Chongqing in December 2015. A total score of ≥80 points determined adequate HL, and HL level was defined as the proportion of students who had adequate HL out of the total number of participants. Multiple logistic regression analysis with a stepwise forward likelihood ratio (LR) method was used to determine the effects of sociodemographic characteristics, health-related behaviors, and family-related factors on HL level. The mean score of HL was 68.56, and the HL level of military college students was 21.05%; the overall knowledge rate was 71.33%. The independent factors that were associated with HL level were years in college, educational system, time playing online games, annual household income and father's education level. Senior (odds ratio [OR] = 1.229, 95% confidence interval [CI] 1.018∼1.484), undergraduate (OR = 1.509, 95% CI 1.151∼1.978), time played games more than 5 hours each week (OR = 0.638, 95% CI 0.486∼0.837), annual household incomes more than 50,000 yuan (OR = 1.231, 95% CI 1.027∼1.476) and father's education level (high school: OR = 2.327, 95% CI 1.186∼4.565; university: OR = 2.450, 95% CI 1.244∼4.825), were independently associated with higher HL level. HL levels of military college students in Chongqing need to be improved across the board. Our data suggests that special emphasis should be placed on students in junior and those in the specialist educational system. School departments may also benefit from incorporating health literacy into their curricula and helping students manage the time they spend playing online games. [ABSTRACT FROM AUTHOR]

Background: Over 90% of outpatient care in China was delivered at public hospitals, making outpatient experience in this setting an important aspect of quality of care. Objective: To assess outpatient experience with different aspects of physician services at China’s public hospitals and its association with overcrowding of the hospital outpatient departments. Research design: Retrospective analysis of a large survey of outpatient experience in Shanghai, China. We tested the hypotheses that patient experience was poorer with physician-patient communication, education, and shared decision-making and where and when there was greater overcrowding of the hospital outpatient departments. Ordered logistic models were estimated separately for general and specialty hospitals. Subjects: 7,147 outpatients at 40 public hospitals in Shanghai, China, in 2014. Measures: Patient experience with physician services were self-reported based on 12 questions as part of a validated instrument. Indicators of overcrowding included time of visit (morning vs. afternoon, Monday vs. rest of the week) and hospital outpatient volume in the first half of 2014. Results: Overall, patients reported very favorable experience with physician services. Two out of the 12 questions pertaining to both communication and shared decision-making consistently received lower ratings. Hospitals whose outpatient volumes were in the top two quartiles received lower patient ratings, but the relationship achieved statistical significance among specialty hospitals only. Conclusions: Inadequate physician-patient communication and shared decision-making and hospital overcrowding compromise outpatient experience with physician services at Chinese public hospitals. Effective diversion of patients with chronic and less complex conditions to community health centers will be critical to alleviate the extreme workloads at hospitals with high patient volumes and, in turn, improve patient experience. [ABSTRACT FROM AUTHOR]

This study explored catastrophic health expenditure in China, due to out-of-pocket payments for dental care, and its associated individual- and contextual-level factors. We pooled data from 31,566 adults who participated in the third National Oral Health Survey with province-level data from different sources. We defined catastrophic dental health expenditure (CDHE) as payments for dental services and/or medication for dental problems during the last year that exceeded the 10% and 20% of the household income. The association of individual and contextual factors with catastrophic dental health expenditure was evaluated using two-level logistic regression models with individuals nested within provinces. Socioeconomic position (education and household income), household size and dental status (pain in teeth or mouth and number of teeth) were the individual-level factors associated with CDHE among the full sample of participants; and, also, among those who used dental services in the past year. Greater gross domestic product per capita was the only contextual factor associated with CDHE, and only at the lower income threshold. This study shows that out-of-pocket expenses for dental services may put a considerable, and unnecessary, burden on households’ finances. Our findings also help characterise those households more likely to face catastrophic expenditure on health if they have to pay for dental services. [ABSTRACT FROM AUTHOR]

Background: China is reforming and restructuring its health insurance system to achieve the goal of universal coverage. This study aims to understand the determinants of public, private and multiple insurance coverage among people of retirement-age in China. Methods: We used data from the China Health and Retirement Longitudinal Survey 2011 and 2013, a nationally representative survey of Chinese people aged 45 and over. Multinomial logit regression was performed to identify the determinants of public, private and multiple health insurance coverage. We also conducted logit regression to examine the association between public insurance coverage and demand for private insurance. Results: In 2013, 94.5% of this population had at least one type of public insurance, and 12.2% purchased private insurance. In general, we found that rural residents were less likely to be uninsured (Relative Risk Ratio (RRR) = 0.40, 95% Confidence Interval (CI): 0.34–0.47) and were less likely to buy private insurance (RRR = 0.22, 95% CI: 0.16–0.31). But rural-to-urban migrants were more likely to be uninsured (RRR = 1.39, 95% CI: 1.24–1.57). Public health insurance coverage may crowd out private insurance market (Odds Ratio = 0.55, 95% CI: 0.48–0.63), particularly among enrollees of Urban Resident Basic Medical Insurance. There exists a huge socioeconomic disparity in both public and private insurance coverage. Conclusion: The migrants, the poor and the vulnerable remained in the edge of the system. The growing private insurance market did not provide sufficient financial protection and did not cover the people with the greatest need. To achieve universal coverage and reduce socioeconomic disparity, China should integrate the urban and rural public insurance schemes across regions and remove the barriers for the middle-income and low-income to access private insurance. [ABSTRACT FROM AUTHOR]

Purpose: Shenzhen is the first pilot city in China implementing the gatekeeper policy, with community health service (CHS) centers as the gatekeepers. We aim to investigate patient satisfaction with this policy and its influencing factors in Shenzhen. Methods: 3,848 patients visiting eight CHS centers in Shenzhen of China between May 1 and July 28, 2013 were recruited. We interviewed them using a structured questionnaire to investigate their satisfaction with the gatekeeper policy of CHS. Multivariable logistic regression models were used to identify influencing factors. Results: Of the respondents, 28.17%, 47.27% and 24.56% were satisfied with, neutral to, and not satisfied with the gatekeeper policy respectively. Patient satisfaction with this policy was found to be associated with education level, familiarity with the policy, referral experience, satisfaction with convenience of seeing a doctor, satisfaction with waiting time, satisfaction with medical facility, satisfaction with general medical practitioners’ professional skill, and proportion of expense reimbursed. Conclusions: Our investigation shows that patient satisfaction with the gatekeeper policy was low. To improve patient satisfaction, efforts should be made to increase the convenience of seeing a doctor in community, shorten waiting time, improve general medical practitioners’ professional skill, and increase proportion of expense reimbursement. [ABSTRACT FROM AUTHOR]

Migrants usually exhibit similar or better health outcomes than native-born populations despite facing socioeconomic disadvantages and barriers to healthcare use; this is known as the “migrant paradox.” The migrant paradox among children is highly complex. This study explores whether the migrant paradox exists in the health of internal migrant children in China and the role of schools in reducing children’s health disparities, using a multi-stage stratified cluster sampling method. Participants were 1,641 student and parent pairs from Grades 4, 5, and 6 of eight primary schools in Beijing. The following school types were included: state schools with migrant children comprising over 70% of total children (SMS), private schools with migrant children comprising over 70% (PMS), and state schools with permanent resident children comprising over 70% (SRS). Children were divided into Groups A, B, C or D by the type of school they attended (A and B were drawn from SRSs, C was from SMSs, and D was from PMSs) and whether they were in the migrant population (B, C, and D were, but A was not). Related information was collected through medical examination and questionnaires completed by parents and children. Prevalence of caries, overweight and obesity, poor vision, and self-reported incidence of colds and diarrhea in the previous month were explored as health outcomes. The results partially demonstrated the existence of the migrant paradox and verified the role of schools in lowering health disparities among children; there are theoretical and practical implications for improving the health of migrant children. [ABSTRACT FROM AUTHOR]

Objective: The purpose of this study is to evaluate the prevalence, awareness, treatment and glycemic control of diabetes mellitus (DM) in a Chinese population. The findings from this study are expected to offer scientific evidence to better prevent and control the growing number of reported and untreated cases. Methods: A cross-sectional survey was conducted in Jiangsu, China. We recruited permanent residents over 18 years of age from eight towns in Jintan (JT) and six towns in Yangzhong (YZ) using a three-stage stratified cluster sampling method. The rates of DM prevalence, awareness, treatment and control as well as their related factors were analyzed. Results: A total number of 15404 people were entered into the analysis. The DM prevalence, awareness, treatment and control rates were 7.31%, 58.35%, 51.87% and 14.12%, respectively. Multivariable logistic regression analysis showed that being female was positively related to prevalence (OR = 1.21, 95% CI: 1.07–1.37), awareness (OR = 1.52, 95% CI: 1.19–1.93), treatment (OR = 1.48, 95% CI: 1.17–1.88) and control (OR = 1.87, 95% CI: 1.30–2.67) of DM. Having a family history of diabetes was significantly correlated with DM risk (OR = 1.86, 95% CI: 1.37–2.54) and increased awareness (OR = 3.12, 95% CI: 2.19–4.47), treatment (OR = 3.47, 95% CI: 2.45–4.90) and control (OR = 1.81, 95% CI: 1.22–2.68) of DM. Former smoking status (OR = 1.82, 95% CI: 1.23–2.71), overweight (OR = 2.11, 95% CI: 1.72–2.60) and obesity (OR = 3.46, 95% CI: 2.67–4.50) were related to the risk of DM. Additionally, we found current drinking status to be positively correlated with DM risk (OR = 1.30, 95% CI: 1.01–1.66) and negatively correlated with DM awareness (OR = 0.41, 95% CI: 0.29–0.59) and treatment (OR = 0.41, 95% CI: 0.29–0.59). Our study highlights the high prevalence and inadequate awareness, treatment and control of DM in the Chinese population. Conclusions: Management and prevention of DM-related complications should be considered an essential strategy by governments and society. This study assessed the reasons why DM has been increasing and established the first step in determining where to start regarding preventative methods. [ABSTRACT FROM AUTHOR]

Background: Relatively few articles have focused on exploring factors influencing soldiers’ overall satisfaction and differences between inpatients’ and outpatients’ satisfaction, particularly in the Chinese army. Elucidating factors influencing military inpatient and outpatient care separately and analyzing their differences may provide more information for the healthsystem. Methods: The Revised China National Health Service Survey questionnaire was used in the survey. The questionnaire included 5 sections and 32 items concerning demographic, inpatient, and outpatient characteristics and perception variables for both inpatients and outpatients. Bivariate and multivariate techniques were used to reveal relationships between satisfaction and the variables assessed. Results: Outpatients’ and inpatients’ overall satisfaction rates were 19.0% and 18.5%, respectively. The strongest determinant of outpatients’ satisfaction was satisfaction with doctor’s communication regarding therapeutic regimen followed by length of military service, level of trust in medical staff, and disease severity. Determinants of inpatients’ satisfactionincludedstaff categories, satisfaction with environment, and satisfaction with medical quality. Conclusion: The factors influencing military outpatients’ satisfaction differed from those of inpatients. Exploring the causes of satisfaction and dissatisfaction with military health institutions is important in their fulfillment of their responsibility to maintain soldiers’ health. [ABSTRACT FROM AUTHOR]

Background: China has rapidly expanded health insurance coverage over the past decade but its impact on hypertension control is not well known. We analyzed factors associated with hypertension and the impact of health insurance on the management of hypertension in China from 1991 to 2009. Methods and Findings: We used individual-level data from the China Health and Nutrition Survey (CHNS) for blood pressure, BMI, and other socio-economic variables. We employed multi-level logistic regression models to estimate the factors associated with prevalence and management of hypertension. We also estimated the effects of health insurance on management of hypertension using propensity score matching. We found that prevalence of hypertension increased from 23.8% (95% CI: 22.5–25.1%) in 1991 to 31.5% (28.5–34.7%) in 2009. The proportion of hypertensive patients aware of their condition increased from 31.7% (28.7–34.9%) to 51.1% (45.1–57.0%). The proportion of diagnosed hypertensive patients in treatment increased by 35.5% in the 19 years, while the proportion of those in treatment with controlled blood pressure remained low. Among diagnosed hypertensives, health insurance increased the probability of receiving treatment by 28.7% (95% CI: 10.6–46.7%) compared to propensity-matched individuals not covered by health insurance. Conclusions: Hypertension continues to be a major health threat in China and effective control has not improved over time despite large improvements in awareness and treatment access. This suggests problems in treatment quality, medication adherence and patient understanding of the condition. Improvements in hypertension management, quality of medical care for those at high risk, and better health insurance packages are needed. [ABSTRACT FROM AUTHOR]

This study was to identify current A1c understanding status among Chinese patients with type 2 diabetes, assess if knowledge of A1c affects their diabetes self-management and their glycemic control and recognize the factors influencing knowledge of A1c among patients with type 2 diabetes. A multi-center, cross-sectional survey was conducted between April and July 2010 in 50 medical centers in the Mainland China. Participants were recruited from inpatients and outpatients who were admitted to or visited those medical centers. The survey included core questions about their demographic characteristics, diabetes self-management behavior, and A1c knowledge. Overall, of 5957 patients, the percentage of patients with good understanding was 25.3%. In the multivariable logistic regression model, the variables related to the knowledge of A1c status are presented. We discovered that patients with longer diabetes duration (OR = 1.05; 95%CI = 1.04–1.06) and having received diabetes education (OR = 1.80; 95%CI = 1.49–2.17) were overrepresented in the good understanding of A1c group. In addition, compared to no education level, higher education level was statistically associated with good understanding of A1c (P<0.001). The percentage of patients with good understanding varied from region to region (P<0.001), with Eastern being highest (OR = 1.54; 95%CI = 1.32–1.80), followed by Central (OR = 1.25; 95%CI = 1.02–1.53), when referring to Western. Only a minority of patients with type 2 diabetes in China understood their A1c value. The patients who had a good understanding of their A1c demonstrated significantly better diabetes self-management behavior and had lower A1c levels than those who did not. [ABSTRACT FROM AUTHOR]

Objectives: This study focuses on East Asian countries and investigates the difference in the marriage premium on the health-marriage protection effect (MPE) between younger and older generations and the intra-couple education concordance effect (ECE) on the health of married individuals. This study used inter-country comparative data from China, Japan, and Korea. Methods: This study focused on individuals (n = 7,938) in China, Japan, and Korea who were sampled from the 2010 East Asian Social Survey. To investigate MPE and ECE, four health indicators were utilized: a physical and mental components summary (PCS and MCS), self-rated health status (Dself), and happiness level (Dhappy). Ordinary least squares regression was conducted by country- and gender-specific subsamples. Results: We found that the MPE on PCS, MCS, and Dself was more significant for the older generation than for the younger generation in both China and Japan, whereas the results were inconclusive in Korea. With regard to the ECE on happiness (Dhappy), for both men and women, couples tend to be happier when both the husband and the wife are well educated (“higher balanced marriage”) compared to couples with a lower level of educational achievement (“lower balanced marriage”). Significant benefits from a “higher balanced marriage” on MCS and Dself were observed for women only. In contrast, no statistically significant differences in health status were observed between “higher balanced marriage” couples and couples with different levels of educational achievements (“upward marriage” or “downward marriage”). Conclusions: This study found that (1) the MPE was more significant for the older generation, and (2) the health gap, particularly the happiness gap, between higher- and lower-balanced married couples was significant. The inter-country comparative findings are useful to explain how the role of marriage (and therefore of family) on health has been diluted due to the progress of industrialization and modernization. [ABSTRACT FROM AUTHOR]

Internal migrants are the individuals who migrate between regions in one country. The number of internal migrants were estimated at 245 million in China in 2013. Results were inconsistent in the literature about the relationship between their health statuses and social integration. The main difference exists on how to measure the social integration and whether health statuses of internal migrants improve with years of residence. To complement the existing literature, this study measured social integration more comprehensively and estimated the internal migrants’ health statuses with varying years of residence, and explored the associations between the migrants’ social integration and health. We used the data from 2014 Internal Migrant Dynamic Monitoring Survey of Health and Family Planning in ZhongShan, China. Health status was measured from four aspects: self-reported health, subjective well-being, perception of stress, mental health. We measured social integration through four dimensions: economy, social communication, acculturation, and self-identity. The analyses used multiple linear regressions to examine the associations between self-reported health, subjective well-being, and perception of stress, mental health and social integration. The analytical sample included 1,999 households of the internal migrants and 1,997 local registered households, who were permanent residents in ZhongShan. Among the internal migrants, Adults in the labor force, who were aged 25 to 44 years old, accounted for 91.2% of the internal migrant population, while 74.6% of the registered population were in that age group. Median residential time among migrants was 2.8 (1.3–6.2) years, and 20.2% of them were migrating in the same Guangdong province. Except for mental health, other health statuses among migrants had significant differences compared with local registered population, e.g. self-reported health was better, but subjective well-being was worse. However, these health measurements were improved with more years of residence. Moreover, our results show that two aspects of social integration, economic integration and self-identity, were significantly associated with health status. Subjective feeling of relative social status levels were more associated with health, which prompted the attention to social fairness and the creation of a fair and respectful culture. More interventions could be experimented, such as encouraging internal migrants to participate in community activities more actively, educating local registered residents to treat internal migrants more equally, and developing self-identity among internal migrants. Better social, economic, and cultural environment can benefit internal migrants’ health statuses. [ABSTRACT FROM AUTHOR]