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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]

The changing population age structure has a significant influence on the economy, society, and numerous other aspects of a country. This paper has innovatively applied the method of compositional data forecasting for the prediction of population age changes of the young (aged 0–14), the middle-aged (aged 15–64), and the elderly (aged older than 65) in China, India, and Vietnam by 2030 based on data from 1960 to 2016. To select the best-suited forecasting model, an array of data transformation approaches and forecasting models have been extensively employed, and a large number of comparisons have been made between the aforementioned methods. The best-suited model for each country is identified considering the root mean squared error and mean absolute percent error values from the compositional data. As noted in this study, first and foremost, it is predicted that by the year 2030, China will witness the disappearance of population dividend and get mired in an aging problem far more severe than that of India or Vietnam. Second, Vietnam’s trend of change in population age structure resembles that of China, but the country will sustain its good health as a whole. Finally, the working population of India demonstrates a strong rising trend, indicating that the age structure of the Indian population still remains relatively “young”. Meanwhile, the continuous rise in the proportion of elderly population and the gradual leveling off growth of the young population have nevertheless become serious problems in the world. The present paper attempts to offer crucial insights into the Asian population size, labor market and urbanization, and, moreover, provides suggestions for a sustainable global demographic development. [ABSTRACT FROM AUTHOR]

To balance the supply and demand in China's beef market, beef consumption must be scientifically and effectively forecasted. Beef consumption is affected by many factors and is characterized by gray uncertainty. Therefore, gray theory can be used to forecast the beef consumption, In this paper, the structural defects and unreasonable parameter design of the traditional gray model are analyzed. Then, a new gray model termed, EGM(1,1,r), is built, and the modeling conditions and error checking methods of EGM(1,1,r) are studied. Then, EGM(1,1,r) is used to simulate and forecast China’s beef consumption. The results show that both the simulation and prediction precisions of the new model are better than those of other gray models. Finally, the new model is used to forecast China’s beef consumption for the period from 2019–2025. The findings will serve as an important reference for the Chinese government in formulating policies to ensure the balance between the supply and demand for Chinese beef. [ABSTRACT FROM AUTHOR]

This paper combines a Granger causality test and a VAR model to investigate the relationships among oil price shocks, global economic policy uncertainty (GEPU), and China’s industrial economic growth. Based on monthly data from 2000 to 2017, we reveal that GEPU and world oil prices jointly Granger cause China's industrial economic growth; world oil prices have a positive effect on China's industrial economic growth, while GEPU has a negative effect. Further analyses investigate the asymmetry effect of oil prices and find that the negative component shows a more significant impact on China's industrial economic growth. The results are robust to different oil price and EPU proxies. [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]

The Hospital Authority (HA) is a statutory body managing all the public hospitals and institutes in Hong Kong (HK). In recent decades, Hong Kong Hospital Authority (HKHA) has been making efforts to improve the healthcare services, but there still exist some problems like unfair resource allocation and poor management, as reported by the Hong Kong medical legislative committee. One critical consequence of these problems is low healthcare efficiency of hospitals, leading to low satisfaction among patients. Moreover, HKHA also suffers from the conflict between limited resource and growing demand. An effective evaluation of HA is important for resource planning and healthcare decision making. In this paper, we propose a two-phase method to evaluate HA efficiency for reducing healthcare expenditure and improving healthcare service. Specifically, in Phase I, we measure the HKHA efficiency changes from 2000 to 2013 by applying a novel DEA-Malmquist index with undesirable factors. In Phase II, we further explore the impact of some exogenous factors (e.g., population density) on HKHA efficiency by Tobit regression model. Empirical results show that there are significant differences between the efficiencies of different hospitals and clusters. In particular, it is found that the public hospital serving in a richer district has a relatively lower efficiency. To a certain extent, this reflects the socioeconomic reality in HK that people with better economic condition prefers receiving higher quality service from the private hospitals. [ABSTRACT FROM AUTHOR]

Background: Understanding the past-year prevalence of male-perpetrated intimate partner violence (IPV) and risk factors is essential for building evidence-based prevention and monitoring progress to Sustainable Development Goal (SDG) 5.2, but so far, population-based research on this remains very limited. The objective of this study is to compare the population prevalence rates of past-year male-perpetrated IPV and nonpartner rape from women's and men's reports across 4 countries in Asia and the Pacific. A further objective is to describe the risk factors associated with women's experience of past-year physical or sexual IPV from women's reports and factors driving women's past-year experience of partner violence.Methods and Findings: This paper presents findings from the United Nations Multi-country Study on Men and Violence in Asia and the Pacific. In the course of this study, in population-based cross-sectional surveys, 5,206 men and 3,106 women aged 18-49 years were interviewed from 4 countries: Cambodia, China, Papua New Guinea (PNG), and Sri Lanka. To measure risk factors, we use logistic regression and structural equation modelling to show pathways and mediators. The analysis was not based on a written plan, and following a reviewer's comments, some material was moved to supplementary files and the regression was performed without variable elimination. Men reported more lifetime perpetration of IPV (physical or sexual IPV range 32.5%-80%) than women did experience (physical or sexual IPV range 27.5%-67.4%), but women's reports of past-year experience (physical or sexual IPV range 8.2%-32.1%) were not very clearly different from men's (physical or sexual IPV range 10.1%-34.0%). Women reported much more emotional/economic abuse (past-year ranges 1.4%-5.7% for men and 4.1%-27.7% for women). Reports of nonpartner rape were similar for men (range 0.8%-1.9% in the past year) and women (range 0.4%-2.3% in past year), except in Bougainville, where they were higher for men (11.7% versus 5.7%). The risk factor modelling shows 4 groups of variables to be important in experience of past-year sexual and/or physical IPV: (1) poverty, (2) all childhood trauma, (3) quarrelling and women's limited control in relationships, and (4) partner factors (substance abuse, unemployment, and infidelity). The population attributable fraction (PAF) was largest for quarrelling often, but the second greatest PAF was for the group related to exposure to violence in childhood. The relationship control variable group had the third highest PAF, followed by other partner factors. Currently married women were also more at risk. In the structural model, a resilience pathway showed less poverty, higher education, and more gender-equitable ideas were connected and conveyed protection from IPV. These are all amenable risk factors. This research was cross-sectional, so we cannot be sure of the temporal sequence of exposure, but the outcome being a past-year measure to some extent mitigates this problem.Conclusions: Past-year IPV indicators based on women's reported experience that were developed to track SDG 5 are probably reasonably reliable but will not always give the same prevalence as may be reported by men. Report validity requires further research. Interviews with men to track past-year nonpartner rape perpetration are feasible and important. The findings suggest a range of factors are associated with past-year physical and/or sexual IPV exposure; of particular interest is the resilience pathway suggested by the structural model, which is highly amenable to intervention and explains why combining economic empowerment of women and gender empowerment/relationship skills training has been successful. This study provides additional rationale for scaling up violence prevention interventions that combine economic and gender empowerment/relationship skills building of women, as well as the value of investing in girls' education with a view to long-term violence reduction. [ABSTRACT FROM AUTHOR]

Objective: The world population is aging rapidly and the well-being of older people is of great interest. Therefore, this study investigates the determinants of life satisfaction among the oldest-old (i.e. individuals aged 80 or over) in China. Materials and methods: We use the 2011/2012 Chinese Longitudinal Healthy Longevity Survey data (n = 6530) for this paper. Logistic regression is used to analyse the effects of socio-demographic, economic, health, instrumental activities of daily living, family and community factors on life satisfaction and depression among the oldest-old in China. Results: Our analysis confirms the significance of many factors affecting life satisfaction among the oldest-old in China. Factors that are correlated with life satisfaction include respondent’s sex, education, place of residence, self-rated health status, cognitive ability (using mini mental state examination), regular physical examination, perceived relative economic status, access to social security provisions, commercialized insurances, living arrangements, and number of social services available in the community (p<0.05 for all these variables). Although life satisfaction is negatively associated with instrumental activities of daily living (β = -0.068, 95%CI = -.093—.043), and depression (β = -0.463, 95%CI = -.644—.282), the overall effect of self-rated health status is positive (p<0.001). This confirms the primacy of health as the determinant of well-being among the oldest-old. Conclusions: Majority of the oldest-old in China rated their life satisfaction as good or very good. Our findings show that health and economic status are by far the most significant predictors of life satisfaction. Our finding on the primacy of health and relative income as determinants of well-being among the oldest-old, and the greater influence of self-rated health status over objective health measures is consistent with the findings of many past studies. Our results suggest that efforts should be directed at enhancing family support as well as health and social service provisions in the community to improve life satisfaction of older people. [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]

Pigs have played a major role in the economic, social and symbolic systems of China since the Early Neolithic more than 8,000 years ago. However, the interaction between the history of pig domestication and transformations in Chinese society since then, have not been fully explored. In this paper, we investigated the co-evolution from the earliest farming communities through to the new political and economic models of state-like societies, up to the Chinese Empire, using 5,000 years of archaeological records from the Xiawanggang (XWG) and Xinzhai (XZ) sites (Henan Province). To trace the changes of pig populations against husbandry practices, we combined the geometric morphometric analysis of dental traits with a study of the stable carbon and nitrogen isotope ratios from bone collagen. The domestication process intensified during the Neolithic Yangshao, prompted by greater selective pressure and/or better herd control against wild introgression. After that, pig farming, in XWG, relied on local livestock and a gradual change of husbandry practices overtime. This was characterized by a gentle increase in millet foddering and animal protein intake, until a complete change over to household management during the Han dynasty. The only rupture in this steady trend of husbandry occurred during the Longshan period, with the appearance of small sized and idiosyncratic pigs with specific feeding practices (relying on millet and household scraps). From three exploratory hypothesis, we explored the possibility of anti-elite pig production in XWG during the Longshan period, as a means to resist incorporation into a new economic model promoting intensified domestic production. This exploratory hypothesis is the most suitable to our dataset; however, numerous areas need to be explored further in order to adequately document the role of pigs in the rise of China’s complex societies. [ABSTRACT FROM AUTHOR]

Objective: The paper examines whether out-of-pocket health care expenditure also has regional discrepancies, comparing to the equity between urban and rural areas, and across households. Method: Sampled data were derived from Urban Household Survey and Rural Household Survey data for 2011/2012 for Anhui Province, and 11049 households were included in this study. The study compared differences in out-of-pocket expenditure on health care between regions (urban vs. rural areas) and years (2011 vs. 2012) using two-sample t-test, and also investigated the degree of inequality using Lorenz and concentration curves. Result: Approximately 5% and 8% of total household consumption expenditure was spent on health care for urban and rural populations, respectively. In 2012, the wealthiest 20% of urban and rural population contributed 49.7% and 55.8% of urban and rural total health expenditure respectively, while the poorest 20% took only 4.7% and 4.4%. The concentration curve for out-of-pocket expenditure in 2012 fell below the corresponding concentration curve for 2011 for both urban and rural areas, and the difference between curves for rural areas was greater than that for urban areas. Conclusion: A substantial and increasing gap in health care expenditures existed between urban and rural areas in Anhui. The health care financing inequality merits ample attention, with need for policymaking to focus on improving the accessibility to essential health care services, particularly for rural and poor residents. This study may provide useful information on low income areas of China. [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]

Choosing a valid and feasible method to measure child developmental outcomes is key to addressing developmental delays, which have been shown to be associated with high levels of unemployment, participation in crime, and teen pregnancies. However, measuring early childhood development (ECD) with multi-dimensional diagnostic tests such as the Bayley Scales of Infant and Toddler Development III (Bayley-III) can be time-consuming and expensive; therefore, parental screening tools such as the Ages and Stages Questionnaire (ASQ-3) are frequently an alternative measure of early childhood development in large-scale research. The ASQ is also becoming more frequently used as the first step to identify children at risk for developmental delays before conducting a diagnostic test to confirm. However, the effectiveness of the ASQ-3 is uncertain. In this study, we evaluate the accuracy of the ASQ-3 as a screening measure for children at risk of developmental delay in rural China by age group. To do so, we administered the Bayley-III, widely considered to be the “gold standard” of ECD diagnostic tests, to a sample of 1,831 five to twenty-four month-old children and also administered the ASQ-3 to their caregivers. We then compared the outcomes of the ASQ-3 test to those of the Bayley-III. We find that the ASQ-3 was significantly though weakly correlated with the Bayley-III and that the strength of this correlation increased with child age and was stronger when the mother was the primary caregiver (as compared to the grandmother). We also find that the sensitivity and specificity of ASQ-3 ranged widely. The overall findings suggest that the ASQ-3 may not be a very accurate screening tool for identifying developmentally delayed children, especially for children under 13 months of age or children whose primary caregiver is not the mother. [ABSTRACT FROM AUTHOR]

Prior to the introduction of wheat and barley from Central Asia during the Neolithic period, northern Chinese agricultural groups subsisted heavily on millet. Despite being the focus of many decades of intensive interest and research, the exact route(s), date(s), and mechanisms of the spread and adoption of wheat and barley into the existing well-established millet-based diet in northern China are still debated. As the majority of the important introduced crops are C3 plants, while the indigenous millet is C4, archaeologists can effectively identify the consumption of any introduced crops using stable carbon isotope analysis. Here we examine published stable isotope and dental caries data of human skeletal remains from 77 archaeological sites across northern and northwestern China. These sites date between 9000 to 1750 BP, encompassing the period from the beginning of agriculture to wheat’s emergence as a staple crop in northern China. The aim of this study is to evaluate the implications of the spread and adoption of these crops in ancient China. Detailed analysis of human bone collagen δ13C values reveals an almost concurrent shift from a C4-based to a mixed C3/ C4– based subsistence economy across all regions at around 4500–4000 BP. This coincided with a global climatic event, Holocene Event 3 at 4200 BP, suggesting that the sudden change in subsistence economy across northern and northwestern China was likely related to climate change. Moreover, the substantially increased prevalence of dental caries from pre–to post–4000 BP indicates an increase in the consumption of cariogenic cereals during the later period. The results from this study have significant implications for understanding how the adoption of a staple crop can be indicative of large-scale environmental and socio-political changes in a region. [ABSTRACT FROM AUTHOR]

We systematically review the health-financing mechanisms, revenue rising, pooling, purchasing, and benefits, in the Association of Southeast Asian Nations (ASEAN) and the People’s Republic of China, and their impact on universal health coverage (UHC) goals in terms of universal financial protection, utilization/equity and quality. Two kinds of sources are reviewed: 1) academic articles, and 2) countries’ health system reports. We synthesize the findings from ASEAN countries and China reporting on studies that are in the scope of our objective, and studies that focus on the system (macro level) rather than treatment/technology specific studies (micro level).The results of our review suggest that the main sources of revenues are direct/indirect taxes and out of pocket payments in all ASEAN countries and China except for Brunei where natural resource revenues are the main source of revenue collection. Brunei, Indonesia, Philippines, Malaysia, and Viet Nam have a single pool for revenue collection constituting a national health insurance. Cambodia, China, Lao, Singapore, and Thailand have implemented multiple pooling systems while Myanmar has no formal arrangement. Capitation, Fee-for-Service, DRGs, Fee schedules, Salary, and Global budget are the methods of purchasing in the studied countries. Each country has its own definition of the basic benefit package which includes the services that are perceived as essential for the population health. Although many studies provide evidence of an increase in financial protection after reforming the health-financing mechanisms in the studied countries, inequity in financial protection continue to exist. Overall, the utilization of health care among the poor has increased as a consequence of the implementation of government subsidized health insurance schemes which target the poor in most of the studied countries. Inappropriate policies and provider payment mechanisms impact on the quality of health care provision. We conclude that the most important factors to attain UHC are to prioritize and include vulnerable groups into the health insurance scheme. Government subsidization for this kind of groups is found to be an effective method to achieve this goal. The higher the percentage of government expenditure on health, the greater the financial protection is. At the same time, there is a need to weigh the financial stability of the health-financing system. A unified health insurance system providing the same benefit package for all, is the most efficient way to attain equitable access to health care. Capacity building for both administrative and health service providers is crucial for sustainable and good quality health care. [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]

Background: China used to be among the countries with a high prevalence of trachoma. At the launch of The Global Elimination of Trachoma (GET) 2020 campaign by the World Health Organization (WHO) in 1996, China was placed on the list of countries endemic for trachoma based on historical data. However, empirical observation and routinely collected eye care data were suggesting that trachoma was no longer a public health problem. To determine whether the GET 2020 goals had been met in P. R. China, we conducted a targeted assessment with national scope. Methodology/principal finding: Province assessment teams, trained in WHO Trachoma Rapid Assessment (TRA) methodology and in WHO simplified trachoma grading system, carried out assessments in 16 provinces (among them, 2 provinces conducted pilot assessment). Based on the published literature, including national and international reports, suspected trachoma-endemic areas within each province were identified. Within these areas, trachomatous inflammation- follicular (TF) assessments were carried out in at least 50 grade-one children in primary schools serving villages with the lowest socio-economic development. Trachomatous trichiasis (TT) and corneal opacity (CO) assessments were conducted among persons aged 15 and over in villages within the catchment area of the selected schools. Of 8,259 children examined in 128 primary schools in 97 suspected trachoma endemic areas, only 16 cases of conjunctivitis were graded as TF. 38 cases with TT were found among the 339,013 examined residents in villages surrounding the schools. Among these 97 suspected trachoma endemic areas in only three was the prevalence of TT more than 0.2%. Conclusions/significance: This large study suggested that trachoma was not a public health problem in 16 provinces that had been previously suspected to be endemic. These findings will facilitate planning for elimination of trachoma from PR China. [ABSTRACT FROM AUTHOR]

Background: It has been widely understood that well-trained doctors are crucial for a high-quality public health system and safe patient care. Thus, in 2011, China initiated its first national residency training program, called the China Standardized Training for Resident Doctor (C-STRD), for medical graduates to prepare qualified doctors for the medical care system with increasing demands. So far, no studies have specifically address the prevalence of stress and its determinants among residents enrolled in the C-STRD. Participants and methods: The research is performed in two stages. In stage I, the authors conducted a pilot study and met 112 C-STRD residents in person. Based on the preliminary data, a revised questionnaire was adopted in stage II, during which the authors conducted a multi-institutional, cross-sectional survey of 340 participants from 11 hospitals in Shanghai in a self-administered manner. Results: The results showed that C-STRD residents were overall under severe stress as their mean PSS score was 27.5 ± 4.9, which was higher than the threshold of high stress (PSS = 20). Specifically, the PSS score for the residents with Bachelor (MB), Master (MM) and Doctoral of Medicine (MD) educational degree were 26.6 ± 4.1, 27.8 ± 3.5 and 27.1 ± 5.2, respectively (P>0.05). Their stress was mainly associated with their financial income status and workload, as these two factors caused more severe burden than other listed stressors (P<0.05). Specially, the residents indicated that their montly payroll amout were as low as $590.2 ± 127 while no benefit package and allowance were given. Surprisingly, wage arrears up to 5.3 month were reported by 36 (10%) participants. Workload survey showed the residents has high work intensity and inadequate rest. Since no stress management program was provided, the majority of residents tended to cope their stress with unhealthy strategies, such as mesmerizing in TV/computer (88.2%) and overeating (59.7%). Conclusion: The C-STRD residents are at high risk of perceived stress. Although there was a difference in perception of stress for workload and career future among different educational degree owners, low financial income is the major stressor among all C-STRD residents. Unhealthy stress management strategies were adopted by all residents due to lack of appropriate stress-relieving intervention. [ABSTRACT FROM AUTHOR]

Background: China has the highest global prevalence of cigarette smokers, accounting for more than 40% of the total cigarette consumption in the world. Considering the shortage of smoking cessation services in China, and the acceptability, feasibility, and efficacy of mobile-phone-based text messaging interventions for quitting smoking in other countries, we conducted a mobile-phone-based smoking cessation study in China.Methods and Findings: We conducted a randomized controlled trial in China across 30 cities and provinces from August 17, 2016, to May 27, 2017. Adult smokers aged 18 years and older with the intention to quit smoking were recruited and randomized to a 12-week high-frequency messaging (HFM) or low-frequency messaging (LFM) intervention ("Happy Quit") or to a control group in a 5:2:3 ratio. The control group received only text messages unrelated to quitting. The primary outcome was biochemically verified continuous smoking abstinence at 24 weeks. Secondary outcomes included (1) self-reported 7-day point prevalence of abstinence (i.e., not even a puff of smoke, for the last 7 days) at 1, 4, 8, 12, 16, 20, and 24 weeks; (2) self-reported continuous abstinence at 4, 12, and 24 weeks; and (3) self-reported average number of cigarettes smoked per day. A total of 1,369 participants received 12 weeks of intervention or control text messages with continued follow-up for 12 weeks. The baseline characteristics of participants among the HFM (n = 674), LFM (n = 284), and control (n = 411) groups were similar. The study sample included 1,295 (94.6%) men; participants had a mean age of 38.1 (SD 9.79) years and smoked an average of 20.1 (SD 9.19) cigarettes per day. We included the participants in an intention-to-treat analysis. Biochemically verified continuous smoking abstinence at 24 weeks occurred in 44/674 participants in the HFM group (6.5%), 17/284 participants in the LFM group (6.0%), and 8/411 participants (1.9%) in the control group; participants in both the HFM (odds ratio [OR] = 3.51, 95% CI 1.64-7.55, p < 0.001) and the LFM (OR = 3.21, 95% CI 1.36-7.54], p = 0.002) intervention groups were more likely to quit smoking than those in the control group. However, there was no difference in quit rate between the HFM and LFM interventions. We also found that the 7-day point quit rate from week 1 to week 24 ranged from approximately 10% to more than 26% with the intervention and from less than 4% to nearly 12% without the intervention. Those who continued as smokers in the HFM group smoked 1 to 3 fewer cigarettes per day than those in the LFM group over the 24 weeks of trial. Among study limitations, the participants were able to use other smoking cessation services (although very few participants reported using them), cotinine tests can only detect smoking status for a few days, and the proportion of quitters was small.Conclusions: Our findings demonstrate that a mobile-phone-based text messaging intervention (Happy Quit), with either high- or low-frequency messaging, led to smoking cessation in the present study, albeit in a low proportion of smokers, and can therefore be considered for use in large-scale intervention efforts in China. Mobile-phone-based interventions could be paired with other smoking cessation services for treatment-seeking smokers in China.Trial Registration: ClinicalTrials.gov NCT02693626. [ABSTRACT FROM AUTHOR]

Background: China has witnessed a rapid increase of cesarean section (CS) rates in recent years. Several non-clinical factors have been cited as contributing to this trend including maternal request and perceived convenience. We aimed to assess preferences for mode of delivery and reasons for preferences for CS in China to inform the development of future interventions to mitigate unnecessary CSs, which are those performed in the absence of medical indications.Methods and Findings: We conducted a mixed-methods systematic review and included longitudinal, cross-sectional, and qualitative studies in mainland China, Hong Kong, and Taiwan that investigated preferences for mode of delivery among women and family members and health professionals, and the reasons underlying such preferences. We searched MEDLINE/PubMed, Embase, CINAHL, POPLINE, PsycINFO, Global Health Library, and one Chinese database (CNKI) using a combination of the key terms 'caesarean section', 'preference', 'choice', 'knowledge', 'attitude', 'culture', 'non-clinical factors', and 'health professionals-patient relations' between 1990 and 2018 without language restriction. Meta-analysis of quantitative studies and meta-synthesis of qualitative studies were applied. We included 66 studies in this analysis: 47 quantitative and 19 qualitative. For the index pregnancy, the pooled proportions of preference for CS reported by women in longitudinal studies were 14% in early or middle pregnancy (95% CI 12%-17%) and 21% in late pregnancy (95% CI 15%-26%). In cross-sectional studies, the proportions were 17% in early or middle pregnancy (95% CI 14%-20%), 22% in late pregnancy (95% CI 18%-25%), and 30% postpartum (95% CI 19%-40%). Women's preferences for CS were found to rise as pregnancy progressed (preference change across longitudinal studies: mean difference 7%, 95% CI 1%-13%). One longitudinal study reported that the preference for CS among women's partners increased from 8% in late pregnancy to 17% in the immediate postpartum period. In addition, 18 quantitative studies revealed that some pregnant women, ranging from 4% to 34%, did not have a straightforward preference for a mode of delivery, even in late pregnancy. The qualitative meta-synthesis found that women's perceptions of CS as preferable were based on prioritising the baby's and woman's health and appeared to intensify through interactions with the health system. Women valued the convenience of bypassing labour because of fear of pain, antagonistic relations with providers, and beliefs of deteriorating quality of care during labour and vaginal birth, fostering the feeling that CS was the safest option. Health professionals' preference for CS was influenced by financial drivers and malpractice fears. This review has some limitations, including high heterogeneity (despite subgroup and sensitivity analysis) in the quantitative analysis, and the potential for over-reporting of women's preferences for CS in the qualitative synthesis (due to some included studies only including women who requested CS).Conclusions: Despite a minority of women expressing a preference for CS, individual, health system, and socio-cultural factors converge, contributing to a high CS rate in mainland China, Hong Kong, and Taiwan. In order to reduce unnecessary CSs, interventions need to address all these non-clinical factors and concerns.Systematic Review Registry: Prospero CRD42016036596. [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]

Objectives: Self-treatment is a widespread practice among patients with common symptoms and ailments; it is necessary to explore multiple aspects of it. Notably, there is little research into self-treatment among middle-aged and elderly people, who are more likely to fall ill. Our goals are to provide a comprehensive description of self-treatment and explore associated factors with insurance utilization and expenditures among the middle-aged and elderly populations in China. Methods: A survey was conducted in July 2016 in Shanxi, China. A stratified sampling scheme was applied to achieve representativeness. A total of 972 subjects were surveyed. Descriptive statistics, t- and Chi-squared tests, multivariate logistic regression, and multivariate linear regression were utilized. Results: In our study, 772 (79.4%) of the surveyed subjects self-treated during the previous twelve months. Among them, 253 (32.8%) used health insurance. Subjects’ characteristics were associated with insurance utilization and expenditures for self-treatment. Total cost was positively associated with insurance utilization. The subjects with a junior high education (p-value < 0.001, aOR = 0.049) and senior high education (p-value = 0.020, aOR = 0.146) had a lower probability of using insurance. For both total costs and out-of-pocket costs, subjects who were 51 to 60 years old had lower costs. The subjects who were seriously sick and had a primary school education, as well as enterprise occupations, had higher costs. Self-treatment times were also positively associated with costs. Finally, it was found that subjects who didn’t use insurance had lower total costs. Conclusions: The prevalence of self-treatment was high (79.4%). Some characteristics were associated with insurance utilization and expenditures in self-treatment. Our results may be helpful for policy interventions, which are needed to further improve the effectiveness of health insurance in China. [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]

Background: China’s universal medical insurance system (UMIS) is designed to promote social fairness through improving access to medical services and reducing out-of-pocket (OOP) costs for all Chinese. However, it is still not known whether UMIS has a significant impact on the accessibility of medical service supply and the affordability, as well as the seeking-care choice, of patients in China. Methods: Segmented time-series regression analysis, as a powerful statistical method of interrupted time series design, was used to estimate the changes in the quantity and quality of medical service supply before and after the implementation of UMIS. The rates of catastrophic payments and seeking-care choices for UMIS beneficiaries were selected to measure the affordability and medical service flow of patients after the implementation of UMIS. Results: China’s UMIS was established in 2008. After that, the trending increase of the expenditure of the UMIS was higher than that of increase in revenue compared to previous years. Up to 2014, the UMIS had covered 97.5% of the entire population in China. After introduction of the UMIS, there were significant increases in licensed physicians, nurses, and hospital beds per 1000 individuals. In addition, hospital outpatient visits and inpatient visits per year increased compared to the pre-UMIS period. The average fatality rate of inpatients in the overall hospital and general hospital and the average fatality rate due to acute myocardial infarction (AMI) in general hospitals was significantly decreased. In contrast, no significant and prospective changes were observed in rural physicians per 1000 individuals, inpatient visits and inpatient fatality rate in the community centers and township hospitals compared to the pre-UMIS period. After 2008, the rates of catastrophic payments for UMIS inpatients at different income levels were declining at three levels of hospitals. Whichever income level, the rate of catastrophic payments for inpatients of Urban Employee’s Basic Medical Insurance was the lowest. For the low-income patients, a single hospitalization at a tertiary hospital can lead to catastrophic payments. It is needless to say what the economic burden could be if patients required multiple hospitalizations within a year. UMIS beneficiaries showed the intention of growth to seek hospitalization services in tertiary hospitals. Conclusions: Introduction of the UMIS contributed to an increase in available medical services and the use thereof, and a decrease in fatality rate. The affordability of UMIS beneficiaries for medical expenses was successfully ameliorated. The differences in patients’ affordability are mainly manifested in different medical insurance schemes and different seeking-care choices. The ability of the poor patients covered by UMIS to resist catastrophic medical payments is still relatively weak. Therefore, the current UMIS should reform the insurance payment model to promote the integration of medical services and the formation of a tiered treatment system. UMIS also should establish supplementary medical insurance packages for the poor. [ABSTRACT FROM AUTHOR]

Objectives: Among the dramatic increased internal migration in China in past three decades, a considerable proportion of young females migrated to urban areas and found employment in “entertainment venues”, who may be vulnerable to psychological distress. This study examines the prevalence of depression and explores its associations with health-risk behaviors and social capital among this subgroup. Methods: 358 female migrants were recruited from entertainment venues in a rapidly growing urban city in China. A survey which included measures of depressive symptoms, health-risk behaviors, social capital, and socio-demographic characteristics was administered. Multivariable logistic regression was conducted to identify the independent correlates of depression. Results: Of participants, 31.0% had clinically significant depressive symptoms (CES-D score ≥ 16). In multivariable models, greater likelihood of depressive symptoms was associated with working in massage centers/hotels (OR = 3.20, 95% CI: 1.80–5.70), having probable alcohol dependence (OR = 2.25, 95% CI: 1.22–4.16), self-reported lifetime use of illicit drugs (OR = 2.98, 95% CI: 1.26–7.06), growing up in a non-nuclear family (OR = 2.46, 95% CI: 1.18–5.16), and poor social capital (OR = 6.01, 95% CI = 2.02–17.87). Conclusion: Intervention strategies to address the high prevalence of depression among female migrants are needed, and should also aim to reduce problematic alcohol and drug use, improve social capital, and target women working in massage centers or hotels. [ABSTRACT FROM AUTHOR]

Background: Healthcare system reform of Sanming city has become a leading healthcare reform model in China. It has developed a rigorous pharmaceutical reform consisted of the Zero Mark-up Drug Policy and the Centralized Procurement of Medicine Policy to bring down drug expenses and total health expenditures. However, despite the credit and much attention have been given to Sanming’s pharmaceutical reform, its impact still remains unclear. Therefore, the purpose of this study was to explore the impact of the pharmaceutical reform of Sanming on both drug and total health expenditures. Methods: Interrupted time series analysis with three segments divided by two intervention points was employed to evaluate the impact of the pharmaceutical reform. Segment 1 was the pre-reform period which captured the baseline information. Segment 2 occurred after the first intervention point when the Zero Mark-up Drug Policy was implemented, whereas Segment 3 was after the implementation of the Centralized Procurement of Medicine Policy. Primary outcomes are outpatient drug expenditure, outpatient total health expenditure, inpatient drug expenditure, and inpatient total health expenditure. Data spanning from May 2012 to May 2014 are included. Results: Both drug and total health expenditures exhibited rising trends before any policy was carried out. The launch of Zero Mark-up Drug Policy led to significant instant reductions in levels of outpatient drug expenditure (coefficient = -6,602.99, p<0.01), outpatient total health expenditure (coefficient = -9,958.58, p<0.05), inpatient drug expenditure (coefficient = -7,520.90, p<0.01), and inpatient total health expenditure (coefficient = -16,737, p<0.01). Moreover, the previous upward trends were changed into downward trends for inpatient drug expenditure (coefficient = -2,747.02, p = 0.00) and total health expenditure (coefficient = -3,069.29, p = 0.12). However, after the implementation of Centralized Procurement of Medicine Policy, we observed no significant instant level changes and also, the inpatient drug expenditure (coefficient = 372.95, p = 0.01) and total health expenditure (coefficient = 788.76, p = 0.06) resumed upward trends again. Conclusions: Although the pharmaceutical reform could control or reduced drug expenditure and total health expenditure in short term, expenditures gradually resumed growing again and reached or even exceeded their baseline levels of pre-reform period, indicating the effect became weakened or even faded out in long term. In all, the pharmaceutical reform as a whole failed to meet its goal of combating sharp growth of drug and total health expenditure. [ABSTRACT FROM AUTHOR]

Background: Intimate partner violence (IPV) is the most common form of violence against women worldwide. IPV during pregnancy is an important risk factor for adverse health outcomes for women and their offspring. However, the prevalence of IPV during pregnancy is not well understood in China. The objective of this study was to estimate the pooled prevalence of IPV during pregnancy in China using a systematic review and meta-analysis. Methods: Systematic literature searches were conducted in PubMed, Web of Science, CNKI, Wanfang, Weipu and CBM databases to identify relevant articles published from the inception of each database to January 31, 2016 that reported data on the prevalence of IPV during pregnancy in China. The Risk of Bias Tool for prevalence studies was used to assess the risk of bias in individual studies. Owing to significant between-study heterogeneity, a random-effects model was used to calculate the pooled prevalence and corresponding 95% confidence interval, and then univariate meta-regression analyses were performed to investigate the sources of heterogeneity. Subgroup analysis was conducted to explore the risk factors associated with IPV during pregnancy. Results: Thirteen studies with a total of 30,665 individuals were included in this study. The overall pooled prevalence of IPV during pregnancy was 7.7% (95% CI: 5.6–10.1%) with significant heterogeneity (I2 = 97.8%, p < 0.001). The results of the univariate meta-regression analyses showed that only the variable “sample source” explained part of the heterogeneity in this study (p < 0.05). The characteristics “number of children” and “unplanned pregnancy” were determined as risk factors for experiencing violence during pregnancy. Conclusions: The prevalence of IPV during pregnancy in China is considerable and one of the highest reported in Asia, which suggests that issues of violence against women during pregnancy should be included in efforts to improve the health of pregnant women and their offspring. In addition, a nationwide epidemiological study is needed to confirm the prevalence estimates and identify more risk factors for IPV during pregnancy. [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]

Background: Blood collection agencies worldwide are facing ongoing and increasing medical demands for blood products. Many potential donors would search related information online before making decision of whether or not to donate blood. However, there is little knowledge of the online information and services provided by blood centers in China, despite the constantly increase of internet users. Our research investigates the number of blood centers’ official websites and their quality, and highlights the deficiencies that required future advances. Methods: Identified official websites of blood centers were scored using a newly developed evaluation instrument with 42 items concerning technical aspects, information quality, information comprehensiveness and interactive services. Scores of websites were compared between blood centers with different level (provincial vs. regional blood centers) and location (blood centers located in economically developed vs. developing region). Results: For the 253 working official websites all the 350 blood centers in China, and the mean overall score of websites was 24.7 out of 42. 79.1% websites were rated as fair (50–75% of maximum), 5.5% as good (≥75% of maximum) and 15.4% as poor(25–50% of maximum;). Websites got very low sub-scores in information quality (mean = 3.8; range 1–8; maximum = 9) and interactive services (3.3; 0–10; 10). Higher proportions of provincial (vs. regional) blood centers and economically developed (vs. developing) blood centers had official websites (p = 0.044 and p = 0.001; respectively) with better overall quality (p<0.001 and p <0.01) and better sub-scores (in all of the four sections and in technical aspects and information quality). Website overall scores was positively correlated with the number of people served by each blood center (p< 0.001) and the donation rate of each province (p = 0.046). Conclusions: This study suggests there is a need to further develop and improve official websites in China, especially for regional and inland blood centers. The poor information quality and interactive services provided by these websites is of particular concern, given the challenges in blood donor counselling and recruitment. [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]

Background: Mental illness has brought great economic burden related to misdiagnosis by non-mental health professionals in general hospitals. The aim of this study was to explore non-mental health professionals’ conceptions related to the identification of mental illness and perceived treatments, first aid and prognosis. Methods: In 2014–2015, we presented 1123 non-mental health professionals from six general hospitals in Hunan Province with one of three vignettes describing a person with schizophrenia, depression, or generalized anxiety disorder. Identification rates, beliefs about various interventions, best methods, and the prognosis with or without treatment were measured. Results: Less than 60% of the non-mental health professionals could identify the mental disorders correctly. Psychiatrists and psychologists were considered to be the people who would be most helpful in all vignettes. Over 70% of participants identified the correct medication for each vignette. Participants gave higher ratings to lifestyle interventions than to psychological and medical interventions, especially in the depression and generalized anxiety disorder vignettes. For the question about how the person could best be helped, about half of the participants rated listening or talking with the person more highly than accompanying the person to professional help or encouraging the person to visit a psychiatrist or psychologist. Participants believed that, with professional help, the people in the vignettes would fully recover but that problems would probably reoccur and that, without professional help, the people described would get worse. Conclusions: The beliefs that non-mental health professionals hold about mental disorders are inadequate to provide appropriate help. There is an urgent need for mental health education campaigns to improve non-mental health professionals’ mental health knowledge in mainland China in order to provide better support for mental health service users. [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]

Objectives: China has high burden on both of tuberculosis (TB) and tobacco use. This study aims to explore the potential link between smoking and TB infection using baseline survey data of a large-scale population-based prospective study in rural China Methods: Between July 1 and Sept 30, 2013, based on the baseline survey of a population-based, prospective study in rural China, the relationship between smoking and TB infection, assessed by interferon-gamma release assays (IGRA), was investigated among the total study population and only among those smokers, respectively. Results: A total of 21,008 eligible rural registered residents (≥ 5 years old) from 4 rural sites were included in the analysis. Ever-smokers were more likely to be QuantiFERON-TB Gold In-Tube (QFT) positive than never smokers with an adjusted odds ratio (OR) of 1.34 (95% confidence interval (CI): 1.21–1.49). Among ever smokers, a significant linear dose–response relation was observed between duration of smoking (by years) and QFT positivity (p < 0.001). Stratified analysis suggested that such an association was not influenced by gender and age. Evidence for interaction of smoking status with age was found. Conclusions: Our results provide further evidence to support smoking might increase host susceptibility to TB infection. Populations under high risk of infection, such as elderly smokers, should be prior to TB infection controlling under a premise of community level intervention. [ABSTRACT FROM AUTHOR]

Extensive evidence has revealed that street greenery, as a quality-of-life component, is important for oxygen production, pollutant absorption, and urban heat island effect mitigation. Determining how green our streets are has always been difficult given the time and money consumed using conventional methods. This study proposes an automatic method using an emerging online street-view service to address this issue. This method was used to analyze street greenery in the central areas (28.3 km2 each) of 245 major Chinese cities; this differs from previous studies, which have investigated small areas in a given city. Such a city-system-level study enabled us to detect potential universal laws governing street greenery as well as the impact factors. We collected over one million Tencent Street View pictures and calculated the green view index for each picture. We found the following rules: (1) longer streets in more economically developed and highly administrated cities tended to be greener; (2) cities in western China tend to have greener streets; and (3) the aggregated green view indices at the municipal level match with the approved National Garden Cities of China. These findings can prove useful for drafting more appropriate policies regarding planning and engineering practices for street greenery. [ABSTRACT FROM AUTHOR]

Objective: This study assessed the long-term cost-effectiveness of saxagliptin+metformin (SAXA+MET) versus acarbose+metformin (ACAR+MET) in Chinese patients with type 2 diabetes mellitus (T2DM) inadequately controlled on MET alone. Methods: Systematic literature reviews were performed to identify studies directly comparing SAXA+MET versus ACAR+MET, and to obtain diabetes-related events costs which were modified by hospital surveys. A Cardiff Diabetes Model was used to estimate the long-term economic and health treatment consequences in patients with T2DM. Costs (2014 Chinese yuan) were calculated from the payer’s perspective and estimated over a patient’s lifetime. Results: SAXA+MET predicted lower incidences of most cardiovascular events, hypoglycemia events and fatal events, and decreased total costs compared with ACAR+MET. For an individual patient, the quality-adjusted life-years (QALYs) gained with SAXA+MET was 0.48 more than ACAR+MET at a cost saving of ¥18,736, which resulted in a cost saving of ¥38,640 per QALY gained for SAXA+MET versus ACAR+MET. Results were robust across various univariate and probabilistic sensitivity analyses. Conclusion: SAXA+MET is a cost-effective treatment alternative compared with ACAR+MET for patients with T2DM in China, with a little QALYs gain and lower costs. SAXA is an effective, well-tolerated drug with a low incidence of adverse events and ease of administration; it is anticipated to be an effective second-line therapy for T2DM treatment. [ABSTRACT FROM AUTHOR]

Cultural orientation is defined as an individual’s cultural preferences when encountering imported culture while still living in the native culture. Data was analyzed from 1305 Chinese university students attending universities in Beijing, Kunming, and Wuhan. Cultural orientation was assessed with the Chinese Cultural Orientation Questionnaire, which assesses both Western and Traditional Chinese cultural orientations. The analysis used hierarchical logistic regression with nondrinkers as the reference group and controlling for demographic factors (age, gender, and urban/rural background). Western cultural orientation was found to significantly increase the odds of recent drinking. The results indicated that higher Western cultural orientation was, after gender, the second most important factor associated with Chinese college student drinking frequency. Traditional Chinese cultural orientation was not associated with drinking frequency. This study highlights an unexpected outcome of globalization on students who have not left their home cultures. [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]

Mairead Black and Sohinee Bhattacharya discuss research findings on preferences for cesarean delivery in Asian settings and share their Perspective on facilitating woman-centered birth choices in China following the end of the one-child policy. [ABSTRACT FROM AUTHOR]

Chinese children are facing dual burden of malnutrition—coexistence of under-and over-nutrition. Little systematic evidence exists for explaining the simultaneous presence of under-and over-nutrition. This study aims to explore underlying mechanisms of under-and over-nutrition among children in rural China. This study used a nationwide longitudinal dataset of children (N = 5,017) from 9 provinces across China, with four exclusively categories of nutritional outcomes including under-nutrition (stunting and underweight), over-nutrition (overweight only including obesity), paradox (stunted overweight), with normal nutrition as reference. Multinomial logit models (Level-1: occasions; Level-2: children; Level-3: villages) were fitted which corrected for non-independence of observations due to geographic clustering and repeated observations of individuals. A mixture of risk factors at the individual, household and neighbourhood levels predicted under-and over-nutrition among children in rural China. Improved socioeconomic status and living in more urbanised villages reduced the risk of stunted overweight among rural children in China. Young girls appeared to have higher risk of under-nutrition, and the risk decreased with age more markedly than for boys up to age 5. From age 5 onwards, boys tended to have higher risk of under-nutrition than girls. Girls aged around 12 and older were less likely to suffer from under-nutrition, while boys’ higher risk of under-nutrition persisted throughout adolescence. Children were less likely to suffer from over-nutrition compared to normal nutrition. Boys tended to have an even lower risk of over-nutrition than girls and the gender difference widened with age until adolescence. Our results have important policy implications that improving household economic status, in particular, maternal education and health insurance for children, and living environment are important to enhance rural children’s nutritional status in China. Investments in early years of childhood can be effective to reduce gender inequality in nutritional health in rural China. [ABSTRACT FROM AUTHOR]

Background: Global literature has suggested a negative impact of acculturative stress on both physical and mental health among international migrants. In China, approximately 20 percent of its population is rural-to-urban migrant workers and there are significant cultural differences between rural and urban societies, but no data are available regarding the acculturative stress of Chinese migrant workers. This study aimed to explore the forms and contexts of acculturative stress among Chinese migrant workers. Methods: Qualitative data were collected from four focus group discussions with 17 Chinese rural-to-urban migrant workers and three individual interviews with three medical professionals who provided mental health services for factory-workers in Shenzhen, China. Results: The data in the current study showed that rural-to-urban migrant workers in China had experienced various forms of acculturative stress including difficulties in adapting to the environment, work-related stress, family-related stress, financial hardship, and lack of sense of belonging to cities. Conclusion: Rural-to-urban migration in China is a challenging transition with significant acculturative stress and demands for major adjustments among migrant workers. The assessment and management of acculturative stress is a necessary first step in providing mental health services to migrant workers. [ABSTRACT FROM AUTHOR]

In the past decade, developing countries have been experiencing rapid land use and land cover changes, including deforestation and cultivation of previously forested land. However, little is known about the impact of deforestation and land-use changes on the life history of malaria vectors and their effects on malaria transmission. This study examined the effects of deforestation and crop cultivation on the adult survivorship of major malaria mosquitoes, Anopheles sinensis and An. minimus in the China-Myanmar border region. We examined three conditions: indoor, forested, and banana plantation. Mean survival time of An. sinensis in banana plantation environment was significantly longer than those in forested environment, and mosquitoes exhibited the longest longevity in the indoor environment. This pattern held for both males and females, and also for An. minimus. To further test the effect of temperature on mosquito survival, we used two study sites with different elevation and ambient temperatures. Significantly higher survivorship of both species was found in sites with lower elevation and higher ambient temperature. Increased vector survival in the deforested area could have an important impact on malaria transmission in Southeast Asia. Understanding how deforestation impacts vector survivorship can help combat malaria transmission. [ABSTRACT FROM AUTHOR]

Background: Millions of people move from rural areas to urban areas in China to pursue new opportunities while leaving their spouses and children at rural homes. Little is known about the impact of migration-related separation on mental health of these rural migrants in urban China. Methods: Survey data from a random sample of rural-to-urban migrants (n = 1113, aged 18–45) from Wuhan were analyzed. The Domestic Migration Stress Questionnaire (DMSQ), an instrument with four subconstructs, was used to measure migration-related stress. The relationship between spouse/child separation and stress was assessed using survey estimation methods to account for the multi-level sampling design. Results: 16.46% of couples were separated from their spouses (spouse-separation only), 25.81% of parents were separated from their children (child separation only). Among the participants who married and had children, 5.97% were separated from both their spouses and children (double separation). Spouse-separation only and double separation did not scored significantly higher on DMSQ than those with no separation. Compared to parents without child separation, parents with child separation scored significantly higher on DMSQ (mean score = 2.88, 95% CI: [2.81, 2.95] vs. 2.60 [2.53, 2.67], p < .05). Stratified analysis by separation type and by gender indicated that the association was stronger for child-separation only and for female participants. Conclusion: Child-separation is an important source of migration-related stress, and the effect is particularly strong for migrant women. Public policies and intervention programs should consider these factors to encourage and facilitate the co-migration of parents with their children to mitigate migration-related stress. [ABSTRACT FROM AUTHOR]

Both pulmonary tuberculosis (PTB) and intestinal helminth infection (IHI) affect millions of individuals every year in China. However, the national-scale estimation of prevalence predictors and prevalence maps for these diseases, as well as co-endemic relative risk (RR) maps of both diseases’ prevalence are not well developed. There are co-endemic, high prevalence areas of both diseases, whose delimitation is essential for devising effective control strategies. Bayesian geostatistical logistic regression models including socio-economic, climatic, geographical and environmental predictors were fitted separately for active PTB and IHI based on data from the national surveys for PTB and major human parasitic diseases that were completed in 2010 and 2004, respectively. Prevalence maps and co-endemic RR maps were constructed for both diseases by means of Bayesian Kriging model and Bayesian shared component model capable of appraising the fraction of variance of spatial RRs shared by both diseases, and those specific for each one, under an assumption that there are unobserved covariates common to both diseases. Our results indicate that gross domestic product (GDP) per capita had a negative association, while rural regions, the arid and polar zones and elevation had positive association with active PTB prevalence; for the IHI prevalence, GDP per capita and distance to water bodies had a negative association, the equatorial and warm zones and the normalized difference vegetation index had a positive association. Moderate to high prevalence of active PTB and low prevalence of IHI were predicted in western regions, low to moderate prevalence of active PTB and low prevalence of IHI were predicted in north-central regions and the southeast coastal regions, and moderate to high prevalence of active PTB and high prevalence of IHI were predicted in the south-western regions. Thus, co-endemic areas of active PTB and IHI were located in the south-western regions of China, which might be determined by socio-economic factors, such as GDP per capita. [ABSTRACT FROM AUTHOR]

Background: Data from the Chinese police service suggest substantial reductions in road traffic injuries since 2002, but critics have questioned the accuracy of those data, especially considering conflicting data reported by the health department. Methods: To address the gap between police and health department data and to determine which may be more accurate, we conducted a simulation study based on the modified Smeed equation, which delineates a non-linear relation between road traffic mortality and the level of motorization in a country or region. Our goal was to simulate trends in road traffic mortality in China and compare performances in road traffic safety management between China and 13 other countries. Results: Chinese police data indicate a peak in road traffic mortalities in 2002 and a significant and a gradual decrease in population-based road traffic mortality since 2002. Health department data show the road traffic mortality peaked in 2012. In addition, police data suggest China’s road traffic mortality peaked at a much lower motorization level (0.061 motor vehicles per person) in 2002, followed by a reduction in mortality to a level comparable to that of developed countries. Simulation results based on health department data suggest high road traffic mortality, with a mortality peak in 2012 at a moderate motorization level (0.174 motor vehicles per person). Comparisons to the other 13 countries suggest the health data from China may be more valid than the police data. Conclusion: Our simulation data indicate China is still at a stage of high road traffic mortality, as suggested by health data, rather than a stage of low road traffic mortality, as suggested by police data. More efforts are needed to integrate safety into road design, improve road traffic management, improve data quality, and alter unsafe behaviors of pedestrians, drivers and passengers in China. [ABSTRACT FROM AUTHOR]

Objective: To understand the disease burden due to Herpes Zoster (HZ) among people aged ≥50 years old in China and provide baseline data for future similar studies, and provide evidence for development of herpes zoster vaccination strategy. Methods: Retrospective cohort study was conducted in 4 townships and one community. A questionnaire was used to collect information on incidence and cost of HZ among people aged ≥ 50 years old. Results: The cumulative incidence rate was 22.6/1,000 among people aged ≥ 50 years old. The average annual incidence rate of HZ was 3.43/1,000 among people aged ≥ 50 years old in 2010–2012. Cumulative incidence and average annual incidence rate increased with age: the cumulative incidence of HZ among people aged ≥ 80 years old was 3.34 times of that among 50- years old (52.3/1000vs15.7/1,000); average annual incidence rate rises from 2.66/1,000 among 50- years old to 8.55/1,000 among 80- year old. Cumulative incidence and average annual incidence rate for females were higher than that for males (cumulative incidence, 26.5/1000vs18.7/1,000; annual incidence rate, 3.95/1000vs2.89/1,000). Cumulative incidence and average annual incidence rate in urban were higher than in rural (cumulative incidence, 39.5/1000vs 17.2/1,000; annual incidence rate, 7.65/1000vs2.06/1,000). The hospitalization rate of HZ was 4.53%. And with the increase of age, the rate has an increasing trend. HZ costs 945,709.5 RMB in total, corresponding to 840.6 RMB per patient with a median cost of 385 RMB (interquartile range 171.7–795.6). Factors associated with cost included the first onset year, area, whether hospitalized and whether sequelae left. Conclusion: Incidence rate, complications, hospitalization rate and average cost of HZ increase with age. We recommend that the HZ vaccinations should target people aged ≥50 years old if Zoster vaccine is licensed in China. [ABSTRACT FROM AUTHOR]

Background: Our objective is to compare the cost-utility of icotinib and gefitinib for the second-line treatment of advanced non-small cell lung cancer (NSCLC) from the perspective of the Chinese healthcare system. Methods: Model technology was applied to assess the data of randomized clinical trials and the direct medical costs from the perspective of the Chinese healthcare system. Five-year quality-adjusted life years (QALYs) and incremental cost-utility ratios (ICURs) were calculated. One-way and probabilistic sensitivity analyses (PSA) were performed. Results: Our model suggested that the median progression-free survival (PFS) was 4.2 months in the icotinib group and 3.5 months in the gefitinib group while they were 4.6 months and 3.4 months, respectively, in the trials. The 5-year QALYs was 0.279 in the icotinib group and 0.269 in the gefitinib group, and the according medical costs were $10662.82 and $13127.57. The ICUR/QALY of icotinib versus gefitinib presented negative in this study. The most sensitive parameter to the ICUR was utility of PFS, ranging from $-1,259,991.25 to $-182,296.61; accordingly the icotinib treatment consistently represented a dominant cost-utility strategy. Conclusions: The icotinib strategy, as a second-line therapy for advanced NSCLC patients in China, is the preferred strategy relative to gefitinib because of the dominant cost-utility. In addition, icotinib shows a good curative effect and safety, resulting in a strong demand for the Chinese market. [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]

Background: China accounted for 87% (9.8 million/11.3 million) of all hand, foot, and mouth disease (HFMD) cases reported to WHO during 2010-2014. Enterovirus 71 (EV71) is responsible for most of the severe HFMD cases. Three EV71 vaccines recently demonstrated good efficacy in children aged 6-71 mo. Here we assessed the cost-effectiveness of routine pediatric EV71 vaccination in China.Methods and Findings: We characterized the economic and health burden of EV71-associated HFMD (EV71-HFMD) in China using (i) the national surveillance database, (ii) virological surveillance records from all provinces, and (iii) a caregiver survey on the household costs and health utility loss for 1,787 laboratory-confirmed pediatric cases. Using a static model parameterized with these data, we estimated the effective vaccine cost (EVC, defined as cost/efficacy or simply the cost of a 100% efficacious vaccine) below which routine pediatric vaccination would be considered cost-effective. We performed the base-case analysis from the societal perspective with a willingness-to-pay threshold of one times the gross domestic product per capita (GDPpc) and an annual discount rate of 3%. We performed uncertainty analysis by (i) accounting for the uncertainty in the risk of EV71-HFMD due to missing laboratory data in the national database, (ii) excluding productivity loss of parents and caregivers, (iii) increasing the willingness-to-pay threshold to three times GDPpc, (iv) increasing the discount rate to 6%, and (v) accounting for the proportion of EV71-HFMD cases not registered by national surveillance. In each of these scenarios, we performed probabilistic sensitivity analysis to account for parametric uncertainty in our estimates of the risk of EV71-HFMD and the expected costs and health utility loss due to EV71-HFMD. Routine pediatric EV71 vaccination would be cost-saving if the all-inclusive EVC is below US$10.6 (95% CI US$9.7-US$11.5) and would remain cost-effective if EVC is below US$17.9 (95% CI US$16.9-US$18.8) in the base case, but these ceilings could be up to 66% higher if all the test-negative cases with missing laboratory data are EV71-HFMD. The EVC ceiling is (i) 10%-14% lower if productivity loss of parents/caregivers is excluded, (ii) 58%-84% higher if the willingness-to-pay threshold is increased to three times GDPpc, (iii) 14%-19% lower if the discount rate is increased to 6%, and (iv) 36% (95% CI 23%-50%) higher if the proportion of EV71-HFMD registered by national surveillance is the same as that observed in the three EV71 vaccine phase III trials. The validity of our results relies on the following assumptions: (i) self-reported hospital charges are a good proxy for the opportunity cost of care, (ii) the cost and health utility loss estimates based on laboratory-confirmed EV71-HFMD cases are representative of all EV71-HFMD cases, and (iii) the long-term average risk of EV71-HFMD in the future is similar to that registered by national surveillance during 2010-2013.Conclusions: Compared to no vaccination, routine pediatric EV71 vaccination would be very cost-effective in China if the cost of immunization (including all logistical, procurement, and administration costs needed to confer 5 y of vaccine protection) is below US$12.0-US$18.3, depending on the choice of vaccine among the three candidates. Given that the annual number of births in China has been around 16 million in recent years, the annual costs for routine pediatric EV71 vaccination at this cost range should not exceed US$192-US$293 million. Our results can be used to determine the optimal vaccine when the prices of the three vaccines are known. [ABSTRACT FROM AUTHOR]

Objective: The contribution of unhealthy dietary patterns to the epidemic of obesity has been well recognized. Differences in availability of foods may have an important influence on individual eating behaviors and health disparities. This study examined the availability of food stores and food service places by city characteristics on city level of income and urbanization. Methods: The cross-sectional survey was comprised of two parts: (1) an on-site observation to measure availability of food stores and food service places in 12 cities of China; (2) an in-store survey to determine the presence of fresh/frozen vegetables or fruits in all food stores. Trained investigators walked all the streets/roads within study tracts to identify all the food outlets. An observational survey questionnaire was used in all food stores to determine the presence of fresh/frozen vegetables or fruits. Urbanization index was determined for each city using a principal components factor analysis. City level of income and urbanization and numbers of each type of food stores and food service places were examined using negative binomial regression models. Results: Large-sized supermarkets and specialty retailers had higher number of fresh/frozen vegetables or fruits sold compared to small/medium-sized markets. High-income versus low-income, high urbanized versus low urbanized areas had significantly more large-sized supermarkets and fewer small/medium-sized markets. In terms of restaurants, high urbanized cities had more western fast food restaurants and no statistically significant difference in the relative availability of any type of restaurants was found between high- and low-income areas. Conclusions: The findings suggested food environment disparities did exist in different cities of China. [ABSTRACT FROM AUTHOR]