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The Pearl River Estuary (PRE), the largest estuary in Southern China, historically has suffered from metal contamination as a result of inputs from different riverine discharges. Determining the sources of metals accumulation in local aquatic flora and fauna remains a great challenge for this estuarine system with complex water circulation. In this study, Zn isotope ratios were measured in local oysters (Crassostrea hongkongensis) collected at 8 locations in the estuary on four occasions from 2014 to 2018, to better understand and assess the contamination sources. The results showed no significant differences (p < 0.05) in δ66Zn values in oysters among the four sampling dates within individual sites. However, approximately a 0.67‰ (range from -0.66‰ to 0.01‰) difference in average δ66Zn values was consistently found in oysters collected from the east side of the estuary compared to the west side, despite their comparable Zn concentrations. A mixing model was subsequently used to estimate the relative contributions from various sources to the δ66Zn values in these oysters. The mixing model predicts that zinc derived from the dissolved fraction (approximately 80 %) was the dominant uptake pathway for oysters collected at the east shore whereas approximately 50 % of the Zn in oysters collected at the west shore was derived from the particulate fraction. The mixing model also was used to estimate the relative impacts of fresh versus saline water on the measured δ66Zn values. Contributions from these two sources also varied between the east and west shores. This study presents the first data for Zn isotope ratios in oysters from the PRE, providing new insight for using Zn isotope ratios in oysters as a powerful tracer of sources in a complex estuarine system. [Display omitted] • Zn isotope ratios were measured in oysters from a contaminated estuary over 4 years. • Dissolved Zn was the dominant uptake pathway in oysters at the east shore. • Around 40 % of Zn in oysters at the west shore was derived from the particulate fraction. • Contributions from freshwater and marine waters of Zn varied between the east and west shores. • Zn isotope ratios are powerful source tracing in complex estuarine system. [ABSTRACT FROM AUTHOR]

This paper studies China's response to the Severe Acute Respiratory Syndrome (SARS) epidemic in 2003. It first assesses the current nature, structure and development of the Chinese infectious disease system, and then evaluates the state response to infectious disease epidemics. Turning to the role of non-state actors, it discusses their contributions to the state's efforts. Following a case study of Shaanxi province, it concludes that the SARS outbreak reveals the state's capacity to re-centralize power in the face of high-priority events. However, it also concludes that this government capacity alone, while necessary, is not sufficient to overcome SARS. [ABSTRACT FROM AUTHOR]

The objectives of this study were (1) to develop and test a new index, the Chronological Fluorosis Assessment (CFA) Index, for measuring variation in the chronological distribution and intensity of dental fluorosis, and (2) to determine whether the new index was sufficiently sensitive for detection of a decline in dental fluorosis corresponding to the reduction in the waterborne fluoride level in Hong Kong. According to the CFA Index, the cervical, middle, and incisal third divisions of the labial surface of a maxillary central incisor crown are each classified into one of six categories of an ordinal scale of fluorosis. Data from 1295 life-long resident Hong Kong Chinese children exposed to known water fluoride concentrations were analyzed. Fluorosis declined from incisal to cervical in 41% of cases, and a reverse gradient was apparent in 29%. Overall, fluorosis intensity was higher on incisal thirds than on both middle and cervical thirds. However, when tooth thirds were regrouped according to common 16-month developmental periods, in order to control for time-related variation in fluoride concentration, the incisal-middle difference was of reduced statistical significance, and both the incisal-cervical and the middle-cervical differences became insignificant. A regression analysis of CFA Index on cohort indicated a significant cohort-related fluorosis decrease, in relation to cervical, middle, and incisal tooth thirds. It was concluded (1) that fluorosed enamel which forms in chronological sequence tends toward a uniform intensity, and (2) that the new index was sufficiently sensitive for a decline to be measured in dental fluorosis in Hong Kong. [ABSTRACT FROM AUTHOR]

A sociological study was conducted in 1987 on a sample of 490 Hong Kong Chinese civil servants for the purpose of investigating factors which influenced their utilization of a freely available Government dental service. The proportions of regular, irregular and non-users of the dental service were 69, 18, and 13% respectively. Regular users had a higher educational standard and income level than the other two user-types. Most of the regular users attended the dental clinics for a check-up. The irregular users did not regularly utilize the service mainly because it took a long time to obtain an appointment. Non-users referred to the long waiting time to obtain an appointment and to their perception of not having dental problems when asked to give their main reasons for not utilizing the dental service. The majority of the user-types considered that shortening the waiting time and employing more dentists would increase the utilization of the Government dental service. [ABSTRACT FROM AUTHOR]

A representative sample of Hong Kong children aged 6-8 yr was examined for dental caries, and data on possible explanatory variables for dmft were obtained from questionnaires. Variation in dmft was partially accounted for by the effect of some demographic variables and other variables having a socioeconomic base. Girls had a lower dmft index than boys, and being born in Hong Kong rather than elsewhere (that is, China) was also associated with a lower dmft index. Better dental status was strongly associated with increasing educational level of the mother, monthly household income, and with an increasingly positive perception of the questionnaire respondent's own dental status. Preschool dental visits and enrolment in the School Dental Care Service were associated with higher dmft indices. Altogether, 22.5% of the variance in dmft was explained. It was concluded that 1) demographic and socioeconomic factors significantly affect dmft variation in Hong Kong. 2) the mother's role in determining the dental status of her child is probably important, and 3) further elucidation of the variation in dmft will depend on the analysis of data pertaining to dietary and oral hygiene practices during the preschool years and to an analysis of tooth morphology, fluoride exposure, and microbiologic, salivary, and genetic factors. [ABSTRACT FROM AUTHOR]

An oral health survey was conducted in 1986 on a representative sample of primary school children in Hong Kong. 1483 Chinese children of both sexes, aged 6-12 yr, attending 56 primary schools were surveyed. The DMFT index for the 6- yr-olds was 0.1, and for the 12-yr-olds it was 1.5. Forty percent of the 12-yr-olds were clinically caries-free. The permanent molars constituted 90% of the total caries experience of the 12-yr-aids. Over 90% of the caries lesions were found in pits and fissures. The dental caries treatment need in the permanent dentition was low and of the simple type. A great reduction in the dental caries experience of the permanent dentition of children has occurred since the introduction of water fluoridation 25 yr ago. In addition to treatment care, preventive measures should be provided by the School Dental Care Service for children with a high caries risk. [ABSTRACT FROM AUTHOR]

Introduction: Village clinics (VCs) are the foundation of the three-tiered health service system in China, delivering basic and routine outpatient services to citizens in rural China. VC technical efficiency and its convergence play a critical role in policy decisions regarding the distribution of health service resources in rural China., Methods: This study measured VC technical efficiency (using the slacks-based measure model), its convergence (using the convergence model), and the factors that influence the convergence in Shanxi Province, China. Data were obtained from the Shanxi Rural Health Institute 2014-2018 Health Statistics Report , which involved 3,543 VCs., Results: The results showed that VC technical efficiency was low and differed by region. There was no α convergence in VC technical efficiency, but evidence of β convergence was found in Shanxi. The main factors that influence convergence were the building area of each VC (BA), proportion of government subsidies (PGS), and ratio of total expenditure to total income of each VC (RTETI)., Conclusion: The government should increase investments in VCs and improve VC technical efficiency. Meanwhile, the government should be aware of and take measures to curb the inequity in VC technical efficiency among different regions and take suitable measures to curb this disparity., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2024 Ye, Evans, Huang, Xu and Lu.)

This study, inspired by the Risk Information Seeking and Processing (RISP) model, examines the mechanisms by which perceived hazard characteristics and the informational subjective norms of Chinese youth, aged from 14 to 44 years old, become associated with their intentions to seek cancer risk information online. A sample of 684 Chinese youths was collected from four cities in Mainland China with results revealing that perceived hazard characteristics and informational subjective norms motivate their online cancer risk information seeking intentions. Specifically, perceived probability, perceived severity, and institutional trust are positively related to negative affect, however the relationship between personal control and negative affect is not significant. Institutional trust and personal control are positively related to positive affect while perceived probability and perceived severity have no significant effect on positive affect. Negative affect and informational subjective norms are positively related to perceived information insufficiency, while the relationship between positive affect and perceived information insufficiency is not significant. Negative affect, positive affect, informational subjective norms, and perceived information insufficiency are all positively related to the online cancer risk information seeking intentions of Chinese youth.

China introduced the county medical community (CMC) reform, aimed to provide high-quality medical resources to rural citizens, in 2017. This study examines the impact of the reform on the medical service efficiency of county-level public general hospitals in Shanxi Province, China. In total, 92 county-level public general hospitals from Shanxi Province were taken as the research objective, and the super-efficiency SBM-DEA model was applied to measure medical service efficiency. Further, a two-way fixed-effect model was used to evaluate the impact of CMC reform on the medical service efficiency of county-level public general hospitals by using health statistics data from 2014 to 2018. The study reveals that the CMC reform improved the medical service efficiency of county-level public general hospitals by 15.6%. Moreover, the CMC reform had regional heterogeneity in its impact on the medical service efficiency of county-level public general hospitals. The CMC reform improved the medical service efficiency of hospitals in the southern region more than in the northern region of the province. The medical service efficiency of hospitals in the central region was also improved by CMC reform, but the causal relationship was not found significant. Further, hospital-level factors (e.g., fixed assets, hospital stay, and regional health center) and environmental factors (e.g., GDP, population, urbanization rate, and government subsidies) affected the medical service efficiency of county-level public hospitals during the process of promoting the CMC reform., Competing Interests: The authors declare no conflict of interest..

Government agencies around the world are increasingly using social media to promote public engagement with government-initiated activities, such as Household Waste Separation (HWS). However, existing studies fail to examine how governments can use their official social media accounts to promote public engagement with HWS. This pioneering study investigates the effects of dialogic loop, media richness, content theme, and emotional valence on public engagement with HWS through Government Social Media (GSM). Moreover, the influencing mechanisms are explored by examining the moderating role of social media capital. In total, 1795 posts were scraped from the official Sina Weibo accounts of seventeen Shanghai governments and later analyzed. Results reveal that dialogic loop positively predicts public engagement with HWS through GSM, but media richness negatively affects public engagement. Content themes have significantly different impacts on the level of public engagement with HWS through GSM. Unexpectedly, the effect of emotional valence is not significant. This study is the first of its kind to demonstrate the moderating role of social media capital which is seen to weaken the positive effect of dialogic loop on public engagement with HWS through GSM and mitigate the negative effect of media richness., (Copyright © 2022 Elsevier Ltd. All rights reserved.)

Background: In recent years, the Chinese government has frequently issued policies to promote the rapid development of telemedicine with the aim of improving the primary medical service capacity and public medical conditions in remote areas of China., Methods: A three-dimensional analytical framework was built to analyze the rationality of existing national telemedicine policies, providing valuable insights for the future construction and formulation of telemedicine policy. In total, 271 telemedicine policy documents with 537 policy clauses in relation to telemedicine were identified, and they are subjected to a rigorous analysis from the perspectives of policy instrument, telemedicine development stage, and telemedicine development element., Results: China's telemedicine policies have grown rapidly since 1997 and gradually moved towards exploratory stage (9/551, 1.68%), normative stage (93/551, 17.62%), mature stage (239/551, 44.51%), and rapid growth stage (196/551, 36.50%). Meanwhile, the types of telemedicine policy instruments adopted include mandatory tools (360/551, 61.71%), voluntary tools (82/551, 14.88%), information tools (74/551, 13.43%), and economic tools (55/551, 9.98%). The majority of telemedicine policies were related to platform construction, accounting for 45.07% (242/537), while telemedicine policies relating to service operation (20.67%, 111/537), service application (20.86%, 112/537), and organizational management (13.41%, 72/537) were comparatively less., Conclusion: China's policy instruments have developed from simplification to diversification, from relative imbalance to equilibrium, and the balance between the vertical and horizontal objectives of the policy have also strengthened. However, some policy tools are improperly applied at the policy stage, and there is still room for improvement in the allocation of policy elements., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2022 Elsevier B.V. All rights reserved.)

The COVID-19 pandemic has demonstrated that social media can impact society both positively (e.g., keeping citizens connected and informed) and negatively (e.g., the deliberate spreading of misinformation). This study aims to examine the underlying mechanisms of the relationship between official social media accounts and the infodemic, experienced during the first wave of COVID-19 in China. A theoretical model is proposed to examine how official social media accounts affected the infodemic during this period. In total, 1398 questionnaire responses were collected via WeChat and Tencent QQ, two leading Chinese social media platforms. Data analysis was conducted using Partial Lease Squares Structural Equation Modeling (PLS-SEM), moderation effect analysis, and mediation effect analysis. Results indicate that the Information Quality (IQ) of Official social media accounts (β = −0.294, p < 0.001) has a significant negative effect on the infodemic. Mediation effect analysis revealed that both social support (β = −0.333, 95% Boot CI (−0.388, −0.280)) and information cascades (β = −0.189, 95% Boot CI (−0.227, −0.151)) mediate the relationship between IQ and the infodemic. Moderation effect analysis shows that private social media usage (F = 85.637, p < 0.001) positively moderates the relationship between IQ and the infodemic, while health literacy has a small negative moderation effect on the relationship between IQ and the infodemic. Our findings show that, in the context of Chinese media, official social media accounts act as a major source of information for influencing the infodemic through increasing social support and reducing information cascades for citizens.

Widespread misinformation about COVID-19 poses a significant threat to citizens long-term health and the combating of the disease. To fight the spread of misinformation, Chinese governments have used official social media accounts to participate in fact-checking activities. This study aims to investigate why citizens share fact-checks about COVID-19 and how to promote this activity. Based on the elaboration likelihood model, we explore the effects of peripheral cues (social media capital, social media strategy, media richness, and source credibility) and central cues (content theme and content importance) on the number of shares of fact-checks posted by official Chinese Government social media accounts. In total, 820 COVID-19 fact-checks from 413 Chinese Government Sina Weibo accounts were obtained and evaluated. Results show that both peripheral and central cues play important roles in the sharing of fact-checks. For peripheral cues, social media capital and media richness significantly promote the number of shares. Compared with the push strategy, both the pull strategy and networking strategy facilitate greater fact-check sharing. Fact-checks posted by Central Government social media accounts receive more shares than local government accounts. For central cues, content importance positively predicts the number of shares. In comparison to fact-checks about the latest COVID-19 news, government actions received fewer shares, while social conditions received more shares.

Background: During the COVID-19 pandemic, growth in citizen engagement with social media platforms has enabled public health departments to accelerate and improve health information dissemination, developing transparency and trust between governments and citizens. In light of these benefits, it is imperative to learn the antecedents and underlying mechanisms for this to maintain and enhance engagement., Objective: The aim of this study is to determine the factors and influencing mechanisms related to citizen engagement with the TikTok account of the National Health Commission of China during the COVID-19 pandemic., Methods: Using a web crawler, 355 short videos were collected from the Healthy China account on TikTok (with more than 3 million followers throughout China), covering the period from January 21, 2020, to April 25, 2020. The title and video length, as well as the number of likes, shares, and comments were collected for each video. After classifying them using content analysis, a series of negative binomial regression analyses were completed., Results: Among the 355 videos, 154 (43.4%) related to guidance for clinicians, patients, and ordinary citizens, followed by information concerning the government's handling of the pandemic (n=100, 28.2%), the latest news about COVID-19 (n=61, 17.2%), and appreciation toward frontline emergency services (n=40, 11.3%). Video length, titles, dialogic loop, and content type all influenced the level of citizen engagement. Specifically, video length was negatively associated with the number of likes (incidence rate ratio [IRR]=0.19, P<.001) and comments (IRR=0.39, P<.001). Title length was positively related to the number of shares (IRR=24.25, P=.01), likes (IRR=8.50, P=.03), and comments (IRR=7.85, P=.02). Dialogic loop negatively predicted the number of shares (IRR=0.56, P=.03). In comparison to appreciative information, information about the government's handling of the situation (IRR=5.16, P<.001) and guidelines information (IRR=7.31, P<.001) were positively correlated with the number of shares, while the latest news was negatively related to the number of likes received (IRR=0.46, P=.004). More importantly, the relationship between predictors and citizen engagement was moderated by the emotional valence of video titles. Longer videos with positive titles received a higher number of likes (IRR=21.72, P=.04) and comments (IRR=10.14, P=.047). Furthermore, for short videos related to government handling of the pandemic (IRR=14.48, P=.04) and guidance for stakeholders (IRR=7.59, P=.04), positive titles received a greater number of shares. Videos related to the latest news (IRR=66.69, P=.04) received more likes if the video title displayed higher levels of positive emotion., Conclusions: During the COVID-19 pandemic, videos were frequently published on government social media platforms. Video length, title, dialogic loop, and content type significantly influenced the level of citizen engagement. These relationships were moderated by the emotional valence of the video's title. Our findings have implications for maintaining and enhancing citizen engagement via government social media., (©Qiang Chen, Chen Min, Wei Zhang, Xiaoyue Ma, Richard Evans. Originally published in the Journal of Medical Internet Research (http://www.jmir.org), 04.02.2021.)

Background: The COVID-19 pandemic has created a global health crisis that is affecting economies and societies worldwide. During times of uncertainty and unexpected change, people have turned to social media platforms as communication tools and primary information sources. Platforms such as Twitter and Sina Weibo have allowed communities to share discussion and emotional support; they also play important roles for individuals, governments, and organizations in exchanging information and expressing opinions. However, research that studies the main concerns expressed by social media users during the pandemic is limited., Objective: The aim of this study was to examine the main concerns raised and discussed by citizens on Sina Weibo, the largest social media platform in China, during the COVID-19 pandemic., Methods: We used a web crawler tool and a set of predefined search terms (New Coronavirus Pneumonia, New Coronavirus, and COVID-19) to investigate concerns raised by Sina Weibo users. Textual information and metadata (number of likes, comments, retweets, publishing time, and publishing location) of microblog posts published between December 1, 2019, and July 32, 2020, were collected. After segmenting the words of the collected text, we used a topic modeling technique, latent Dirichlet allocation (LDA), to identify the most common topics posted by users. We analyzed the emotional tendencies of the topics, calculated the proportional distribution of the topics, performed user behavior analysis on the topics using data collected from the number of likes, comments, and retweets, and studied the changes in user concerns and differences in participation between citizens living in different regions of mainland China., Results: Based on the 203,191 eligible microblog posts collected, we identified 17 topics and grouped them into 8 themes. These topics were pandemic statistics, domestic epidemic, epidemics in other countries worldwide, COVID-19 treatments, medical resources, economic shock, quarantine and investigation, patients' outcry for help, work and production resumption, psychological influence, joint prevention and control, material donation, epidemics in neighboring countries, vaccine development, fueling and saluting antiepidemic action, detection, and study resumption. The mean sentiment was positive for 11 topics and negative for 6 topics. The topic with the highest mean of retweets was domestic epidemic, while the topic with the highest mean of likes was quarantine and investigation., Conclusions: Concerns expressed by social media users are highly correlated with the evolution of the global pandemic. During the COVID-19 pandemic, social media has provided a platform for Chinese government departments and organizations to better understand public concerns and demands. Similarly, social media has provided channels to disseminate information about epidemic prevention and has influenced public attitudes and behaviors. Government departments, especially those related to health, can create appropriate policies in a timely manner through monitoring social media platforms to guide public opinion and behavior during epidemics., (©Junze Wang, Ying Zhou, Wei Zhang, Richard Evans, Chengyan Zhu. Originally published in the Journal of Medical Internet Research (http://www.jmir.org), 26.11.2020.)

Zinc isotope ratios in water and suspended particles (SP) were measured in the Pearl River Estuary (PRE), China. Site-to-site δ 66 Zn values in water varied by approximately 1.3‰ (i.e., -0.66‰ to 0.65‰ relative to IRMM-3702 in August 2017). There were larger variations in δ 66 Zn values in water collected from the east shore (i.e., -0.66‰ to 0.37‰) of the PRE close to industrialized areas, in comparison to those from the western shore (i.e., -0.23‰ to 0.13‰), indicating that the PRE was influenced by different Zn sources. The variations in δ 66 Zn values in water from estuarine locations were much larger than those collected from river mouths. Similarly, larger variations in δ 66 Zn values were observed in suspended particles (i.e., -1.45‰ to 0.63‰) relative to the water. Zinc isotopic differences (i.e., Δ 66 Zn‰) between particles and water were significantly ( p < 0.05) and linearly correlated with Zn concentrations in particles between 0.8 and 10 μm in size at most of the estuary stations, suggesting that Zn partitioning between dissolved and particulate phases influences the observed differences in Zn isotope ratios. A significant ( p < 0.0001) linear correlation between the predicted δ 66 Zn values (using variations in water salinities) vs observed δ 66 Zn values indicates that Zn isotope ratios in water in the PRE can be useful for predicting the mixing processes in the water.

Background: Since the turn of this century, the internet has become an invaluable resource for people seeking health information and answers to health-related queries. Health question and answer websites have grown in popularity in recent years as a means for patients to obtain health information from medical professionals. For patients suffering from chronic illnesses, it is vital that health care providers become better acquainted with patients' information needs and learn how they express them in text format., Objective: The aims of this study were to: (1) explore whether patients can accurately and adequately express their information needs on health question and answer websites, (2) identify what types of problems are of most concern to those suffering from chronic illnesses, and (3) determine the relationship between question characteristics and the number of answers received., Methods: Questions were collected from a leading Chinese health question and answer website called "All questions will be answered" in January 2018. We focused on questions relating to diabetes and hepatitis, including those that were free and those that were financially rewarded. Content analysis was completed on a total of 7068 (diabetes) and 6685 (hepatitis) textual questions. Correlations between the characteristics of questions (number of words per question, value of reward) and the number of answers received were evaluated using linear regression analysis., Results: The majority of patients are able to accurately express their problem in text format, while some patients may require minor social support. The questions posted were related to three main topics: (1) prevention and examination, (2) diagnosis, and (3) treatment. Patients with diabetes were most concerned with the treatment received, whereas patients with hepatitis focused on the diagnosis results. The number of words per question and the value of the reward were negatively correlated with the number of answers. The number of words per question and the value of the reward were negatively correlated with the number of answers., Conclusions: This study provides valuable insights into the ability of patients suffering from chronic illnesses to make an understandable request on health question and answer websites. Health topics relating to diabetes and hepatitis were classified to address the health information needs of chronically ill patients. Furthermore, identification of the factors affecting the number of answers received per question can help users of these websites to better frame their questions to obtain more valuable answers., (©Ziying Hong, Zhaohua Deng, Richard Evans, Haiyan Wu. Originally published in the Journal of Medical Internet Research (http://www.jmir.org), 16.04.2020.)

During the last two decades, social media has immersed itself into all facets of our personal and professional lives. The healthcare sector is no exception, with public health departments now capitalizing on the benefits that social media offers when delivering healthcare education and communication with citizens. Provincial Health Committees (PHCs) in China have begun to adopt the micro-video sharing platform, Tik Tok, to engage with local residents and communicate health-related information. This study investigates the status quo of official Tik Tok accounts managed by PHCs in mainland China. In total, 31 PHC accounts were analyzed during August 2019, while the top 100 most liked micro-videos were examined using content analysis. Coding included three major aspects: Quantified Impact, Video Content, and Video Form. 45.2% (n = 14) of PHCs had official Tik Tok accounts. A limited number of accounts (n = 2) were yet to upload a micro-video, while most (n = 9) had uploaded their first micro-video during 2019. For the top 100 most liked micro-videos, a sharp difference was observed in terms of number of Likes, Comments and Reposts. Videos containing cartoons or documentary-style content were most frequently watched by citizens. Similarly, content that promoted professional health or provided knowledge of diseases was frequently viewed. Content containing original music, formal mandarin language, subtitles, and which lasted less than 60 s, were most frequently followed. It is considered a missed opportunity that most PHCs struggle to take advantage of the Tik Tok platform, especially given its growing popularity and daily increase in account creation.

Background: Widespread adoption and continued developments in mobile health care technologies have led to the improved accessibility and quality of medical services. In China, WeChat, an instant messaging and social networking app released by the company Tencent, has developed a specific type of user account called WeChat official account (WOA), which is now widely adopted by hospitals in China. It enables health care providers to connect with local citizens, allowing them to, among other actions, send regular updates through mass circulation. However, with the diversity in function provided by WOA, little is known about its major constitution as well as the influence factors on the WeChat communication index (WCI). The WCI has been widely used in social media impact ranking with various types of WeChat content to fully reflect the dissemination and coverage of tweets as well as the maturity and impact of WOA., Objective: There are two typical WOAs available to users, namely, WeChat subscription account (WSSA) and WeChat service account (WSVA). The biggest difference between them is the frequency of messages transmitted. This study aimed to explore the function constitution of WSVA adopted by top tertiary hospitals in China and the major contributors of the WCI score., Methods: A total of 681 top tertiary hospitals were selected from the Hospital Quality Monitoring System; the WOA of every top tertiary hospital was retrieved in the WeChat app. We divided core functional items of WSVAs using categorical principal component analysis. To elicit the factors that influenced the use of WSVA, quantile regression was employed to analyze the WCI score., Results: From the 668 WOAs identified, adoption of WSVAs (543/668, 81.3%) was more than that of WSSAs (125/668, 18.7%). Functional items of WSVAs were categorized into four clusters: (1) hospital introduction, (2) medical services, (3) visiting assistants, and (4) others. With regard to the influence factors on the WCI, the impact of the activity index of WSVA and the total visiting number of outpatients and emergencies on WCI were statistically significant and positive in all quantiles. However, the year of certification, the type of hospital, the year of public hospital reform, and the number of beds merely affected the WCI at some quantiles., Conclusions: Our findings are considered helpful to tertiary hospitals in developing in-depth functional items that improve patient experience. The tertiary hospitals should take full advantage of times of posting and provide high-quality tweets to meet the various needs of patients., (©Lining Shen, Shimin Wang, Wenqiang Chen, Qiang Fu, Richard Evans, Fuqiang Lan, Wei Li, Juan Xu, Zhiguo Zhang. Originally published in the Journal of Medical Internet Research (http://www.jmir.org), 09.12.2019.)

Background: Social media has become the most popular communication tool used by Chinese citizens, including expectant mothers. An increasing number of women have adopted various forms of social media channels, such as interactive websites, instant messaging, and mobile apps, to solve problems and obtain answers to queries during pregnancy. Although the use of the internet by pregnant women has been studied extensively worldwide, limited research exists that explores the changing social media usage habits in China, where the 1 child policy ended in 2015., Objective: This study aimed to (1) present the status quo of pregnancy-related information seeking and sharing via social media among Chinese expectant mothers, (2) reveal the impact of social media usage, and (3) shed light on pregnancy-related health services delivered via social media channels., Methods: A qualitative approach was employed to examine social media usage and its consequences on pregnant women. A total of 20 women who had conceived and were at various stages of pregnancy were interviewed from July 20 to August 10, 2017. Thematic analysis was conducted on the collected data to identify patterns in usage., Results: Overall, 80% (16/20) of participants were aged in their 20s (mean 28.5 years [SD 4.3]). All had used social media for pregnancy-related purposes. For the seeking behavior, 18 codes were merged into 4 themes, namely, gravida, fetus, delivery, and the postpartum period; whereas for sharing behaviors, 10 codes were merged into 4 themes, namely, gravida, fetus, delivery, and caretaker. Lurking, small group sharing, bad news avoidance, and cross-checking were identified as the preferred patterns for using social media. Overall, 95% (19/20) of participants reported a positive mental impact from using social media during their pregnancy., Conclusions: It is indisputable that social media has played an increasingly important role in supporting expectant mothers in China. The specific seeking and sharing patterns identified in this study indicate that the general quality of pregnancy-related information on social media, as well as Chinese culture toward pregnancy, is improving. The new themes that merge in pregnancy-related social media use represent a shift toward safe pregnancy and the promotion of a more enjoyable pregnancy. Future prenatal care should provide further information on services related to being comfortable during pregnancy and reducing the inequality of social media-based services caused by the digital divide., (©Chengyan Zhu, Runxi Zeng, Wei Zhang, Richard Evans, Rongrong He. Originally published in the Journal of Medical Internet Research (http://www.jmir.org), 04.12.2019.)

Background: Nowadays, patients are seeking physician information more frequently via the internet. Physician-rating websites (PRWs) have been recognized as the most convenient way to gain insight and detailed information about specific physicians before receiving consultation. However, little is known about how the information provided on PRWs may affect patients' decisions to seek medical advice., Objective: This study aimed to examine whether the physicians' online efforts and their reputation have a relationship with patients' choice of physician on PRWs., Methods: A model, based on social exchange theory, was developed to analyze the factors associated with the number of online patients. A 3-wave data collection exercise, covering 4037 physicians on China's Good Doctor website, was conducted during the months of February, April, and June 2017. Increases in consultation in a 60-day period were used as the dependent variable, whereas 2 series of data were analyzed using linear regression modeling. The fixed-effect model was used to analyze the 3-wave data., Results: The adjusted R 2 value in the linear regression models were 0.28 and 0.27, whereas in the fixed-effect model, it was .30. Both the linear regression and fixed-effect models yielded a good fit. A positive effect of physicians' effort on the aggregated number of online patients was identified in all models (R 2 =0.30 and R 2 =0.37 in 2 regression models; R 2 =0.23 in fixed effect model; P<.001). The proxies of physicians' reputations indicated different results, with total number of page views of physicians' homepages (R 2 =0.43 and R 2 =0.46; R 2 =0.16; P<.001) and number of votes received (R 2 =0.33 and R 2 =0.27; R 2 =0.43; P<.001) being seen as positive. Virtual gifts were not significant in all models, whereas thank-you messages were only significant in the fixed-effect model (R 2 =0.11; P=.02). The effort made by physicians online is positively associated with their aggregated number of patients consulted, whereas the effect of a physician's reputation remains uncertain. The control effect of a physician's title and hospital's level was not significant in all linear regressions., Conclusions: Both the effort and reputation of physicians online contribute to the increased number of online patients' consultation; however, the influence of a physician's reputation varies. This may imply that physicians' online effort and reputation are critical in attracting patients and that strategic manipulation of physician profiles is worthy of study. Practical insights are also discussed., (©Zhaohua Deng, Ziying Hong, Wei Zhang, Richard Evans, Yanyan Chen. Originally published in the Journal of Medical Internet Research (http://www.jmir.org), 08.03.2019.)

Objectives: The combination of biomedicine and traditional and complementary medicine (T&CM) is often referred to as integrative medicine. However, the degree to which the medical disciplines are integrated varies between medical settings, and it is believed by some to be impossible due to epistemological and paradigmatic differences. Clinicians' perspectives are important determinants of how different medical disciplines are used together. This study explores the perspectives of experienced Chinese medicine practitioners when asked about the most ethical model (opposition, integration, or pluralism) for the relationship between biomedicine and T&CM., Design: Thirty-one Chinese medicine practitioners, undertaking a doctoral upgrade program at the Pacific College of Oriental Medicine, participated in this study. Participants were asked to read a publication discussing three models (opposition, integration, and pluralism) for the relationship between biomedicine and T&CM and then discuss, via an online forum within Moodle learning management system, the most ethical model. An inductive content analysis of the forum posts was undertaken to identify common themes, followed by member checking., Results: The data were found to contain six major and six minor themes. There was a clear preference for pluralism. The Chinese medicine practitioners expressed reservations about the integrative model, and, above all, cared about the quality of patient care. Much dialogue occurred around issues related to a power imbalance within health care, and possible cooptation issues. Paradigmatic differences and a lack of compatibility between biomedical research models and the practice of Chinese medicine were seen as problematic to the validity of research findings. Interprofessional education was viewed as critical for the development of respect, shared patient care, and referrals between clinicians from different disciplines., Conclusions: This study provides insight into the issues associated with combining biomedicine and T&CM that are perceived by Chinese medicine practitioners. Such insights are important for the development and management of clinical settings that provide complementary and integrative health care, especially as the provision of insurance coverage for T&CM increases.

Rare earth element (REE) concentrations and patterns were measured in surface water, suspended particles (SP) and oysters from the Pearl River Estuary, China. During the rainy season of 2017, higher REE concentrations were found at the stations in the estuary (ΣREE = 0.06-0.42 μg L -1 ) than those at the river mouths (referred to as 'outlet' stations, ΣREE = 0.001-0.14 μg L -1 ). However, the reverse occurred in the dry season of 2016 (ΣREE = 0.07-0.16 μg L -1 in the mid-estuary vs. 0.001-0.02 μg L -1 in the outlet stations). Elevated concentrations of Pr, Nd, Dy and Ho, relative to the other REEs were found in water in both seasons at most sampling locations. However, in some estuary stations, no anomalies were detected in the SP or in the oysters while some anomalies were seen in SP from the outlet stations. Significant correlations between REE concentrations in SP and oysters as well as between both total REE concentrations and the La/Yb ratio (reflecting enhanced accumulation of light REEs (LREEs)) in oysters indicate that, in the Pearl River Estuary, the dominant REE uptake pathway in oysters is from particles. The elevated concentrations of Pr, Nd, Dy and Ho, which are reported here for the first time suggest that elevated levels of these elements may result from REE recycling and other industrialized activities in this area of southern China. Specific REEs could be used to indicate emerging contamination by the modern REE industry; furthermore, REE anomalies and patterns may be suitable tools to track REE sources., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

Background: Social media has penetrated all walks of life. Chinese health care institutions are increasingly utilizing social media to connect with their patients for better health service delivery. Current research has focused heavily on the use of social media in developed countries, with few studies exploring its usage in the context of developing countries, such as China. Tertiary hospitals in China are usually located in city centers, and they serve as medical hubs for multiple regions, with comprehensive and specialized medical care being provided. These hospitals are assumed to be the pioneers in creating official social media accounts to connect with their patients due to the fact that they appear to have more resources to support this innovative approach to communication and health care education., Objective: The objective of our study was to examine China's best tertiary hospitals, as recognized by The National Health Commission of the People's Republic of China (NHCPRC), and to map out the landscape of current social media usage by hospitals when engaging with patients., Methods: We examined the best 705 tertiary hospitals in China by collecting and analyzing data regarding their usage of popular Chinese social media apps Sina Weibo and WeChat. The specific data included (1) hospital characteristics (ie, time since established, number of beds, hospital type, and regions or localities) and (2) status of social media usage regarding two of the most popular local social media platforms in China (ie, time of initiation, number of followers, and number of tweets or posts). We further used a logistic regression model to test the association between hospital characteristics and social media adoption., Results: Of all, 76.2% (537/705) tertiary referral hospitals have created official accounts on either Sina Weibo or WeChat, with the latter being more popular among the two. In addition, our study suggests that larger and newer hospitals with greater resources are more likely to adopt social media, while hospital type and affiliation with universities are not significant predictors of social media adoption among hospitals., Conclusions: Our study demonstrated that hospitals are more inclined to use WeChat. The move by hospitals from Sina Weibo to WeChat indicates that patients are not satisfied by mere communication and that they now place more value on health service delivery. Meanwhile, utilizing social media requires comprehensive thinking from the hospital side. Once adopted, hospitals are encouraged to implement specific rules regarding social media usage. In the future, a long journey still lies ahead for hospitals in terms of operating their official social media accounts., (©Wei Zhang, Zhaohua Deng, Richard Evans, Fei Xiang, Qing Ye, Runxi Zeng. Originally published in the Journal of Medical Internet Research (http://www.jmir.org), 09.08.2018.)

Background: With the rise in popularity of Web 2.0 technologies, the sharing of patient experiences about physicians on online forums and medical websites has become a common practice. However, negative comments posted by patients are considered to be more influential by other patients and physicians than those that are satisfactory., Objective: The aim of this study was to analyze negative comments posted online about physicians and to identify possible solutions to improve patient satisfaction, as well as their relationship with physicians., Methods: A Java-based program was developed to collect patient comments on the Good Doctor website, one of the most popular online health communities in China. A total of 3012 negative comments concerning 1029 physicians (mean 2.93 [SD 4.14]) from 5 highly ranked hospitals in Beijing were extracted for content analysis. An initial coding framework was constructed with 2 research assistants involved in the codification., Results: Analysis, based on the collected 3012 negative comments, revealed that unhappy patients are not alike and that their complaints cover a wide range of issues experienced throughout the whole process of medical consultation. Among them, physicians in Obstetrics and Gynecology (606/3012, 20.12%; P=.001) and Internal Medicine (487/3012, 16.17%; P=.80) received the most negative comments. For negative comments per physician, Dermatology and Sexually Transmitted Diseases (mean 5.72, P<.001) and Andrology (mean 5, P=.02) ranked the highest. Complaints relating to insufficient medical consultation duration (577/3012, 19.16%), physician impatience (527/3012, 17.50%), and perceived poor therapeutic effect (370/3012, 12.28%) received the highest number of negative comments. Specific groups of people, such as those accompanying older patients or children, traveling patients, or very important person registrants, were shown to demonstrate little tolerance for poor medical service., Conclusions: Analysis of online patient complaints provides an innovative approach to understand factors associated with patient dissatisfaction. The outcomes of this study could be of benefit to hospitals or physicians seeking to improve their delivery of patient-centered services. Patients are expected to be more understanding of overloaded physicians' workloads, which are impacted by China's stretched medical resources, as efforts are made to build more harmonious physician-patient relationships., (©Wei Zhang, Zhaohua Deng, Ziying Hong, Richard Evans, Jingdong Ma, Hui Zhang. Originally published in the Journal of Medical Internet Research (http://www.jmir.org), 25.01.2018.)

Purpose: The purpose of this study was to determine an improved estimate of the critical period for susceptibility to fluorosis in human maxillary central incisors., Methods: The fluorosis score, S, of the incisal (I), middle (M), and cervical (C) third divisions on the labial surface of right maxillary central incisors of subjects (a representative sample of 1,085 Hong Kong Chinese children aged 7 to 12 years surveyed in 1986) was determined according to the Chronological Fluorosis Assessment (CFA) Index. Subject data were grouped by month of birth relative to June 1978, when the designated concentration for waterborne fluoride in the community water supply was reduced from 1.0 to 0.7 mg/L. The analytical task was one of finding the correlation maximum in a system of 12 variates and adjustable parameters including the waterborne fluoride concentration, [F-], and the fluorosis score., Results: The main findings were: (1) the peak correlation of S vs [F-] for the male incisal third centered at 17.5 months after birth; (2) and six months later for females; (3) the correlation of S with [F-] is maximized for S(M) following S(I) by two months, and S(C) following S(M) by a further two months for both males and females; and (4) the critical period for exposure to fluoride is of about four months' duration for each third., Conclusions: The maxillary central incisor, as a whole, appears most at risk to fluorosis from dietary fluoride between age 15 and 24 months for males and between 21 and 30 months for females.

It has been shown that ultrasonographic measurements can be used to predict body composition in adults. The purpose of this study was to assess the relationship between ultrasonograph and caliper (SKF) measurements of subcutaneous adipose tissue thickness in athletic Caucasian (English, E) and Asian (Chinese, C) men against estimates of body composition determined from hydrodensitometry (HYD). The usefulness of a proposed ultrasonographic method of estimating lean and fat proportions in the upper and lower limbs was also evaluated as a potential method of predicting body composition. Ultrasonography (US) was used to measure adipose and skin thickness at the following sites: biceps, triceps, subscapular, suprailiac, abdominal, pectoral, thigh and calf. Caliper measurements were also made at the above sites. Subcutaneous fat thickness and segmental radius were measured directly from the display screen of the ultrasonic scanner (Aloka 500 SD). By applying the geometry of a cone, the proximal and distal radii of the upper arm and upper leg were used to calculate the proportionate volumes of adipose tissue. The best correlations for US and SKF were obtained at the quadriceps, subscapular and pectoral sites for E (r = 0.96, 0.93 and 0.90, respectively) and at the quadriceps, calf and abdominal sites for C (r = 0.90, 0.81 and 0.75, respectively). The best ultrasonographic predictor of the percentage fat in both groups was the percentage adipose tissue volume in the upper leg (r = 0.83 and 0.79 for C and E, respectively). Stepwise multiple regression analysis indicated that the prediction of percentage fat was improved by the addition of the ultrasonographic abdomen measurement in both groups: Chinese sample: %fat = %fat(leg) (0.491) + US abdomen (0.337) + 0.95 ( R = 0.89, s.e.e. = 1.9%); English sample: %fat = %fat(leg) (0.435) + US abdomen (0.230) - 0.765 ( R = 0.80, s.e.e. = 3.6%). It is concluded that ultrasonographic measurements of subcutaneous adipose tissue and volumetric assessment of percentage adipose tissue in the thigh are useful estimates of body composition in athletic English and Chinese males.