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Globally, the rollout of COVID‐19 vaccine had been faced with a significant barrier in the form of vaccine hesitancy. This study adopts a multi‐stage perspective to explore the prevalence and determinants of COVID‐19 vaccine hesitancy, focusing on their dynamic evolutionary features. Guided by the integrated framework of the 3Cs model (complacency, confidence, and convenience) and the EAH model (environmental, agent, and host), this study conducted three repeated national cross‐sectional surveys. These surveys carried out from July 2021 to February 2023 across mainland China, targeted individuals aged 18 and older. They were strategically timed to coincide with three critical vaccination phases: universal coverage (stage 1), partial coverage (stage 2), and key population coverage (stage 3). From 2021 to 2023, the surveys examined sample sizes of 29 925, 6659, and 5407, respectively. The COVID‐19 vaccine hesitation rates increased from 8.39% in 2021 to 29.72% in 2023. Urban residency, chronic condition, and low trust in vaccine developer contributed to significant COVID‐19 vaccine hesitancy across the pandemic. Negative correlations between the intensity of vaccination policies and vaccine hesitancy, and positive correlations between vaccine hesitancy and long COVID, were confirmed. This study provides insights for designing future effective vaccination programs for emerging vaccine‐preventable infectious X diseases. [ABSTRACT FROM AUTHOR]

[Display omitted] A new high-quality chironomid-based temperature record was obtained from Shuanghu Lake in arid NW China. Combined with hydroclimatic and historical datasets, we demonstrated the direct effect (water shortages) and indirect effect (geopolitical conflicts) of climate change on the shift of the Silk Road route from the Tarim Basin to the northern slopes of the Tianshan Mountains during ∼420–850 CE. Although climate change has convincingly been linked to the evolution of human civilization on different temporal scales, its role in influencing the spatial patterns of ancient civilizations has rarely been investigated. The northward shift of the ancient Silk Road (SR) route from the Tarim Basin (TB) to the Junggar Basin during ∼420–850 CE provides the opportunity to investigate the relationship between climate change and the spatial evolution of human societies. Here, we use a new high-resolution chironomid-based temperature reconstruction from arid China, combined with hydroclimatic and historical datasets, to assess the possible effects of climate fluctuations on the shift of the ancient SR route. We found that a cooling/drying climate in the TB triggered the SR route shift during ∼420–600 CE. However, a warming/wetting climate during ∼600–850 CE did not inhibit this shift, but instead promoted it, because of the favorable climate-induced geopolitical conflicts between the Tubo Kingdom and the Tang Dynasty in the TB. Our findings reveal two distinct ways in which climate change drove the spatial evolution of human civilization, and they demonstrate the flexibility of societal responses to climate change. [ABSTRACT FROM AUTHOR]

Background: Basic public health services for diabetes play an essential role in controlling glycemia in patients with diabetes. This study was conducted to understand the urban-rural disparities in the utilization of basic public health services for people with diabetes and the factors influencing them. Methods: The data were obtained from the 2018 China Health and Retirement Longitudinal Study (CHARLS) with 2976 diabetes patients. Chi-square tests were used to examine the disparities in the utilization of diabetes physical examination and health education between urban and rural areas. Logistic regression was performed to explore the factors associated with the utilization of diabetes public health services. Results: Among all participants, 8.4% used diabetes physical examination in the past year, and 28.4% used diabetes health education services. A significant association with age (OR = 0.64, 95% CI:0.49–0.85; P < 0.05) was found between patients' use of health education services. Compared with diabetes patients living in an urban area, diabetes patients living in a rural area used less diabetes health education. (χ2= 92.39, P < 0.05). Patients' self-reported health status (OR = 2.04, CI:1.24–3.35; P < 0.05) and the use of glucose control (OR = 9.33, CI:6.61–13.16; P < 0.05) were significantly positively associated with the utilization of diabetes physical examination. Patients with higher education levels were more likely to use various kinds of health education services than their peers with lower education levels (OR = 1.64, CI:1.21–2.22; P < 0.05). Conclusion: Overall, urban-rural disparities in the utilization of public health services existed. Vulnerable with diabetes, such as those in rural areas, are less available to use diabetes public health services. Providing convenient health service infrastructure facilitates the utilization of basic public health services for diabetes in older patients with diabetes, especially in rural areas. [ABSTRACT FROM AUTHOR]

Lacking timely access to rescue resources is one of the main causes of casualties in tunnel collapse. To provide timely rescue, this study proposed a multi-objective preallocation model of special emergency resources for tunnel collapse based on demand time. Efficiency, multiple coverage, and cost-effectiveness are taken as the key objectives of the model; the demand time service range is used as a coverage decision factor considering the unique nature of tunnel collapse. The weight of potential disaster-affected points and other general factors are also considered in this model in order to thoroughly combine the distribution of disaster points and service areas. Further, we take 15 main tunnel projects under construction in China as an example. When the relative proximity to the ideal point of the selected optimal scheme εa is smaller than 0.5, we will adjust the weight of three objectives and reselect the optimal scheme until εa > 0.5. Compared with the not preallocated case, the number of rescue rigs needed is reduced by 8.3%, the number of covered potential disaster-affected points is increased by 36.36%, the weighted coverage times are increased from 0.853 to 1.383, and the weighted distance is significantly reduced by 99% when the rescue rigs are preallocated, verifying the feasibility and superiority of the proposed model. [ABSTRACT FROM AUTHOR]

With the increasing emphasis on the ecology and environment of rivers, the construction of ecological waterway projects has become a development trend in China. In recent years, more and more attention has been paid to the qualitative and quantitative evaluation of the ecological effects of ecological waterway construction. Based on pressure-state-response (PSR) and driver-pressure-state-impact-response (DPSIR) logical frameworks, this paper established a state-pressure-impact-response (SPIR) conceptual model. The model took the river ecology and environment state as the main line, and described the disturbance pressure of the engineering construction on the river state, the impacts of the project on the river comprehensive function, and the positive responses taken in the full lifetime cycle of the project. The analytic hierarchy process (AHP) and fuzzy evaluation model were used to study the changes of the river ecosystem status after suffering from the construction pressure and taking positive responses. Taking the 12.5 m deep water waterway project in the Taicang-Nantong section of the lower reaches of the Yangtze River as an example, the disturbance on the ecology and environment at different stages of the project construction and the effort of relieving the negative impacts of the project on the ecology and environment were evaluated by the health level of the ecosystem. The paper can provide a scientific method for the evaluation of ecological projects in river ecosystems. [ABSTRACT FROM AUTHOR]

Environmental geological disasters seriously threaten human lives and property. A reasonable analysis of the susceptibility to environmental geological disasters is the basis for disaster prevention and mitigation and can promote the sustainable development of regional economy. This study analyzes the susceptibility of environmental geological disasters, such as collapses, landslides, and debris flows in Helong City, China. Through investigation and comprehensive analysis, ten environmental, geological disaster causing factors, including stratum lithology, distance from the fault, elevation, slope, aspect, rainfall, distance from the water system, NDVI, distance from the road, and profile curvature, were extracted. Combined with GIS, a vulnerability analysis database of environmental geological disasters was established, and vulnerability zoning prediction was performed by using two models of information amount and a generalized regression neural network (GRNN). Then, disaster-vulnerability factors such as population density, road density, GDP, and land use type were added. The results show that the predicted results of the two models are similar to the actual survey results.. The environmental geological disasters in the study area are mainly low and not prone to occur, and the northeast and central areas are highly prone to environmental geological disasters, which are the key prevention and control areas in the study area. The coverage rate of high-vulnerability areas with a high degree of economic development is 8.63%, and the prediction results of the GRNN model are mostly distributed in spots and strips, which is more conducive to accurate disaster prevention and mitigation and cost reduction, promotes regional sustainable development, and has guiding significance for disaster prevention and control and urban planning and construction. [ABSTRACT FROM AUTHOR]

aims to explore the association between financial incentives and job performance of primary care providers (PCPs) from a nationally representative survey in China. Methods: This is a cross-sectional study conducted in six provinces of China in 2019. A sample of 1388 PCPs participated in the survey was selected using a stratified cluster sampling method. A self-administered questionnaire composed of socio-demographic, work-related characteristics, financial incentives received by PCPs and their job performance was used. The association between financial incentives and job performance are analyzed using logistic regression model. The significance level for statistics is set at P < 0.05. Results: The PCPs with higher real income level have lower contextual performance (OR = 0.67, p < 0.01) and learning performance (OR = 0.63, p < 0.01) than those with lower real income level. The PCPs with the expectation of income rising above 50% have lower contextual performance (OR = 0.66, p < 0.05) than those with the expectation of income rising above 20%. The PCPs with preference for monetary income have lower task performance (OR = 0.62, p < 0.01), contextual performance (OR = 0.55, p < 0.01) and learning performance (OR = 0.57, p < 0.01) than those without lower preference for monetary income. The percent of performance-based income has no significant effect on all the three dimensions of job performance. Conclusion: Financial incentive was regarded as the most important motivating factor of PCPs in China, but existing financial incentives received by PCPs could not improve their job performance. The findings can be attributed to the unsatisfying total income level, "intrinsic motivation crowding out" effect, and the poorly designed performance-based salary system for PCPs. Policy attention is called for to continuing efforts and system reform to increase the total income level for PCPs in China, and improve the performance-based salary system to better motivate PCPs and improve their job performance. [ABSTRACT FROM AUTHOR]

Purpose: To evaluate preferences for medications among patients with type 2 diabetes mellitus (T2DM) from urban community health stations or rural village clinics in Shandong province, China. Methods: We use a discrete choice experiment (DCE) to measure the medication preferences. Each patient completed six DCE choice sets. The attributes for the DCE questionnaire include mode of administration, out-of-pocket medication cost per month, fasting blood glucose control effect and frequency of hypoglycemia events. The conditional logit model (Clogit) and mixed logit model (MXL) were used to evaluate choice data. Results: A total of 887 patients with T2DM completed the survey. The mean age of participants was 64 years, 36.42% experienced complications, and the mean duration of diabetes was about 8 years. Overall, patients' ideal medication would not have hypoglycemia events, provide normal fasting glucose levels, have oral medication three times a day and lower monthly medication cost. Patients prioritized the frequency of hypoglycemia events (β=15.055, P < 0.01) and were willing to spend CNY 393.10 per month to avoid hypoglycemia events. For patients with higher educational levels and with longer diagnosis time, the effect of fasting blood glucose was more relevant than all other outcomes. Conclusion: This study provides information on T2DM patients' preference for medications. Our results suggest that clinical doctors should present patients with a variety of pharmaceutical characteristics and include their preference into medication decision, which will improve patient adherence and health outcomes. [ABSTRACT FROM AUTHOR]

Knowledge of the paleoclimatic record of the northeastern Tibetan Plateau (NETP) can potentially improve our understanding of the evolution of the Asian summer monsoon (ASM). However, the history of climate change and inferred spatial extent of the ASM on the NETP since the last deglaciation remain unclear. Here, we use several environmental proxies from the sediments of Hala Lake (beyond the modern limit of ASM), including chironomids, loss‐on‐ignition, grain size and element data, to explore the climatic history of the NETP and the northern boundary of the ASM since the last deglaciation. The results document a series of climatic events during the deglaciation, including Heinrich Event 1, the Bølling–Allerød interstadial and the Younger Dryas event. The records also reveal the timing of the megathermal and precipitation maximum, the lake‐level maximum, and strongest chemical weathering, which occurred during ~10–7 ka. The inferred precipitation maximum during the early Holocene in the Hala Lake basin, which can be verified by the simulated precipitation change, is consistent with that in typical Indian summer monsoon (ISM) regions, suggesting that the ISM has penetrated into Hala Lake basin at that time. The monsoon‐dominated climate in the Hala Lake basin during the early Holocene and the westerlies‐dominated climate in the arid central Asia indicate that the maximum areal extent of the ASM on the NETP since the last deglaciation lay to the northwest of Hala Lake basin. In combination with other published records, the northernmost boundary of the ASM over China since the last deglaciation has been tentatively delineated, to shed some lights on this long‐standing debate. [ABSTRACT FROM AUTHOR]

Objective: Workplace violence has been recognized globally as a serious occupational hazard in health service occupations, and existing studies have identified that workplace violence can significantly lead to depression. Interpersonal distrust, an important topic, has also been proved associated with workplace violence and depression. However, the mediating effect of interpersonal distrust has not been tested before. Results of such testing can help us to understand further the effect mechanism of workplace violence on depression. Methods: In the current study, we collected 3426 valid questionnaires based on a cross-sectional design distributed among medical staff in Chinese hospitals. Depression, workplace violence, interpersonal distrust, social support, physical diseases, and some other social-demographic variables were evaluated. SPSS macros program (PROCESS v3.3) was used to test the mediating effect of interpersonal distrust on the association between workplace violence and depression. Results: The data analyzed in the current study demonstrated that 52.2% of medical staff had experienced workplace violence before. Experiencing verbal violence (β = 2.99, p < 0.001), experiencing physical violence (β = 3.70, p < 0.01), experiencing both kinds of violence (β = 4.84, p < 0.001), high levels of interpersonal distrust (β = 0.22, p < 0.001), working as a nurse (β = 1.10, p < 0.05), working as a manager (β = − 1.72, p < 0.001), suffering physical disease (β = 3.35, p < 0.001), and receiving social support (β = − 0.23, p < 0.001) were significantly associated with depression. Workplace violence had not only positive direct effects on depression, but also an indirect effect on depression through interpersonal distrust as a mediator. Conclusion: Interpersonal distrust can mediate the association between workplace violence and depression. Increasing interpersonal trust or reducing workplace violence would be beneficial to promoting mental health status among medical staff. [ABSTRACT FROM AUTHOR]

Background: Blood glucose monitoring is essential in diabetic care and management. Monitoring using glucometers in home and in laboratories by professionals in certain health institutes were the common methods of blood glucose monitoring in clinical practice. This study aimed to characterize the profiles of blood glucose monitoring in the view of the discrepancy in methods and frequency conducted by the patients with type 2 diabetes mellitus (T2DM) in China, and to explore factors influencing the profiles. Methods: A cross-sectional, community-based study was conducted in Shandong province, China, with a multi-stage stratified sampling. A total of 2166 T2DM patients completed the structured questionnaires about the real-world status of blood glucose monitoring and other questions composed of demographic and clinical characteristic as well as the diabetes-related cognitive scales. Latent profile analysis (LPA) was used to identify the underlying profiles of blood glucose monitoring based on self-reported frequency of blood glucose monitoring through different methods. Univariate and multivariate logistic regression were used to analyze the characteristics of the profiles and to explore the factors associated with it. Results: Among the 2166 participants, the mean frequency of blood glucose monitoring was 2.77 times (standard deviation: 7.67) per month. LPA indicated that five-class model was the best solution for classifying the latent groups of blood glucose monitoring: Class 1 "Low frequency in all", Class 2 "High frequency in hospitals", Class 3 "High frequency in primary health institutes", Class 4 "High frequency in pharmacies", and Class 5 "High frequency in self-monitoring". The proportions of the patients in class 1, class 2, class 3, class 4, and class 5 were 88.1% (n=1909), 1.3% (n=28), 3.1% (n=67), 6.1% (n=133) and 1.3% (n=29), respectively. Multivariate logistic regression showed that participants who had higher income (OR: 1.58, 95% CI: 1.04∼ 2.41, p< 0.05), had diabetes complication(s) (OR=1.37, 95% CI: 1.03∼ 1.02, p=0.03) and had a good knowledge of blood glucose control (OR=1.59, 95% CI: 1.17∼ 2.16, p< 0.01) were more likely to have high frequency of blood glucose monitoring (in class 2, 3, 4, 5), and the rural patients were less likely to had high frequency of blood glucose monitoring (OR=0.47, 95% CI: 0.35∼ 0.63, p< 0.01). Conclusion: Low frequency dominates the characteristics of the profiles of blood glucose monitoring among T2DM patients in China, though distinct blood glucose monitoring groups can be identified by LPA. Educational and financial supports were recommended to increase the frequency of blood glucose monitoring in patients with T2DM, focusing on the patients with low socioeconomic status. [ABSTRACT FROM AUTHOR]

Changes in water storage of the large freshwater lakes in Arid Central Asia (ACA) have significant implications for the regional social and ecological systems. Here we present a lake‐level record of the past 2,000 years from Bosten Lake, a large freshwater body in the region, using the sedimentary Cladoceran microfossil. The results suggest that a lower lake level and a higher salinity occurred during the cold, high‐precipitation periods of 280–450 AD and 1570–1850 AD, and that a higher lake level and a lower salinity occurred during the warm, low‐precipitation period of 450–1570 AD. The findings show that on the centennial timescale, the water‐level fluctuations of Bosten Lake were modulated mainly by temperature‐driven meltwater input. In addition, the shortage of freshwater during the cold period may have contributed to the collapse of the ancient cities and the depression of the trade along the Silk Road. Plain Language Summary: Bosten Lake, the largest inland freshwater lake of China, is located in the northeast part of Tarim Basin. The lake is important freshwater resources and plays an important role in sustaining regional social and ecological systems. In this study, we reconstructed the water‐level fluctuations of the lake over the past 2,000 years, based mainly on the Cladoceran microfossil analyses of a sediment core. The results suggest that a lower lake level occurred during the cold, high‐precipitation periods of 280–450 AD and 1570–1850 AD, and that a higher lake level occurred during the warm, low‐precipitation period of 450–1570 AD. The findings show that on the centennial timescale, the water‐level fluctuations of Bosten Lake were modulated mainly by temperature‐driven meltwater input. In addition, historical documents reveal that a large number of ancient cities in the Tarim Basin were abandoned in the third‐sixth centuries and that the trade along the ancient Silk Road was relatively depressed during that time, coinciding with the salinization and the shrinking of Bosten Lake. This suggests that the shortage of freshwater during this cold period may have contributed to the collapse of the ancient cities and the depression of the trade along the Silk Road. Key Points: On the centennial timescale, the water‐level fluctuations of Bosten Lake were modulated mainly by temperature‐driven meltwater inputThe shortage of freshwater during the cold period may have contributed to the collapse of the ancient cities along the Silk Road [ABSTRACT FROM AUTHOR]

Background multimorbidity contributes to a large portion of the disease burden in low- and middle-income countries. However, limited research has been undertaken in China. This study has investigated the prevalence of multimorbidity and the associations of multimorbidity with activities of daily living (ADL), instrumental activities of daily living (IADL) and depression in China. Methods the study participants included 10,055 adults aged 45 years and older from three rounds of the China Health and Retirement Longitudinal Study 2011–2015. Random-effects logistic regression models were used to examine the association of multimorbidity with ADL limitation, IADL limitation and mental disease. Results the prevalence of multimorbidity amongst adults in China aged 45 years and older was 62.1% in 2015. The prevalence of multimorbidity was increased with older age, among women, in a higher socio-economic group and in the most deprived regions. Multimorbidity is associated with an increased likelihood of experiencing ADL limitation (adjusted odds ratio [AOR] = 5.738, 95% confidence intervals (CI) = 5.733, 5.744) and IADL limitation (AOR = 2.590, 95% CI = 2.588, 2.592) and depression (AOR = 3.352, 95% CI = 3.350, 3.354). Rural–urban disparities in functional difficulties and depression were also found amongst patients with multimorbidity. Conclusions the burden of multimorbidity is high in China, particularly amongst the older population. Multimorbidity is associated with higher levels of functional limitations and depression. China healthcare reforms should introduce integrated care models and patient-centred healthcare delivery. The increasing need for reorientation of healthcare resources considering the distribution of multimorbidity and its adverse effect requires more attention from health policymakers in China and other developing countries. [ABSTRACT FROM AUTHOR]

Background: To achieve universal health coverage in China, it is necessary to identify access barriers to health care. This study examined the association between health system characteristics and health care utilization in China and identified factors associated with accessing health care among the mid-aged and elderly.Methods: Data were obtained from the 2015 China Health and Retirement Longitudinal Study, and 17 370 respondents aged 45 and above were included in the analysis. The dependent variables were the use of outpatient and inpatient care among respondents. Health system characteristics at the provincial level were measured using the density of doctors and ward beds, health expenditure per visit/admission and health financing. A two-level logistic regression model was constructed to examine association between health care utilization and health system characteristics, controlling for predisposing, enabling and need variables.Results: Of the 17 370 respondents, 18.3% had utilized outpatient care and 13.7% had utilized inpatient care in 2015. Increases in the share of out-of-pocket (OOP) payments as total health spending at the provincial-level was less likely to be associated with outpatient care utilization (odds ratio (OR) = 0.96, 95% confidence interval (CI) = 0.93-0.98) among the mid-age and elderly population. Increases in the share of OOP payments (OR = 0.98, 95% CI = 0.97-1.00) and health expenditure per admission (OR = 0.20, 95% CI = 0.04-0.88) were less likely to be associated with inpatient care utilization, while increases in the density of beds (OR = 1.26, 95% CI = 1.10-1.43) was more likely to be associated with inpatient care utilization. gross domestic product (GDP) per capita at the provincial level and types of health insurance owned by respondents were significantly related to both inpatient and outpatient care utilization.Conclusions: Low affordability of the mid-aged and elderly population is the main barrier to utilizing health care in China. In order to improve access to health care, the government should make more efforts, such as improving health insurance reimbursement rates and implementing prospective provider payment methods, to decrease OOP payment for the ageing population. [ABSTRACT FROM AUTHOR]

Background: Research conducted in Western countries has suggested that high-dose statin therapy can lead to the regression of carotid atherosclerotic plaques and can reduce periprocedural ischemic complication rates in individuals undergoing carotid artery stenting (CAS). However, whether this same therapeutic approach is of value in patients of Chinese ethnicity is not as well-established. Methods: This is a single-center, prospective, parallel-controlled, intervention-based efficacy study that will enroll a total of 130 Chinese patients with cervical carotid stenosis who are scheduled to undergo CAS. These patients will be randomly divided into a routine treatment group and a high-dose atorvastatin group. Individuals in the routine treatment group will be administered standard of care 20 mg/day atorvastatin treatment. Individuals in the high-dose atorvastatin group will be administered 80 mg/day atorvastatin for 3 days prior to and following CAS. The primary outcome of this study will be the cumulative incidence of new cerebral ischemic lesions on diffusion-weighted magnetic resonance imaging (DW-MRI) within 5 days following CAS, and of transient ischemic attacks (TIAs) or ischemic stroke within 30 days after CAS. Discussion: This study is the first to assess whether high-dose atorvastatin treatment is capable of reducing the incidence of perioperative cerebral ischemic injury in patients of Chinese ethnicity undergoing CAS. These results will offer evidence regarding which statin treatment regimens are more appropriate when treating Chinese patients undergoing CAS in an effort to minimize their risk of any perioperative cerebral ischemic injury. Trial Registration: ClinicalTrials.gov NCT03079115; registered March 14, 2017. [ABSTRACT FROM AUTHOR]

Background: Community-based diabetes management is known to be an important strategy for global diabetes control. In China, community-based diabetes management care, including regular blood glucose tests and guidance on medicine use, dietary control, and physical exercise provided by primary health institutions (PHIs), as one of the key contents of the national essential public health services (EPHS), was implemented since 2009 when the new round of health system reform was initiated. This study aimed to investigate the utilization of community-based diabetes management care services, and explore the factors influencing utilization from both patients' and providers' points of view.Methods: In total, 2520 type-2 diabetes mellitus (DM) patients registered for EPHS were selected from 63 PHIs in eight counties of Shandong province, China, using multi-stage stratified sampling. Of those, 2166 patients (response rate: 85.4%) completed face-to-face structured questionnaires on their utilization of community-based diabetes management care services. Further, 63 PHIs were surveyed on diabetes care delivery, and 444 primary healthcare providers were purposively sampled from those PHIs to measure their knowledge of diabetes management care delivery, using a self-developed questionnaire. Descriptive statistics were used to analyze the delivery and utilization of diabetes management care services. Multilevel logistic regression models were used to analyze the factors associated with patients' utilization of diabetes management services.Results: All 63 PHIs reported that all the required four diabetes management services were provided through EPHS. However, only 49.6% of the patients reported they fully used these services, with no statistically significant difference between urban and rural patients. Patients who had higher knowledge of diabetes and better self-efficacy in controlling the condition, were more likely to fully utilize diabetes management care. A larger number of PHI health staff per 1000 population was associated with better utilization of care.Conclusion: Although community-based diabetes management services are well available to Chinese DM patients under the framework of EPHS, the actual utilization of diabetes management services among the patients was poor. The size of the PHI workforce, patients' knowledge and self-efficacy in controlling diabetes, were important predictors of utilization, and could be enhanced to improve control of diabetes. [ABSTRACT FROM AUTHOR]

Background: Low job satisfaction, severe burnout and high turnover intention are found to be prevalent among the primary care providers (PCPs) in township health centers (THCs), but their associations have received scant attention in the literature. In light of this, this study aims to examine the relationships between job satisfaction, burnout and turnover intention, and explore the predictors of turnover intention with a view to retaining PCPs in rural China. Methods: Using the multistage cluster sampling method, a cross-sectional survey was conducted in Shandong Province, China. 1148 PCPs from 47 THCs participated in this study. Job satisfaction, burnout and turnover intention were measured with a multifaceted instrument developed based on the existing literature, the Maslach Burnout Inventory and the participants' responses to a Likert item drawn from the literature, respectively. The relationships of the three factors were examined using Pearson correlation and structural equation modeling, while the predictors of turnover intention were investigated using multivariate logistic regression. Results: The subscale that the PCPs were most dissatisfied with was job rewards (95.12%), followed by working environment (49.65%) and organizational management (47.98%). The percentages of the PCPs reporting high-levels of emotional exhaustion, depersonalization and reduced personal accomplishment were 27.66, 6.06, and 38.74%, respectively. About 14.06% of the respondents had high turnover intention. There was a significant direct effect of job satisfaction on burnout (γ = − 0.52) and turnover intention (γ = − 0.29), a significant direct effect of burnout on turnover intention (γ = 0.28), and a significant indirect effect (γ = − 0.14) of job satisfaction on turnover intention through burnout as a mediator. Work environment satisfaction, medical practicing environment satisfaction, and organizational management satisfaction proved to be negative predictors of turnover intention (p < 0.05), whereas reduced personal accomplishment was identified as a positive predictor (p < 0.05). Conclusions: Plagued by low job satisfaction and severe burnout, the PCPs in rural China may have high turnover intentions. Job satisfaction had not only negative direct effects on burnout and turnover intention, but also an indirect effect on turnover intention through burnout as a mediator. Targeted strategies should be taken to motivate and retain the PCPs. [ABSTRACT FROM AUTHOR]

Background: Self-management is the cornerstone of diabetes care, however, despite the numerous recommendations available for self-management, type-2 diabetes mellitus (T2DM) patients' performance is suboptimal in China. This study aimed to explore the association between self-efficacy and self-management behaviors among Chinese T2DM patients, which might provide evidence to inform effective self-management interventions for these patients. Methods: A cross-sectional survey was conducted using a multi-stage stratified randomized sampling in Shandong Province, China. The Diabetes Empowerment Scale-Short Form (DES-SF) was used to measure patients' self-efficacy to manage diabetes. Latent class analysis (LCA) was used to explore the observed classes of self-management behaviors (dietary control, physical exercise, regular medication and self-monitoring of blood glucose). A two-class solution for self-management behaviors was tested to be the fittest based on LCA; we labelled active and inactive self-management groups. Univariate and multivariate logistic regression analysis were used to examine the associations between self-efficacy and self-management behaviors. Results: A total of 2166 T2DM patients were included in the analysis. The mean DES-SF score was 31.9 (standard deviation: 5.2). The estimated proportions of T2DM in the active and inactive groups were 54.8% and 45.2%, respectively. The multivariate logistic regression showed that higher DES-SF score was significantly associated with higher possibility of active self-management behaviors (odds ratio = 1.06; 95% confidence interval: 1.04–1.08). Conclusions: Self-efficacy in managing diabetes is associated with self-management behaviors among Chinese T2DM patients. To improve self-management behaviors, multiple strategies should be conducted to improve patients' self-efficacy. [ABSTRACT FROM AUTHOR]

Long-term, high-resolution temperature records which combine an unambiguous proxy and precise dating are rare in China. In addition, the societal implications of past temperature change on a regional scale have not been sufficiently assessed. Here, based on the modern relationship between chironomids and temperature, we use fossil chironomid assemblages in a precisely dated sediment core from Gonghai Lake to explore temperature variability during the past 4000 years in northern China. Subsequently, we address the possible regional societal implications of temperature change through a statistical analysis of the occurrence of wars. Our results show the following. (1) The mean annual temperature (TANN) was relatively high during 4000-2700 cal yr BP, decreased gradually during 2700-1270 cal yr BP and then fluctuated during the last 1270 years. (2) A cold event in the Period of Disunity, the Sui-TangWarm Period (STWP), the Medieval Warm Period (MWP) and the Little Ice Age (LIA) can all be recognized in the paleotemperature record, as well as in many other temperature reconstructions in China. This suggests that our chironomidinferred temperature record for the Gonghai Lake region is representative. (3) Local wars in Shanxi Province, documented in the historical literature during the past 2700 years, are statistically significantly correlated with changes in temperature, and the relationship is a good example of the potential societal implications of temperature change on a regional scale. [ABSTRACT FROM AUTHOR]

Traditionally, the evaluation of pollen-based quantitative paleoclimate reconstructions focuses on the ability of calibration sets to infer present climatic conditions and/or the similarity between fossil and modern assemblages. Objective criteria for choosing the most appropriate climate parameter(s) to be reconstructed at a specific site are thus lacking. Using a novel approach for testing the statistical significance of a quantitative reconstruction using random environmental data, in combination with the advantageous large environmental gradients, abundant vegetation types and comprehensive modern pollen databases in China, we describe a new procedure for pollen-based quantitative paleoclimatic reconstructions. First, the most significant environmental variable controlling the fossil pollen assemblage changes is identified. Second, a calibration set to infer changes in this targeted variable is built up, by limiting the modern ranges of other environmental variables. Finally, the pollen-based quantitative reconstruction is obtained and its statistical significance assessed. This novel procedure was used to reconstruct the mean annual precipitation ( P ) from Gonghai Lake in the Lvliang Mountains, and Tianchi Lake in the Liupan Mountains, on the eastern and western fringe of the Chinese Loess Plateau, respectively. Both P reconstructions are statistically significant ( p<0.001), and a sound and stable correlation relationship exists in their common period, showing a rapid precipitation decrease since 3300 cal yr BP. Thus, we propose that this procedure has great potential for reducing the uncertainties associated with pollen-based quantitative paleoclimatic reconstructions in China. [ABSTRACT FROM AUTHOR]

Based on compilation of a large number of archaeological and palaeosol 14C-ages, the Summed Probability Method is used to reconstruct population history and climatic patterns on the Chinese Loess Plateau during the period 8.5–3.5 cal. ka BP. During this period, the population experienced two major expansion periods and several climatic fluctuations. The first population expansion began at around 7.8 cal. ka BP, and the second at around 5.8 cal. ka BP. During the first period, although already in combination with cultivation of broomcorn millet the population growth was supported mainly by hunting and gathering. With the switch from broomcorn millet to foxtail millet, plant cultivation became the major factor promoting a second population increase. In this paper, we demonstrate that, initially, suitable climate and agriculture both can facilitate population growth and climate events had a significant influence on demographic fluctuations. However, when reaching the threshold of land capacity, population became increasingly more sensitive towards climate fluctuations. [ABSTRACT FROM AUTHOR]

Background. China launched its new health care reform in 2009. One of its goals is to improve primary care system and strengthen primary care workforce. Although it has been studied internationally, motivating factors for primary care workforce have not been examined in China. Aim. To provide an overview of major performance motivating factors for primary care providers (PCPs) in China and examine associations between these factors and individual and practice setting characteristics. Methods. Data for the study were from the 2011 China Primary Care Workforce Survey that provides the most current assessment of community-based PCPs. Outcome measures were scores indicating performance improvement due to 11 factors. Covariates representing personal and practice characteristics included age, gender, education, location, types of providers and specialties. Outcomes were compared by PCP category and urban/rural setting. Associations were assessed using logistic regressions. Results. The most important motivating factors for PCPs to improve performance were professional development, training opportunities, living environment, benefits, working conditions and income. There were greater needs for improvement in rural than urban settings, especially in living environment. Types of PCPs were associated with needs for improvement in different factors. There were more needs from nurses and village doctors. Conclusions. A new and comprehensive incentive mechanism could be designed and implemented in China, which (i) focuses on more professional development opportunities, enhanced training programs and better compensation and benefits and (ii) targets PCPs practicing in different settings. [ABSTRACT FROM AUTHOR]

The article offers a study on Eosestheria which is an important component of the Jehol biota and also an important link in the biota chain during its production period. Topics discussed include survey of sedimentary rock systems in the Wenzhigou areas of Liaoning Province and fossils of Eosestheria were collected. Article concludes the first discovery of the Eosestheria in eastern Liaoning confirms the existence of Jehe biota in this region.

Background: Primary health care (PHC) was a keystone toward achieving universal health coverage and Sustainable Development Goals (SDGs). China has made efforts to strengthen its PHC institutions. As part of such efforts, regular in-service training is crucial for primary healthcare workers (PHWs) to strengthen their knowledge and keep their skills up to date. Objective: To investigate if and how the existing training arrangements influenced the competence and job satisfaction of PHWs in township hospitals (THs). Methods: A mixed method approach was employed. We analyzed the associations between in-service training and competence, as well as between in-service training and job satisfaction of PHWs using logistic regression. Interviews were recorded, transcribed, and analyzed using NVivo12 to better understand the trainings and the impacts on PHWs. Results: The study found that training was associated with competence for all the types of PHWs except nurses. The odds of higher competence for physicians who received long-term training were 3.60 (p < 0.01) and that of those who received both types of training was 2.40 (p < 0.01). PHWs who received short-term training had odds of higher competence significantly (OR = 1.710, p < 0.05). PHWs who received training were more satisfied than their untrained colleagues in general (OR = 1.638, p < 0.01). Specifically, physicians who received short-term training (OR = 1.916, p < 0.01) and who received both types of training (OR = 1.941, p < 0.05) had greater odds of general job satisfaction. The odds ratios (ORs) of general job satisfaction for nurses who received short-term training was 2.697 (p < 0.01), but this association was not significant for public health workers. The interview data supported these results, and revealed how training influenced competence and satisfaction. Conclusions: Considering existing evidence that competence and satisfaction serve as two major determinants of health workers' performance, to further improve PHWs' performance, it is necessary to provide sufficient training opportunities and improve the quality of training. [ABSTRACT FROM AUTHOR]

Background: The fragmentation of health insurance schemes in China has undermined equity in access to health care. To achieve universal health coverage by 2020, the Chinese government has decided to consolidate three basic medical insurance schemes. This study aims to evaluate the effects of integrating Urban and Rural Residents Basic Medical Insurance schemes on health care utilization and its equity in China. Methods: The data for the years before (2013) and after (2015) the integration were obtained from the China Health and Retirement Longitudinal Study. Respondents in pilot provinces were considered as the treatment group, and those in other provinces were the control group. Difference-in-difference method was used to examine integration effects on probability and frequency of health care visits. Subgroup analysis across regions of residence (urban/rural) and income groups and concentration index were used to examine effects on equity in utilization. Results: The integration had no significant effects on probability of outpatient visits (β = 0.01, P > 0.05), inpatient visits (β = 0.01, P > 0.05), and unmet hospitalization needs (β =0.01, P > 0.05), while it had significant and positive effects on number of outpatient visits (β = 0.62, P < 0.05) and inpatient visits (β = 0.39, P < 0.01). Moreover, the integration had significant and positive effects on number of outpatient visits (β = 0.77, P < 0.05) and inpatient visits (β = 0.49, P < 0.01) for rural residents but no significant effects for urban residents. Furthermore, the integration led to an increase in the frequency of inpatient care utilization for the poor (β = 0.78, P < 0.05) among the piloted provinces but had no significant effects for the rich (β = 0.25, P > 0.05). The concentration index for frequency of inpatient visits turned into negative direction in integration group, while that in control group increased by 0.011. Conclusions: The findings suggest that the integration of fragmented health insurance schemes could promote access to and improve equity in health care utilization. Successful experiences of consolidating health insurance schemes in pilot provinces can provide valuable lessons for other provinces in China and other countries with similar fragmented schemes. [ABSTRACT FROM AUTHOR]

Objective: Against the backdrop of integrating public health services and clinical services at primary healthcare (PHC) institutions, primary healthcare providers (PCPs) have taken on expanded roles. This posed a potential challenge to China as it may directly impact PCPs' workload, income, and perceived work autonomy, thus affecting their job satisfaction. This study aimed to explore the association between the expanded roles and job satisfaction of the PCPs in township healthcare centers (THCs), the rural PHC institutions in China.Methods: A cross-sectional study using mixed methods was conducted in 47 THCs in China's Shandong province. Based on a sample of 1146 PCPs, the association between the proportion of PCPs' working time spent on public health services and PCPs' self-reported job satisfaction was estimated using the logistic regression. Qualitative data were also collected and analyzed to explore the mechanism of how the expanded roles impacted PCPs' job satisfaction.Results: One hundred eighty-four physicians and 146 nurses undertook increased work responsibilities, accounting for 15.91% and 12.61% of the total sample. For those spending 40-60%, 60-80%, and more than 80% of the working time providing public health services, the time spent on public health was negatively associated with job satisfaction, with the odds ratio being 0.199 [0.067-0.587], 0.083 [0.025-0.276], and 0.030 [0.007-0.130], respectively. Qualitative analysis illustrated that a majority of the PCPs with expanded roles were dissatisfied with their jobs due to the heavy workload, the mismatch between the income and the workload, and the low level of work autonomy. PCPs' heavier work burden was mainly caused by the current public health service delivery policy and the separation of public health service delivery and regular clinical services delivery, a significant challenge undermining the efforts to better integrate public health services and clinical services at PHC institutions.Conclusion: The current policies of adding public health service delivery to the PHC system have negative impacts on PCPs' job satisfaction through increased work responsibilities for PCPs, which have led to low work autonomy and the mismatch between the income and the workload. The fundamental reason lies in the fragmented incentives and external supervision for public health service delivery and clinical service delivery. Policy-makers should balance the development of clinic and public health departments at the institutional level and integrate their financing and supervision at the system level so as to strengthen the synergy of public health service provision and routine clinical service provision. [ABSTRACT FROM AUTHOR]

We investigated the antiasthmatic effect of mogroside V (Mog V) in mice with ovalbumin (OVA)‐induced asthma. Administration of Mog V effectively attenuated OVA‐induced airway hyperresponsiveness and reduced the number of inflammatory cells in bronchoalveolar lavage fluid (BALF). Histological examination showed that Mog V reduced the inflammatory infiltration of the lungs in the asthmatic mice. ELISAs suggested that Mog V effectively decreased the levels of IL‐4, IL‐5, and IL‐13 in BALF and serum levels of OVA‐specific IgE and IgG1 in the asthmatic mice. A quantitative reverse‐transcription PCR assay also indicated that Mog V decreased the mRNA levels of IL‐17A, IL‐23, and RORγt in the lungs of the asthmatic mice (the opposite effect on Foxp3 mRNA). Furthermore, Mog V significantly reduced the OVA‐induced activation of NF‐κB in the lungs. This study indicates that Mog V alleviates OVA‐induced inflammation in airways, and this effect is associated with a reduction in NF‐κB activation. Practical applications: A traditional Chinese medicine herb has been reported to have a strong curative effect on asthma in clinical practice. Siraitia grosvenorii is known in China as a functional food product with the ability to improve lung function. Mogroside V is a triterpene glycoside isolated from S. grosvenorii. Nonetheless, the antiasthmatic effect of mogroside V has not been evaluated yet. The aim of this study was to investigate the antiasthmatic activity of mogroside V in mice with chemically induced asthma. The data from this study will provide some scientific evidence supporting wider use of S. grosvenorii in functional foods. [ABSTRACT FROM AUTHOR]

Alpine lakes not only provide internationally important habitats for endangered species, they also play a crucial role in the regional water balance. Unfortunately, a rapid loss of alpine lakes in China has occurred in recent decades; however, intensive human activities, together with regional differences in the responses of lakes to climate change, has impeded our understanding of the contribution of climate change to the loss of these lakes. To better understand how alpine lakes will evolve with continuing global warming, we used the analysis of new sedimentary proxies from Lake Gonghai, an undisturbed alpine lake, together with a review of published records, to reconstruct variations in integrated lake status since the last deglaciation. From 14,660–11,890 cal. yr BP the lake was in the most unstable state, indicated by the highest amplitude fluctuations in lake level and the within-lake environment. The lake status experienced clear millennial-scale changes. During the early and middle Holocene (11,890–3200 cal. yr BP), the most stable lake status occurred, consistent with the highest precipitation levels. Owing to the highest level of freshwater influx in the middle Holocene (8–5 ka), the lake water was the deepest and most acidic. At this time, the dense vegetation cover resulted in maximum catchment stability and the lowest level of soil erosion, and hence the lowest sediment accumulation rate. From 3200 cal. yr BP, decreasing mean annual precipitation resulted in a moderately stable lake status, a shallow water depth and more alkaline lake water. The sparse vegetation cover caused a dramatic increase in the erosion rate and hence in the sediment accumulation rate. We infer that variations in local humidity were the major control on the integrated lake status during the last ~14,600 cal. yr BP. With the anticipated progression of global warming, the status of the alpine lakes in the region may continue to deteriorate and appropriate mitigation strategies are imperative. [ABSTRACT FROM AUTHOR]

Anthropogenic emissions have resulted in increases in the atmospheric fluxes of both nutrient and toxic elements. However, the long-term geochemical impacts on lake sediments of deposition activities have not been clearly clarified. We selected two small enclosed lakes in northern China—Gonghai, strongly influenced by anthropogenic activities, and Yueliang lake, relatively weakly influenced by anthropogenic activities—to reconstruct historical trends of atmospheric deposition on the geochemistry of the recent sediments. The results showed an abrupt rise in the nutrient levels in Gonghai and the enrichment of toxic metal elements from 1950 (the Anthropocene) onwards. While, at Yueliang lake, the rise on TN was from 1990 onwards. These consequences are attributable to the aggravation of anthropogenic atmospheric deposition in N, P and toxic metals, from fertilizer consumption, mining and coal combustion. The intensity of anthropogenic deposition is considerable, which leave a significant stratigraphic signal of the Anthropocene in lake sediments. [Display omitted] • Since 1950, the anthropogenic atmospheric deposition has surged. • Nutrient supply and warming jointly led eutrophication in lakes. • The transport distance of P deposition is shorter, compared with N. • Anthropogenic deposition has left stratigraphic signals of the Anthropocene. [ABSTRACT FROM AUTHOR]

Holocene evolution of the East Asian summer monsoon (EASM), which provides precipitation to 1.6 billion people and has played a key role in the development of Chinese civilizations, has been hypothesized to be driven directly by summer insolation changes. However, an insolation-driven early-Holocene EASM maximum has not been convincingly validated, because a mid-Holocene summer monsoon precipitation maximum is widely accepted and the timing of a warm-season temperature maximum, which drove the strongest summer monsoon, is still unknown. Here we show that a pronounced shift in diatom life strategy, registered in high-resolution lake sediment records from northern China, tracked a clear change in lake thermal regime triggered by higher mid-Holocene warm-season temperatures. Combined with robust pollen-inferred precipitation data from northern China, we present independent lines of evidence that the East Asian thermal and summer monsoon maxima occurred synchronously during the mid-Holocene, demonstrating that a high- and low-latitude interplay is the most probable mechanism for the EASM throughout the Holocene. This hypothesis may explain both the mid-Holocene maximum of summer monsoon precipitation and the mid-Holocene flourishing of the Neolithic Chinese Yangshao culture in northern China. • Diatom analysis reveals Holocene warm-season temperature changes in northern China. • Both warm-season temperatures and EASM peaked synchronously during the mid-Holocene. • A high- and low-latitude interplay drove the mid-Holocene thermal and EASM maxima. • Coupled temperature and EASM rainfall maxima catalyzed the Chinese Yangshao culture. • The classic insolation forcing hypothesis of Holocene EASM evolution is challenged. [ABSTRACT FROM AUTHOR]

Aeolian landscapes dominate the semiarid dune fields across the Asian summer monsoonal boundary (ASMB) of northern China, where the widespread palaeosols are usually regarded as indicators of enhanced monsoonal precipitation (moisture) during the Late Quaternary. However, the processes of palaeosol development, and their response to climate change, remain controversial due to the complex land-atmosphere interactions within different bioclimatic zones. Here, we review the patterns of palaeosol development, precipitation/moisture (P/M) evolution, and lake level fluctuations across different sub-regions of the ASMB. With the aid of typical temperature and vegetation records, we qualitatively and quantitatively distinguish the contributions of different climatic factors to palaeosol development since 20 ka (1 ka = 1000 cal yr BP) and elucidate the underlying mechanisms. Our results indicate an asynchronous pattern of palaeosol development, with optimum development during 10–4, 8–4, and 6–2 ka in northeastern (NE) China, north central (NC) China, and on the NE Qinghai-Tibetan Plateau (QTP), respectively. This implies a transmeridional asynchronous pattern of palaeosol development on the scale of the ASMB. Our qualitative and quantitative analysis of the contributions of climatic variables elucidates the various relationships between palaeosol development and the climatic background across different sub-regions of the ASMB. The results demonstrate that temperature and precipitation are the dominant factors for palaeosol development in NE and NC China, respectively; whereas effective moisture, rather than temperature and precipitation alone, controls palaeosol development on the NE QTP, demonstrating different pedogenic responses against the same overall climatic background. These mechanisms are supported by the results of multiple studies of Holocene vegetation evolution and the associated climatic conditions. We conclude that the asynchronous pattern of palaeosol development across the ASMB was caused by variations in different dominant climatic factors, highlighting the diverse and complex interactions of climate change and Earth surface processes, even within the relatively uniform climatic environment of semiarid northern China. Our findings emphasize the differing responses of palaeosol development to regional climate change and provide new insights into the interactions of the land-atmosphere system in the critical zone of northern China. [Display omitted] • Asynchronous palaeosol development demonstrates transmeridional characteristics of pedogenesis across the ASMB of northern China • Various qualitative and quantitative relationships are demonstrated between palaeosol development and climate • Asynchronous palaeosol development in the ASMB since 20 ka was caused by variations in different dominant climatic factors [ABSTRACT FROM AUTHOR]

[Display omitted] • The Kangjia and Changlingzi formations are correlative rock units deposited between ∼1111 Ma and ∼924 Ma. • Meso-Neoproterozoic basins in North China craton record provenance of Grenvillian orogens. • Provenance analyses support the North China craton–NW Laurentia conjugation in Rodinia. We present new detrital zircon U–Pb and Hf isotopic dating results from the late Mesoproterozoic to early Neoproterozoic sandstones exposed in the southern-eastern Liaoning Province, eastern North China craton (NCC). The Qiaotou Formation (Fm) in the Benxi and Dalian regions yield similar detrital zircon age patterns characterized by peaks around ∼1750 Ma, ∼1600 Ma, ∼1175 Ma and ∼1100 Ma. The Kangjia Fm in the Benxi region and the Changlingzi Fm in the Dalian region share similar detrital zircon age patterns, which in combination with their similarities in stratigraphic sequences and lithologic associations, suggest that they are correlative rock units. Based on the detrital zircon dating results and U–Pb ages of mafic sills intruding the strata, we suggest that the Qiaotou Fm is younger than ∼1077 Ma and older than ∼948 Ma, and the age of the Kangjia and Changlingzi formations is between ∼1111 Ma and ∼924 Ma. We synthesize the new data with detrital zircon age and Hf isotopic data reported in the region and other Meso-Neoproterozoic basins in the eastern NCC and suggest that Grenville-age (∼1300–1000 Ma) detrital zircons widely discovered in those strata might be transformed from other cratons. The possibility that those non-NCC provenance detrital zircons might be sourced from the Baltica, São Francisco–Congo and Laurentia cratons existed. But the former two solutions that the NCC directly connected to either of those cratons are contradictory to the global paleogeographic reconstruction context of supercontinent Rodinia. The Grenvillian and Sveconorwegian orogenic belts on Laurentia–Baltica conjoined continents are more likely the sediment provenance of non-NCC Grenville-age detrital zircon provenance in the Meso-Neoproterozoic basins in eastern NCC in the configuration context of the possible NCC–NW Laurentia conjugation in Rodinia. [ABSTRACT FROM AUTHOR]

Looks at a study which characterized several Borrelia burgdorferi sensu lato culture isolates from northeastern China. Details on the 5S-23S r ribonucleic acid (RNA) intergenic spacer restriction fragment length polymorphism analysis; Definition of the lyme disease; Methodology used to conduct the study; Results of the study.

Objective: The aim of this study was to understand the psychological insulin resistance status among Chinese patients with type 2 diabetes and investigate its associated factors in these patients., Methods: A multi-stage stratified random sampling was performed to randomly select patients with type 2 diabetes from the eastern, central, and western regions in Shandong Province, China, and 660 valid questionnaires were collected. Psychological insulin resistance was assessed by the scale of My Opinion on Insulin (MOI). Factors associated with psychological insulin resistance were examined in a binary logistic model., Results: Four-fifths of the patients with type 2 diabetes (82.1%) had psychological insulin resistance. Being female (OR = 1.770, 95% CI: 1.063-2.950, p < 0.05), having a monthly income of greater than 4,000 Renminbi (approximately $1,540) (OR = 0.444, 95% CI: 0.216-0.915, p < 0.05), living with type 2 diabetes for 11 years or more (OR = 0.387, 95% CI: 0.238-0.630, p < 0.05), self-rated poor health (OR = 1.706, 95% CI: 1.092-2.664, p < 0.05), and moderate discrimination against type 2 diabetes (OR = 1.924, 95% CI: 1.166-3.175, p < 0.05) were associated with psychological insulin resistance., Conclusions: The prevalence of psychological insulin resistance among Chinese patients with type 2 diabetes is relatively high. Approaches are needed to address the issue of psychological insulin resistance of type 2 diabetes., 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 Zhang, Zhang, Wang, Fan, Ma, Song and Zhang.)

Objectives: To quantify the preference of patients with diabetes mellitus (DM) for primary healthcare (PHC) institutions in China to redirect the patient flow and improve health outcomes., Design: Cross-sectional study. Discrete choice experiment (DCE) surveys asked patients with DM to choose between hypothetical institutions that differed in the medical service capacity, out-of-pocket (OOP) medical costs per month, travel time, the attitude of medical staff and the availability of diabetes drugs., Setting: Shandong province, China., Participants: The participants were 887 patients with DM from 36 urban communities and 36 rural villages in Shandong province. One participant did not provide any DCE answers and a further 57 patients failed the internal consistency test. 829 fully completed surveys were included in the final data analysis., Main Outcomes and Measures: A mixed logit model was used to calculate the willingness to pay and predict choice probabilities for PHC institution attributes. Preference heterogeneity was also investigated., Results: All five attributes were associated with the preferences of patients with DM. The OOP medical costs and the medical service capacity were the most influential attributes. Improvements simultaneously in the attitude of medical staff, drug availability and travel time increased the likelihood of a patient's PHC institution choice. Preferences differed by region, annual household income and duration of diabetes., Conclusions: Our patient preference data may help policymakers improve health services and increase acceptance of choosing PHC institutions. The OOP medical costs and medical service capacity should be regarded as a priority in decision-making., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Geological environment carrying capacity (GECC) is the key to regional sustainable development (RSD). The study has become an international heat due to frequent global geological disasters, which have resulted in socio-economic losses, weakened GECC. Therefore, this study combined with quantity of information (QI), random forest (RF) and XGBoost (XGB) algorithms, constructed a GECC assessment model in Xiuyan, China based on remote sensing (RS) and geographic information system (GIS) techniques. The validity of the model was verified by disaster information in two period. The results reveal that the indicator system of RS image can reflect the geological factors' influence on GECC more truthfully, and avoided duplication of indicators. The correlation coefficients of the indicators were all less than 0.9, which showed the validity of the indicator system. The QI&#95;RF model performed best with high accuracy (0.96). The mean absolute error (MAE) is 0.098. The disaster management cost (DMC), elevation and rainfall were the main indicators with weights over 0.1. The GECC in study area is mainly balanced. Although the overloaded area was smallest, it was the key area to limit the RSD, which had been improved by adjusting the land or human activities planning. Compared with the results of geological disasters in two period, the disasters in overloaded area were reduced by 58%, which showed that the improvement measures under this model were effective. The method of GECC assessment based on RS and integrated model proposed in this study takes into account the common indicators that affect the development of geological disasters. It can provide reference for RSD under the influence of geological disasters and has universal applicability., 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 © 2023 The Authors. Published by Elsevier Inc. All rights reserved.)

Background: Workplace violence (WPV) is common in healthcare settings. However, the association between WPV and depressive symptoms has not been explored among primary healthcare professionals, especially in China. The assumption of the moderating effort of meaning in life on the association has also not been tested. The purposes of the study are to investigate the relationship between WPV and depressive symptoms and identify the moderating role of meaning in life among primary healthcare professionals in China., Methods: In this study, we collected 2530 valid questionnaires. The participants were composed of primary healthcare professionals in Shandong province, China. WPV, meaning in life (including presence of life and search for life), depressive symptoms, and some social-demographic variables were evaluated. The SPSS macro was used to build the moderating relationship., Results: WPV was positively correlated with depressive symptoms (β = 9.09, p < 0.001), and meaning in life was negatively associated with WPV and depressive symptoms (β = -0.13, p < 0.05) among primary healthcare professionals in China. For primary healthcare professionals with low presence of life, presence of life aggravated the relationship., Conclusions: The current study has verified the association between WPV and meaning in life, and the relationship between WPV and depressive symptoms has been supported among primary healthcare professionals in China. Meaning in life and presence of life as moderators play crucial roles in the relationship between WPV and depressive symptoms.

Background: Although community health education has drawn lots of attention from the public, evidence on resident satisfaction is still sparse. This study aims to explore the relationships among five dimensions (perceived quality, perceived value, public expectation, public trust, and public satisfaction) of satisfaction with community health education among Chinese residents., Methods: We constructed a theoretical public satisfaction model for community health education based on the American Customer Satisfaction Index (ACSI) model. There are five dimensions in the theoretical model, including public expectation, perceived quality, perceived value, public satisfaction, and public trust. We recruited 474 respondents from a quota sampling based on gender and age, and collected information on five dimensions of satisfaction with community health education. The relationships of the five dimensions were examined using structural equation model., Results: The mean scores of public expectation, perceived quality, perceived value, public satisfaction, and public trust for the participants were 11.44 (total 15), 123.89 (total 170), 14.18 (total 20), 10.19 (total 15), and 15.61 (total 20), respectively. We obtained a structural equation model with a good fitting degree. There was a direct effect of perceived quality on perceived value (γ = 0.85, P < 0.01), public trust (γ = 0.81, P < 0.01) and public satisfaction (γ = 0.58, P < 0.01), and a direct effect of public expectation on public satisfaction (γ = 0.36, P < 0.01) and perceived value (γ = 0.25, P < 0.01)., Conclusions: We provide a good tool to measure public satisfaction with community health education, which can be potentially used to measure public satisfaction and improve the effectiveness of health education., 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 © 2022 Tong, Wang, Zhu, Zhao, Qi, Guan, Ma, Li, Sun and Wu.)

Objective: This study aimed to examine the urban-rural disparities and associated factors of health care utilization among cancer patients in China., Methods: This study used the data collected from a cross-sectional survey conducted in China. A total of 1,570 cancer survivors from three urban districts and five rural counties were selected by using a multistage stratified random sampling method. We measured health care utilization with the way of cancer diagnosis, the number of hospitals visited, and receiving alternative therapies. Chi-square test was used to examine the differences between urban and rural cancer patients. Binary logistic regression analysis was performed to explore the determinants of health care utilization., Results: Among 1,570 participants, 84.1% were diagnosed with cancer after developing symptoms, 55.6% had visited two and above hospitals, and 5.7% had received alternative therapies. Compared with urban cancer patients, rural ones were more likely to be diagnosed with cancer after developing symptoms (χ2 = 40.04, p < 0.001), while they were less likely to visit more than one hospital (χ2 = 27.14, p < 0.001). Residence area (urban/rural), health insurance type, household income, age at diagnosis, tumor site, stage of tumor, and survival years were significantly associated with health care utilization of cancer patients ( p < 0.01)., Conclusions: Health care utilization was suboptimal among cancers patients in China. Rural cancer patients had less health care utilization including screenings and treatments than urban ones. Policymakers should implement specific strategies to ensure equitable utilization of cancer care. More attention should be paid to the disadvantaged groups and rural cancer patients. Prioritizing health resources allocation is needed to prevent, screen, and treat cancers in rural areas., 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 © 2022 Wang, Hua, Yao, Zhang, Wang, Anderson and Sun.)

Background: Multimorbidity is a significant contributor to inequalities in healthcare and has become a major unaddressed challenge for the health system in China. The aim of this study is to assess the socio-demographic distribution of multimorbidity and the relationships between multimorbidity, primary healthcare, hospitalization and healthcare spending., Methods: We conducted this nationwide population-based panel data study in China. Study participants included 12,306 residents aged ≥45 years from the China Health and Retirement Longitudinal Study in 2011, 2013 and 2015. Random-effects logistic regression models were applied to estimate the association between multimorbidity and primary healthcare as well as admission to the hospital. We used log-linear regression models to investigate the association between multimorbidity and health spending., Results: Overall, 46.2% of total interviewees reported multimorbidity. Random-effects logistic regression analyses showed that multimorbidity was associated with a higher likelihood of medication use (Adjusted odds ratio (AOR) =19.19, 95% CI = 17.60, 20.93), health check (AOR = 1.51, 95% CI = 1.43, 1.59), outpatient care (AOR = 2.39, 95% CI = 2.23, 2.56) and admission to hospital (AOR = 2.94, 95% CI = 2.68, 3.21). Log-linear regression models showed that multimorbidity was also positively associated with spending for outpatient care (coefficient = 0.64, 95% CI = 0.59, 0.68) and hospitalization (coefficient = 0.65, 95% CI = 0.60, 0.71)., Conclusions: Multimorbidity is associated with higher levels of primary care, hospitalization and greater financial burden to individuals in China. Health systems need to shift from single-disease models to new financing and service delivery models to more effectively manage multimorbidity., (© 2021. The Author(s).)

Objective: Metabolic diseases have been a clinical challenge worldwide and a major public health issue. Very few studies from China investigated the impact of metabolic multimorbidity on healthcare and health outcomes at the national level. This study aims to examine the association of metabolic multimorbidity with health service utilization, spending, functional and mental health. Materials and Methods: This is a nationally representative cross-sectional study, utilizing the data from the China Health and Retirement Longitudinal Study in 2015, including 11,377 participants aged 45 years and older. Multivariable regression models were used to assess the association of metabolic multimorbidity with healthcare, out-of-pocket expenditure (OOPE), the activities of daily living (ADL) limitation, the instrumental activities of daily living (IADL) limitation, and depression. Results: Overall, 30.50% of total participants had metabolic multimorbidity in 2015 in China. Compared with single disease, metabolic multimorbidity were associated with the number of outpatient visits [incident rate ratio (IRR) = 1.30, 95% CI = 1.05, 1.62] and days of inpatient care (IRR = 1.52, 95% CI = 1.28, 1.81). Metabolic multimorbidity was positively associated with the OOPE on outpatient care (coefficient = 82.99, 95% CI = 17.70, 148.27) and physical functional difficulties, including ADL limitation (odds ratio = 1.36, 95% CI = 1.18, 1.57). Conclusions: Metabolic multimorbidity is associated with higher levels of health-care service use, greater expenditure for outpatient care, and more difficulties in ADL among Chinese adults. China's health-care systems need to shift from single-disease models to new financing and service delivery models to effectively manage metabolic multimorbidity., 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 © 2021 Zhao, Zhang, Lee, Oldenburg, Heusden, Haregu and Wang.)

Objective: There is a high prevalence of poor glycaemic control among patients with type 2 diabetes (T2DM) in China. This study aimed to explore both organisational and individual characteristics associated with glycaemic control among patients with T2DM., Design: Cross-sectional survey., Setting: Shandong Province, China., Participants: The participants were 2166 patients with T2DM and 337 healthcare providers from 36 urban communities and 36 rural villages in Shandong Province., Primary and Secondary Outcome Measures: Multistage stratified sampling procedures were used to measure demand-side individual demographic, clinical and self-management characteristics, and supply-side organisational characteristics, and the status of glycaemic control. Multilevel logistic regression analysis was performed to assess key determinants of glycaemic control., Results: Only 42.8% of the patients with T2DM achieved good glycaemic control. Age, income, hypertension and self-efficacy were significantly positive predictors of optimal glycaemic control, while duration of diabetes, antidiabetic drugs and monitoring of blood glucose were significantly negative predictors of that. Private VCs (OR=0.48, 95% CI 0.29 to 0.82, p<0.01) and lack of healthcare providers (OR=0.69, 95% CI 0.53 to 0.89, p<0.01; OR=0.71, 95% CI 0.52 to 0.98, p<0.05) were significantly negative predictors of optimal glycaemic control, while diabetes knowledge level of healthcare providers (OR=1.36, 95% CI 1.02 to 1.83, p<0.05; OR=1.45, 95% CI 1.00 to 2.10, p<0.05) and kinds of antidiabetic drugs (OR=1.37, 95% CI 0.97 to 1.93, p<0.1; OR=1.46, 95% CI 1.07 to 2.00, p<0.05) were significantly positive predictors of that., Conclusions: Glycaemic control was suboptimal among patients with T2DM in China. The determinants of failing to achieve good glycaemic control included both organisational and individual characteristics. Potential interventions that target patients, providers and the healthcare organisations should be taken to improve the glycaemic control and health outcome among patients with T2DM., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Introduction: Antibiotic consumption is associated with the development of antibiotic resistance. Our aim was to study the relationship between antibiotic consumption and carbapenem-resistant Klebsiella pneumoniae (CRKP) in three public general tertiary hospitals from 2011-2015 in the eastern, western and central regions of China., Methodology: Valid data were collected quarterly, and the antibiotic consumption data were expressed as the defined daily dose (DDD) per 100 inpatient days (ID). Bacterial resistance was reported as the percentage of resistant isolates among all tested isolates. Individual trends were calculated by linear regression, while possible correlations between antibiotic consumption and CRKP were evaluated by distributed lags time series analysis., Results: Over the 5-year period, an overall significant increasing trend (P < 0.1, R2 > 0.3) of carbapenems consumption and the prevalence of CRKP was observed in all three hospitals. This correlated with the use of ceftazidime, cefoperazone/sulbactam, cefminox and meropenem at a hospital in eastern China, with the increased use of meropenem at a hospital in eentral China and with the increased use of doxycycline, ceftriaxone, ceftazidime, meropenem and biapenem at a hospital in western China., Conclusions: We report a high incidence of CRKP in all three hospitals and that an increase in carbapenem usage is associated with this. Further research is needed to elucidate which factors influence the increased consumption of carbapenems., Competing Interests: No Conflict of Interest is declared, (Copyright (c) 2019 Xiaoyuan Qu, Haipeng Wang, Chaoran Chen, Chang Yin, Aitian Yin, Chunyan Ma, Adi Idris.)

Background: There is a deficiency of healthcare administrators in China as compared with other countries; furthermore, the distribution is unequal. To inform an effective policy intervention, it is crucial to understand healthcare administration students' career decision-making. This study aims to investigate the undergraduate students' stated preferences when choosing a job., Methods: A discrete choice experiment (DCE) was conducted among a population-based multistage sample of 668 final year undergraduate healthcare administration students during April to June 2017 in eight universities of China to elicit their job preferences. Attributes include location, monthly income, bianzhi (which refers to the established posts and can be loosely regarded as state administrative staffing), training and career development opportunity, working environment and workload. Conditional and mixed logit models were used to analyze the relative importance of job attributes., Results: All six attributes were statistically significant with the expected sign and demonstrated the existence of preference heterogeneity. Monthly income, workload and working environment were of most concern to healthcare administration students when deciding their future. Among the presented attributes bianzhi was of the least concern. Sub-group analysis showed that students who have an urban background and/or with higher annual family incomes were willing to pay more for working in the city. In addition, students from western and middle universities valued bianzhi higher than students from eastern universities., Conclusions: This is the first study focusing on the career decision-making of Chinese healthcare administration students at a critical career decision-making point. Both monetary and non-monetary interventions could be considered by policy-makers to attract students to work in health institutions, especially in rural and remote health institutions in China. There exists preference heterogeneity on healthcare administration students' job preferences, which should also be taken into account in developing more effective policy incentive packages., Competing Interests: The authors have declared that no competing interests exist.

Objective: To investigate the epidemiological and clinical characteristics of breast cancer associated with multiple primary malignant neoplasmas (MPMNs)., Methods: The data of 519 patients of breast cancer associated with MPMNs admitted to the Cancer Hospital, CAMS and diagnosed by operation and pathology in the period of 1958 to 2001 were studied retrospectively to analyze the morbity, age of onset, sex ratio, predilection site of tumor, and the interval time between sequential tumors. The 519 patients, all female, were divided into four groups: bilateral primary breast cancer (1st group), synchronic Paget's disease (PD) associated with breast cancer in the same breast (2nd group), breast cancer as the first tumor associated with MPMNs (3rd group), and breast cancer as the second or third tumour associated with MPMNs (4th group)., Results: The constituent rate of bilateral primary breast cancer, synchronic Paget's disease (PD) associated with breast cancer in the same breast, breast cancer as the first tumor associated with MPMNs, and breast cancer as the second or third primary tumour associated with MPMNs was 3.0%, 0.8%, 3.2%, and 2.5% respectively. The median age of onset was 42.5, 47.3, 51.4, and 51.8 years respectively for the four groups. The mean interval time between the appearance of the first tumor and the appearance of the second tumor was 5.4, 0, 8.6, and 7.6 years in the four groups respectively. The predilection sites of second and third primary cancers in the third group were lung, breast, esophageal, ovary, and large intestine. The predilection sites of first primary cancer in the 4th group were uterus, ovary, large intestine, lung, lymphatic tissue, and esophagus successively. The involvement rate of breast in breast cancer associated with MPMNs was 72.4%., Conclusion: (1) Breast is one of the predilection organs of MPMNs. (2) The predilection organs of breast associated with MPMNs are the target organs of female hormone (eg, breast, ovary and uterus) and the organs involved by radiotherapy for breast cancer (eg, lung and esophagus). (3) Early diagnosis and timely and proper treatment have satisfactory effect.