Publications by authors named "Zhongliang Zhou"

73 Publications

Rural and urban differences in patient experience in China: a coarsened exact matching study from the perspective of residents.

BMC Health Serv Res 2021 Apr 13;21(1):330. Epub 2021 Apr 13.

School of Public Health, Health Science Center, Xi'an Jiaotong University, Xi'an, 710061, China.

Background: Patient experience is a key measure widely used to evaluate quality of healthcare, yet there is little discussion about it in China using national survey data. This study aimed to explore rural and urban differences in patient experience in China.

Methods: Data regarding this study were drawn from Chinese General Social Survey (CGSS) 2015, with a sample size of 9604. Patient experience was measured by the evaluation on healthcare services. Coarsened exact matching (CEM) method was used to balance covariates between the rural and urban respondents. Three thousand three hundred seventy-two participants finally comprised the matched cohort, including 1592 rural residents and 1780 urban residents. Rural and urban differences in patient experience were tested by ordinary least-squares regression and ordered logistic regression.

Results: The mean (SD) score of patient experience for rural and urban residents was 72.35(17.32) and 69.45(17.00), respectively. Urban residents reported worse patient experience than rural counterparts (Crude analysis: Coef. = - 2.897, 95%CI: - 4.434, - 1.361; OR = 0.706, 95%CI: 0.595, 0.838; Multivariate analysis: Coef. = - 3.040, 95%CI: - 4.473, - 1.607; OR = 0.675, 95%CI: 0.569, 0.801). Older (Coef. = 2.029, 95%CI: 0.338, 3.719) and healthier (Coef. = 2.287, 95%CI: 0.729, 3.845; OR = 1.217, 95%CI: 1.008, 1.469) rural residents living in western area (Coef. = 2.098, 95%CI: 0.464, 3.732; OR = 1.276, 95%CI: 1.044, 1.560) with higher social status (Coef. = 1.158, 95%CI: 0.756, 1.561; OR = 1.145, 95%CI: 1.090, 1.204), evaluation on adequacy (Coef. = 7.018, 95%CI: 5.045, 8.992; OR = 2.163, 95%CI: 1.719, 2.721), distribution (Coef. = 4.464, 95%CI: 2.471, 6.456; OR = 1.658, 95%CI: 1.312, 2.096) and accessibility (Coef. = 2.995, 95%CI: 0.963, 5.026; OR = 1.525, 95%CI: 1.217, 1.911) of healthcare resources had better patient experience. In addition, urban peers with lower education (OR = 0.763, 95%CI: 0.625, 0.931) and higher family economic status (Coef. = 2.990, 95%CI: 0.959, 5.021; OR = 1.371, 95%CI: 1.090,1.723) reported better patient experience.

Conclusions: Differences in patient experience for rural and urban residents were observed in this study. It is necessary to not only encourage residents to form a habit of seeking healthcare services in local primary healthcare institutions first and then go to large hospitals in urban areas when necessary, but also endeavor to reduce the disparity of healthcare resources between rural and urban areas by improving quality and capacity of rural healthcare institutions and primary healthcare system of China.
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http://dx.doi.org/10.1186/s12913-021-06328-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8042990PMC
April 2021

Income-related inequality in distribution of health human resource among districts of Pakistan.

BMC Health Serv Res 2021 Feb 15;21(1):142. Epub 2021 Feb 15.

School of Public Policy and Administration, Xi'an Jiaotong University, Xi'an, PR China.

Background: Solving inequality of health human resource (HHR) is one of the motives of Pakistan health policies, however, there is still exists a massive quantity of HHR inequality in almost every district of Pakistan. The main goal of this research is to scrutinize the disparity in allocation of human health resources among 114 regions of Pakistan from the year 2012 to 2016 and to expose the foundations and aspects of HHR inequality.

Methods: The data regarding this research has been obtained from Pakistan Statistical Bureau from the year 2012 to 2016. The statistics had also been collected from United Nation Development Program (UNDP) Pakistan 2017, Pakistan economic surveys, Ministry of finance Islamabad, Pakistan, Pakistan Social and Living standards Measurement (PSLM) Surveys from 2012 to 2016. The information incorporates district wise; the number of specialists and medical caretakers those are doctors and nurses, number of hospitals, number of beds, number of dispensaries, number of beds in dispensaries, urbanization, total estimated GNI per capita, infant mortality rate, geographical area, and population size. The concentration index is used to compute the extent of disparity in allocation of human health resources and decomposition analysis is also carried out to enumerate the contribution of each variable towards total inequality. Furthermore, the horizontal concentration was used to measure the participation of the need variable.

Results: 7. The consequent Concentration Indexes (CI) of the doctors and nurses for the year 2016 are 0.60 (95% CI= 0.42, 0.78) and 0.67 (95% CI= 0.42, 0.92) respectively. Decomposition of the concentration indexes exposed that the monetary status accounts are the leading percentage contributor in doctors disparity (77.5, 44.9, 30.6, - 11.6% and 13%) and population size (- 20.7,-10.5%, 4.6, 49.8, 19.7%). Furthermore, the monetary status formulates the superior contribution HHR disparity from nurses inequality (104.5, 75.1, 59.2, - 54.3%, - 40.1%), and population size (- 53.7, - 53.6%, - 36.3, 83.8, 65.3%). Moreover, after the identification of the need variable the Horizontal Concentration Index (HCI) values of doctors from the year 2012 to 2016 are 0.62, 0.64, 0.63, 0.62 and 0.61 and HCI of the nurses are 0.69, 0.70, 0.69, 0.68 and 0.67.

Conclusion: The pro-rich disparity in allocation of HHR has been scrutinized from the year 2012 to 2016 among 114 districts of Pakistan. The hard concern of HHR disparity should be concentrated by the complete procedures from a multidisciplinary approach.
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http://dx.doi.org/10.1186/s12913-021-06102-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7885567PMC
February 2021

Comparing quality of primary healthcare between public and private providers in China: study protocol of a cross-sectional study using unannounced standardised patients in seven provinces of China.

BMJ Open 2021 01 12;11(1):e040792. Epub 2021 Jan 12.

Department of Global Health and Population, Harvard University, Cambridge, Massachusetts, USA.

Introduction: The Chinese government has encouraged the development of private sector in delivering healthcare, including primary healthcare (PHC) in the new round of national health reform since 2009. However, the debate about the role of the private sector in achieving universal health coverage continues with poor support from theories and empirical evidence. This study intends to compare the quality of PHC services between the private and public providers in seven provinces in China, using unannounced standardised patients (USPs).

Methods: We are developing and validating 13 USP cases most commonly observed in the PHC setting. Six domains of quality will be assessed by the USP: effectiveness, safety, patient centredness, efficiency, timeliness and equity. The USP will make 2200 visits to 705 public and 521 private PHC institutions across seven provinces, following a multistage clustered sample design. Using each USP-provider encounter as the analytical unit, we will first descriptively compare the raw differences in quality between the private and public providers and then analyse the association of ownership types and quality, using propensity score weighting.

Ethics And Dissemination: The study was primarily funded by the National Natural Science Foundation of China (#71974211, #71874116 and # 72074163) and was also supported by the China Medical Board (#16-260, #18-300 and #18-301), and have received ethical approval from Sun Yat-sen University (#2019-024). The validated USP tool and the data collected in this study will be freely available for the public after the primary analysis of the study.

Trial Registration Number: Chinese Clinical Trial Registry: #ChiCTR2000032773.
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http://dx.doi.org/10.1136/bmjopen-2020-040792DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7805374PMC
January 2021

The effects of family physician-contracted service on health-related quality of life and equity in health in China.

Int J Equity Health 2021 Jan 6;20(1):15. Epub 2021 Jan 6.

School of Public Policy and Administration, Xi'an Jiaotong University, No. 28 West Xianning Road, Xi'an, 710048, Shaanxi, China.

Background: Family physician-contracted service (FPCs) has been recently implemented in Chinese primary care settings. This study was aimed at measuring the effects of FPCs on residents' health-related quality of life (HRQoL) and equity in health among the Chinese population.

Methods: The study data was drawn from the 2018 household health survey (Shaanxi Province, China) using multistage, stratified cluster random sampling. We measured HRQoL using EQ-5D-3L based on the Chinese-specific time trade-off values set. Coarsened exact matching (CEM) technique was used to control for confounding factors between residents with and without a contracted family physician. The concentration index (C) was calculated to measure equity in health.

Results: Individuals with a contracted family physician had significantly higher HRQoL than those without, after data matching (0.9355 vs. 0.8995; P <  0.001). Additionally, the inequity in HRQoL among respondents with a contracted family physician was significantly lower than those without a contracted family physician (Cs of EQ-5D utility score: 0.0084 vs. 0.0263; p <  0.001).

Conclusions: This study highlights the positive effects of FPCs on HRQoL and socioeconomic-related equity in HRQoL. Future efforts should prioritize the economically and educationally disadvantaged groups, the expansion of service coverage, and the competency of family physician teams to further enhance health outcome and equity in health.
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http://dx.doi.org/10.1186/s12939-020-01348-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7788691PMC
January 2021

Comparison of inequity in health-related quality of life among unemployed and employed individuals in China.

BMC Public Health 2021 Jan 6;21(1):52. Epub 2021 Jan 6.

School of Public Policy and Administration, Xi'an Jiaotong University, No. 28 Xianning West Road, Xi'an, 710049, Shaanxi, China.

Background: In China, achieving health equity has been regarded as a key issue for health reform and development in the current context. It is well known that unemployment has a negative effect on health. However, few studies have addressed the association between unemployment and inequity in health-related quality of life (HRQOL). This study aims to compare the inequality and inequity in HRQOL between the unemployed and employed in China.

Methods: The material regarding this study was derived from the Chinese National Health Services Survey of Shaanxi Province for 2013. We controlled for confounding factors by utilizing the coarsened exact matching method. Finally, 7524 employed individuals and 283 unemployed individuals who were 15 to 64 years old in urban areas were included in this study. We used HRQOL as the outcome variable, which was evaluated by using the Chinese version of EQ-5D-3L. The health concentration index, decomposition analysis based on the Tobit model, and the horizontal inequity index were employed to compute the socioeconomic-related equity between the unemployed and employed and the contribution of various factors.

Results: After matching, unemployed people tended to have poorer EQ-5D utility scores than employed people. There were statistically pro-rich inequalities in HRQOL among both employed and unemployed people, and the pro-rich health inequity of unemployed people was substantially higher than that of employed people. Economic status, age, education, smoking and health insurance were the factors influencing inequality in HRQOL between employed and unemployed individuals. Education status and basic health insurance have reduced the pro-rich inequity in HRQOL for unemployed people.

Conclusion: It is suggested that unemployment intensifies inequality and inequity in HRQOL. According to policymakers, basic health insurance is still a critical health policy for improving health equity for the unemployed. Intervention initiatives aiming to tackle long-term unemployment through active labour market programmes, narrow economic gaps, improve educational equity and promote the health status of the unemployed should be considered by the government to achieve health equity.
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http://dx.doi.org/10.1186/s12889-020-10038-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7789144PMC
January 2021

Comparison of health care utilization among patients affiliated and not affiliated with healthcare professionals in China.

BMC Health Serv Res 2020 Dec 3;20(1):1118. Epub 2020 Dec 3.

Department of Health Policy and Management, Yale School of Public Health, 60 College Street, New Haven, CT, 06520, USA.

Background: Doing "more" in healthcare can be a major threat to the delivery of high-quality health care. It is important to identify the supplier-induced demand (SID) of health care. This study aims to test SID hypothesis by comparing health care utilization among patients affiliated with healthcare professionals and their counterpart patients not affiliated with healthcare professionals.

Methods: We used coarsened exact matching to compare the health care utilization and expenditure between patients affiliated and not affiliated with healthcare professionals. Using cross-sectional data of the China Labour-force Dynamics Survey (CLDS) in 2014, we identified 806 patients affiliated with healthcare professionals and 22,788 patients not affiliated with healthcare professionals. The main outcomes were outpatient proportion and expenditure as well as inpatient proportion and expenditure.

Results: The matched outpatient proportion of patients not affiliated with healthcare professionals was 0.6% higher (P = 0.754) than that of their counterparts, and the matched inpatient proportion was 1.1% lower (P = 0.167). Patients not affiliated with healthcare professionals paid significantly more (680 CNY or 111 USD, P < 0.001) than their counterparts did per outpatient visit (1126 CNY [95% CI 885-1368] vs. 446 CNY [95% CI 248-643]), while patients not affiliated with healthcare professionals paid insignificantly less (2061 CNY or 336 USD, P = 0.751) than their counterparts did per inpatient visit (15583 CNY [95% CI 12052-19115] vs. 17645 CNY [95% CI 4884-30406]).

Conclusion: Our results lend support to the SID hypothesis and highlight the need for policies to address the large outpatient care expenses among patients not affiliated with healthcare professionals. Our study also suggests that as the public becomes more informed, the demand of health care may persist while heath care expenditure per outpatient visit may decline sharply due to the weakened SID. To address misbehaviors and contain health care costs, it is important to realign provider incentives.
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http://dx.doi.org/10.1186/s12913-020-05895-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7713311PMC
December 2020

Does inpatient health services utilization vary by remoteness in the medical financial assistance population? Evidence from Shaanxi province, China.

BMC Health Serv Res 2020 Nov 19;20(1):1051. Epub 2020 Nov 19.

Centre for Health Economics, Monash University, 900 Dandenong Road, Caulfield East, VIC, 3145, Australia.

Background: Medical Financial Assistance (MFA) provides health insurance and financial support for millions of low income and disabled Chinese people, yet there has been little systematic analysis focused on this vulnerable population. This study aims to advance our understanding of MFA recipients' access to health care and whether their inpatient care use varies by remoteness.

Methods: Data were collected from the Surveillance System of Civil Affairs of Shaanxi province in 2016. To better proxy remoteness (geographic access), drive time from the respondent's village to the nearest county-level or city-level hospital was obtained by a web crawler. Multilevel models were used to explore the impacts of remoteness on inpatient services utilization by MFA recipients. Furthermore, the potential moderating role of hospital grade (i.e. the grade of medical institution where recipient's latest inpatient care services were taken in the previous year) on the relationship between geographic access and inpatient care use was explored.

Results: The analytical sample consisted of 9516 inpatient claims within 73 counties of Shaanxi province in 2016. We find that drive time to the nearest hospital and hospital grade are salient predictors of inpatient care use and there is a significant moderation effect of hospital grade. Compared to those with shortest drive time to the nearest hospital, longer drive time is associated with a longer inpatient stay but fewer admissions and lower annual total and out-of-pocket (OOP) inpatient costs. In addition, these associations are lower when recipients are admitted to a tertiary hospital, for annual total and OOP inpatient expenditures, but higher for length of the most recent inpatient stay no matter what medical treatments are taken in secondary or tertiary hospitals for the most remote recipients.

Conclusion: Our results suggest that remoteness has a significant and negative association with the frequency of inpatient care use. These findings advance our understanding of inpatient care use of the extremely poor and provide meaningful insights for further MFA program development as well as pro-poor health strategies.
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http://dx.doi.org/10.1186/s12913-020-05907-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7678078PMC
November 2020

Effect of a Text Messaging-Based Educational Intervention on Cesarean Section Rates Among Pregnant Women in China: Quasirandomized Controlled Trial.

JMIR Mhealth Uhealth 2020 11 3;8(11):e19953. Epub 2020 Nov 3.

School of Public Policy and Administration, Xi'an Jiaotong University, Xi'an, China.

Background: Consensus exists that appropriate regional cesarean rates should not exceed 15% of births, but China's cesarean rate exceeds 50% in some areas, prompting numerous calls for its reduction. At present, China's 2016 two-child policy has heightened the implications of national cesarean section trends.

Objective: This study leveraged pervasive cellular phone access amongst Chinese citizens to test the effect of a low-cost and scalable prenatal advice program on cesarean section rates.

Methods: Participants were pregnant women presenting for antenatal care at a clinic in Xi'an, China. Assignment was quasirandomized and utilized factorial assignment based on the expecting mother's birthday. Participants were assigned to one of the following four groups, with each receiving a different set of messages: (1) a comparison group that received only a few "basic" messages, (2) a group receiving messages primarily regarding care seeking, (3) a group receiving messages primarily regarding good home prenatal practices, and (4) a group receiving text messages of all groups. Messages were delivered throughout pregnancy and were tailored to each woman's gestational week. The main outcome was the rates of cesarean delivery reported in the intervention arms. Data analysts were blinded to treatment assignment.

Results: In total, 2115 women completed the trial and corresponding follow-up surveys. In the unadjusted analysis, the group receiving all texts was associated with an odds ratio of 0.77 (P=.06), though neither the care seeking nor good home prenatal practice set yielded a relevant impact. Adjusting for potentially confounding covariates showed that the group with all texts sent together was associated with an odds ratio of 0.67 (P=.01). Notably, previous cesarean section evoked an odds ratio of 11.78 (P<.001), highlighting that having a cesarean section predicts future cesarean section in a subsequent pregnancy.

Conclusions: Sending pregnant women in rural China short informational messages with integrated advice regarding both care-seeking and good home prenatal practices appears to reduce women's likelihood of undergoing cesarean section. Reducing clear medical indications for cesarean section seems to be the strongest potential pathway of the effect. Cesarean section based on only maternal request did not seem to occur regularly in our study population. Preventing unnecessary cesarean section at present may have a long-term impact on future cesarean section rates.

Trial Registration: ClinicalTrials.gov NCT02037087; https://clinicaltrials.gov/ct2/show/NCT02037087.

International Registered Report Identifier (irrid): RR2-10.1136/bmjopen-2015-011016.
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http://dx.doi.org/10.2196/19953DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7671841PMC
November 2020

Income-related inequities of adult obesity and central obesity in China: evidence from the China Health and Nutrition Survey 1997-2011.

BMJ Open 2020 10 30;10(10):e034288. Epub 2020 Oct 30.

School of Public Policy and Administration, Xi'an Jiaotong University, Xi'an, China

Objectives: The aim of this study was to analyse the status regarding inequities in adult obesity and central obesity in China. Thus, income-related inequality for both diseases and the underlying factors were examined.

Methods And Design: The China Health and Nutrition Survey (CHNS)-conducted from 1997 to 2011-included 128 307 participants; in this study, 79 566 individuals classified as obese and 65 250 regarded as suffering from central obesity according to the CHNS were analysed. A body mass index greater than 27 was considered indicative of obesity; men and women with a waist circumference of more than 102 cm and 80 cm, respectively, were considered as suffering from central obesity. The concentration index was employed to analyse inequality in adult obesity and central obesity. The decomposition of this index based on a probit model was used to calculate the horizontal inequality index.

Results: The prevalence of adult obesity increased from 8.34% in 1997 to 17.74% in 2011, and that of central obesity increased from 6.52% in 1997 to 16.79% in 2011. The horizontal inequality index for adult obesity decreased from 0.1377 in 1997 to 0.0164 in 2011; for central obesity, it decreased from 0.0806 in 1997 to -0.0193 in 2011. The main causes of inequality for both diseases are, among others, economic status, marital status and educational attainment.

Conclusions: From 1997 to 2011, the prevalence of adult obesity and central obesity increased annually. The pro-rich inequalities in both adult and central obesity decreased from 1997 to 2011. The inequality in central obesity was more prominent in the low-income group in 2011. Future policies may need to address obesity reduction among the poor.
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http://dx.doi.org/10.1136/bmjopen-2019-034288DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7604817PMC
October 2020

Changing Income-Related Inequality in Daily Nutrients Intake: A Longitudinal Analysis from China.

Int J Environ Res Public Health 2020 10 19;17(20). Epub 2020 Oct 19.

School of Public Policy and Administration, Xi'an Jiaotong University, Xi'an 710049, China.

Because of economic reform, dietary pattern in China changed rapidly during the past two decades. Meanwhile, the changes of income and nutrients intake had the same trend. This study aims to measure the income-related inequality in daily nutrients intake and its health-related income mobility over time. Data was sourced from four waves of China Health and Nutrition Survey. Concentration indexes and health-related income mobility indexes were employed to measure the income-related inequality of nutrients intake and its change over time. This study found that the daily protein intake, daily fat intake, daily energy intake, and proportion of energy from fat over 30% were more concentrated on the rich, whereas daily carbohydrates intake among the poor. The income-related inequalities were more severe than the cross-sectional perspective in the long run. The dynamic change of urbanisation indexes has resulted that over 30% of energy from fat was more concentrated among the rich and carbohydrates intake among the poor. The nutrition transition may bring about more severe disease economic burden to the poor in the future. This study recommends an approach to minimize gaps between rural and city areas by promoting rural revitalization to reduce the income-related inequality in daily nutrient intake.
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http://dx.doi.org/10.3390/ijerph17207627DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7588920PMC
October 2020

Evaluating the effect of hierarchical medical system on health seeking behavior: A difference-in-differences analysis in China.

Soc Sci Med 2021 Jan 18;268:113372. Epub 2020 Sep 18.

School of Public Policy and Administration, Xi'an Jiaotong University, No. 28 Xianning West Road, Xi'an, 710049, Shaanxi, China. Electronic address:

The unbalanced allocation of healthcare resources and the underutilization of primary care facilities are the core problems that restrict the current healthcare reforms in China. In order to encourage residents to go to primary care facilities, China implemented the Hierarchical Medical System (HMS) in 2015. This study aims to evaluate the effect of HMS on health seeking behavior in China using panel data. Statistics for the study were derived from China Family Panel Studies (CFPS) 2012, 2014, 2016 and 2018, and China health and family planning statistical yearbook 2012, 2014, 2016 and 2018. We employed the difference-in-differences (DID) model with multiple periods. In total, 61,932 residents were incorporated for a final sample covered 25 provinces. The results indicated that the implementation of HMS had a significantly positive effect on the probability of urban residents going to primary care facilities for contact. However, the effect of HMS was not significant for rural residents. Basic health insurance was a significant factor for directing residents to primary care facilities. Self-assessed health, chronic disease, economic level and educational status were also found to be focal factors of health seeking behavior. In conclusion, the introduction of HMS has led to improved health seeking behavior and is worth putting more effort into. For policy makers, basic medical insurance is still an important health policy that enables systematic health seeking behavior. Initiatives to continue to expand the adjustment range of economic incentives should be adopted to promote the implementation of HMS. However, the effect of HMS in chronic disease is poor and efforts to formulate chronic disease as a breakthrough to HMS should be carried out. Moreover, the government should increase the publicity of HMS.
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http://dx.doi.org/10.1016/j.socscimed.2020.113372DOI Listing
January 2021

Influence of China's 2009 healthcare reform on the utilisation of continuum of care for maternal health services: evidence from two cross-sectional household surveys in Shaanxi Province.

Int J Equity Health 2020 06 19;19(1):100. Epub 2020 Jun 19.

School of Public Policy and Administration, Xi'an Jiaotong University, No. 28 Xianning West Road, Xi'an, 710049, Shaanxi, China.

Background: Continuum of care for maternal health services (CMHS) is a proven approach to improve health and safety for mothers and newborns. This study aims to explore the influence of China's 2009 healthcare reform on improving the CMHS utilisation.

Methods: This population-based cross-sectional quantitative study included 2332 women drawn from the fourth and fifth National Health Service Surveys of Shaanxi Province, conducted in 2008 and 2013 respectively, before and after China's 2009 healthcare reform. A generalised linear mixed model (GLMM) was applied to analyse the influence of this healthcare reform on utilisation of CMHS. Concentration curves, concentration indexes and its decomposition method were used to analyse the equity of changes in utilisation.

Results: This study showed post-reform CMHS utilisation was higher in both rural and urban women than the CMHS utilisation pre-reform (according to China's policy defining CMHS). The rate of CMHS utilisation increased from 24.66 to 41.55% for urban women and from 18.31 to 50.49% for rural women (urban: χ = 20.64, P < 0.001; rural: χ = 131.38, P < 0.001). This finding is consistent when the WHO's definition of CMHS is applied for rural women after reform (12.13% vs 19.26%; χ = 10.99, P = 0.001); for urban women, CMHS utilisation increased from 15.70 to 20.56% (χ = 2.57, P = 0.109). The GLMM showed that the rate of CMHS utilisation for urban women post-reform was five times higher than pre-reform rates (OR = 5.02, 95%CL: 1.90, 13.31); it was close to 15 times higher for rural women (OR = 14.70, 95%CL: 5.43, 39.76). The concentration index for urban women decreased from 0.130 pre-reform (95%CI: - 0.026, 0.411) to - 0.041 post-reform (95%CI: - 0.096, 0.007); it decreased from 0.104 (95%CI: - 0.012, 0.222) to 0.019 (95%CI: - 0.014, 0.060) for rural women. The horizontal inequity index for both groups of women also decreased (0.136 to - 0.047 urban and 0.111 to 0.019 for rural).

Conclusions: China's 2009 healthcare reform has positively influenced utilisation rates and equity of CMHS's utilisation among both urban and rural women in Shaanxi Province. Addressing economic and educational attainment gaps between the rich and the poor may be effective ways to improve the persistent health inequities for rural women.
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http://dx.doi.org/10.1186/s12939-020-01179-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7304157PMC
June 2020

Measuring spatial accessibility and within-province disparities in accessibility to county hospitals in Shaanxi Province of Western China based on web mapping navigation data.

Int J Equity Health 2020 06 18;19(1):99. Epub 2020 Jun 18.

Department of Health Policy and Management, Yale School of Public Health, New Haven, CT, 06520, USA.

Background: The Chinese government proposed the "XIAO BING BU CHU CUN, DA BING BU CHU XIAN" initiative in 2016, which states the rate of health care service provided by county hospitals should reach 90% of overall health care service provision. The prerequisite for achieving this goal is that citizens should be able to access county hospitals' services conveniently and impartially. However, little research has been done on the actual levels of the spatial accessibility of citizens to county hospitals in Western China. Therefore, we aimed to measure the spatial accessibility to county hospitals for county residents and to identify any regional disparities in Shaanxi Province in Western China.

Methods: We implemented a novel method - involving utilizing navigation data from the AutoNavi web mapping system (knows as Gaode map in Chinese) - to assess the time and distance from villages and neighborhoods to the county hospitals. The navigation data were collected by request through an application-programming-interface using a web crawler (web data extraction tool) in Python. The shortest driving time and distance were extracted from the navigation data. The travel impedance to the nearest provider (TINP) indicator was used to measure spatial accessibility.

Results: The results show that county residents in Western China's Shaanxi Province have poor spatial accessibility to county hospitals. Only 68.8% of villages and neighborhoods are within 60 min travel time (based on driving mode) to a county hospital, while 13.4% of such villages and neighborhoods are beyond 90 min travel time. Moreover, a significant within-province disparity exists, with residents in the central area enjoying the best accessibility to county hospitals, while the northern and southern areas still need improvements in accessibility.

Conclusions: Focused health resource planning is required to improve the spatial accessibility to county hospitals and to eliminate regional disparities. Further studies are called for to integrate the navigation data of web mapping systems with GIS methods to the measure spatial accessibility of health facilities in more complex contexts.
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http://dx.doi.org/10.1186/s12939-020-01217-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7302366PMC
June 2020

Deep evolutionary analysis reveals the design principles of fold A glycosyltransferases.

Elife 2020 04 1;9. Epub 2020 Apr 1.

Institute of Bioinformatics, University of Georgia, Athens, Georgia.

Glycosyltransferases (GTs) are prevalent across the tree of life and regulate nearly all aspects of cellular functions. The evolutionary basis for their complex and diverse modes of catalytic functions remain enigmatic. Here, based on deep mining of over half million GT-A fold sequences, we define a minimal core component shared among functionally diverse enzymes. We find that variations in the common core and emergence of hypervariable loops extending from the core contributed to GT-A diversity. We provide a phylogenetic framework relating diverse GT-A fold families for the first time and show that inverting and retaining mechanisms emerged multiple times independently during evolution. Using evolutionary information encoded in primary sequences, we trained a machine learning classifier to predict donor specificity with nearly 90% accuracy and deployed it for the annotation of understudied GTs. Our studies provide an evolutionary framework for investigating complex relationships connecting GT-A fold sequence, structure, function and regulation.
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http://dx.doi.org/10.7554/eLife.54532DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7185993PMC
April 2020

The Influence of Left-Behind Experience on College Students' Mental Health: A Cross-Sectional Comparative Study.

Int J Environ Res Public Health 2020 02 26;17(5). Epub 2020 Feb 26.

School of Public Policy and Administration, Xi'an Jiaotong University, No. 28 Xianning West Road, Xi'an 710049, China.

China's rapid development and urbanization have created large numbers of migrant laborers, with increasing numbers of young adults and couples migrating from rural areas to large cities. As a result, a large number of children have become left-behind children (LBC), who were left behind in their hometown and cared for by one parent, grandparents, relatives or friends. Some of these LBC have a chance to be college students, who are called college students with left-behind experience. Some studies have indicated that the absence of these college students' parents during childhood may cause them to have some mental health problems. Therefore, we want to examine the effects of left-behind experience on college students' mental health and compare the prevalence of mental health problems in left-behind students and control students (without left-behind experience). For this purpose, a cross-sectional comparative survey was conducted in a coastal city of Shandong province, Eastern China. First, 1605 college students from three universities (national admissions) were recruited, including 312 students with left-behind experience and 1293 controls. Their mental health level was measured using Symptom Check-list 90 (containing ten dimensions: somatization, obsessive-compulsion (OCD), interpersonal sensitivity, depression, anxiety, hostility, terror, paranoia, psychoticism, and other symptoms). The results showed that left-behind experience was a significant risk factor for the mental health problems of college students ( = 2.27, 95%: 1.73 to 2.97). A comparison of the two groups, after controlling the confounding factors using the coarsened exact matching (CEM) algorithm, showed that the prevalence of mental health problems was 35.69% (n = 311) among the left-behind students, while it was 19.68% (n = 1194) among the controls. The two groups were significantly different in terms of these ten dimensions of the SCL-90 scale (p < 0.001), and the prevalence of each dimension among the left-behind students was consistently higher than that among the controls. In addition, different left-behind experiences and social supports during childhood had different effects on mental health problems.
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http://dx.doi.org/10.3390/ijerph17051511DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7084344PMC
February 2020

The Effects on Inappropriate Weight for Gestational Age of an SMS Based Educational Intervention for Pregnant Women in Xi'an China: A Quasi-Randomized Controlled Trial.

Int J Environ Res Public Health 2020 02 25;17(5). Epub 2020 Feb 25.

The Children's Hospital and School of Public Health, Zhejiang University School of Medicine, Hangzhou, Zhejiang 310058, China.

Background: The aim of this study was to estimate the effects of maternal text messages on inappropriate weight for gestational age (IWGA) in newborns in rural China.

Methods: Participants were pregnant women presenting for antenatal care at a Maternal and Child Health Center in Xi'an, China during the 2013-2015 period. In total, 2115 women completed the program with follow-up information included in the final analyses. All mothers were divided into four groups, including (1) a control group that received only a few "Basic" messages, (2) a Care-Seeking (CS) message group, (3) Good Household Prenatal Practices (GHPP) message group, and (4) a group receiving all 148 text messages. The primary outcome was IWGA, including small for gestational age (SGA) and macrosomia (weighing ≥4000g at birth). Multivariable logistic regression using an intent-to-treat estimate was utilized.

Results: In total, 19.5% of newborns were IWGA. The risk of IWGA was 23.0% in the control group, 19.6% in the CS group, 18.9% in the GHPP group, and 16.5% in the group with All Texts. Compared to the control group, the odds ratio of IWGA was 0.65 (0.48-0.89) for the group receiving All Texts, which remained statistically significant after performing the Holm-Bonferroni correction. The odds ratio of macrosomia was 0.54 (0.34-0.87) and 0.57 (0.36-0.49) for the Care Seeking message group and the All Texts group, respectively, with statistical significance.

Conclusion: A package of free informational text messages, including advice for good household prenatal practices and care seeking, may prevent the inappropriate weight for gestational age through a protective effect on macrosomia. Advice to encourage care seeking in pregnancy may prevent macrosomia among neonates in rural China as well.
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http://dx.doi.org/10.3390/ijerph17051482DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7084866PMC
February 2020

Health Disparity between the Older Rural-to-Urban Migrant Workers and Their Rural Counterparts in China.

Int J Environ Res Public Health 2020 02 4;17(3). Epub 2020 Feb 4.

School of Public Policy and Administration, Xi'an Jiaotong University, Xi'an 710049, China.

China's older rural-to-urban migrant workers (age 50 and above) are growing old, but comparative health research on older rural-to-urban migrants in China is still in its infancy. The aim is to explore the health status of older rural-to-urban migrant workers in China; as well as to identify health disparity between older rural-to-urban migrant workers and older rural dwellers. This study employed self-assessed health status (SAH) and chronic disease condition to explore the health status. Coarsened exact matching (CEM) was employed to improve estimation of causal effects. Fairlie's decomposition analysis was conducted to find the health disparity. Older rural-to-urban migrant workers were more prone to suffer from chronic diseases, but they had higher SAH when comparing older rural dwellers. Fairlie's decomposition analysis indicated 10.44% of SAH disparities between two older groups can be traced to bath facility; 31.34% of chronic diseases disparities can be traced to educational attainment, sleeping time and medical scheme. This is the first comparative study examining health disparity focusing on older rural-to-urban migrant workers. Our study highlighted substantial health disparities between older rural-to-urban migrant workers and their older rural dwellers. Based on the contributing factors, government should take the drivers of health disparities into consideration in policy setting.
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http://dx.doi.org/10.3390/ijerph17030955DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7038012PMC
February 2020

Explaining Income-Related Inequalities in Dietary Knowledge: Evidence from the China Health and Nutrition Survey.

Int J Environ Res Public Health 2020 01 15;17(2). Epub 2020 Jan 15.

School of Public Policy and Administration, Xi'an Jiaotong University, Xi'an 710049, China.

Lack of adequate dietary knowledge may result in poor health conditions. This study aims to measure income-related inequality in dietary knowledge, and to explain the sources of the inequality. Data were from the China Health and Nutrition Survey (CHNS) conducted in 2015. A summary of the dietary knowledge score and dietary guideline awareness was used to measure the dietary knowledge of respondents. The concentration index was employed as a measure of socioeconomic inequality and was decomposed into its determining factors. The study found that the proportion of respondents who correctly answered questions on dietary knowledge was significantly low for some questions. Compared to rural residents, urban residents had a higher proportion of correctly answered dietary knowledge questions. In addition, there are pro-rich inequalities in dietary knowledge. This observed inequality is determined not only by individual factors but also high-level area factors. Our study recommends that future dietary education programs could take different strategies for individuals with different educational levels and focus more on disadvantaged people. It would be beneficial to consider local dietary habits in developing education materials.
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http://dx.doi.org/10.3390/ijerph17020532DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7013705PMC
January 2020

Socioeconomic inequalities in the prevalence of chronic diseases and preventive care among adults aged 45 and older in Shaanxi Province, China.

BMC Public Health 2019 Nov 6;19(1):1460. Epub 2019 Nov 6.

School of Public Policy and Administration, Xi'an Jiaotong University, P.O Box 86, No. 76 West Yanta Road, Xi'an, 710061, Shaanxi, China.

Background: Monitoring inequalities in chronic disease prevalence and their preventive care can help build effective strategies to improve health equality. Using hypertension and diabetes as a model, this study measures and decomposes socioeconomic inequalities in their prevalence and preventive care among Chinese adults aged 45 years and older in Shaanxi Province, an underdeveloped western region of China.

Methods: Data of 27,728 respondents aged 45 years and older who participated in the fifth National Health Services Survey conducted in 2013 in Shaanxi Province were analyzed. The relative indexes of inequalities based on Poisson regressions were used to assess disparities in the prevalence of hypertension and diabetes and their preventive care between those with the lowest and the highest socioeconomic status, and the concentration index was used to measure the magnitude of the socioeconomic-related inequality across the entire socioeconomic spectrum. The contribution of each factor to the inequality was further estimated via the concentration index decomposition.

Results: Our results indicate a higher prevalence of hypertension and diabetes among the rich than the poor individuals aged 45 years and older in Shaanxi Province, China. Among individuals with hypertension or diabetes, significant inequalities favoring the rich were observed in the use of preventive care, i.e. in adequate use of medication and of blood pressure/blood glucose monitoring. Furthermore, economic status, educational level, employment status, and urban-rural areas were identified as the key socioeconomic indicators for monitoring the inequalities in the patient preventive care.

Conclusions: Our study suggests that the existence of clear inequities in the prevalence of chronic diseases and preventive care among adults aged 45 and older in Shaanxi Province, China. These inequalities in chronic diseases could be as much a cause as a consequence of socioeconomic inequalities.
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http://dx.doi.org/10.1186/s12889-019-7835-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6833131PMC
November 2019

Mothers' Subjective Well-Being after Having a Second Child in Current China: A Case Study of Xi'an City.

Int J Environ Res Public Health 2019 10 10;16(20). Epub 2019 Oct 10.

The School of Public Policy & Administration, Xi'an Jiaotong University, Xi'an 710049, China.

The introduction of the two-child family planning policy in China calls for a study of the response of mothers' subjective well-being after the birth of a second child. Generally focusing on Western countries, previous studies suggested that a series of factors could influence the response, but insufficient attention has been paid to the relative importance of these factors so far. Based on survey data from mothers of two children in the Xi'an metropolitan area, Shaanxi Province, China, our study indicates that the important factors associated with mothers' life satisfaction after having a second child were, in general, common to Western countries and China. There were also two factors somewhat unique to China: positive adjustment (i.e., becoming happier) by firstborn children (average age, 6 years old) following a sibling's birth, predicted enhanced life satisfaction for mothers; additionally, mothers who had both a son and a daughter reported the highest increase in life satisfaction, while mothers who had two sons reported the lowest increase. Socioenvironmental constraints (i.e., parenting pressure and work-family conflict) had a larger association with mothers' life satisfaction than individual ideational factors (e.g., family orientation and fertility desire). These findings suggest that fertility-friendly policies and convenient family intervention institutions are needed to alleviate potential undesirable consequences and improve maternal life quality following a second childbirth so that the two-child policy can be a success.
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http://dx.doi.org/10.3390/ijerph16203823DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6843609PMC
October 2019

10 years of health-care reform in China: progress and gaps in Universal Health Coverage.

Lancet 2019 Sep;394(10204):1192-1204

School of Public Health, Fudan University, Shanghai, China.

In 2009, China launched a major health-care reform and pledged to provide all citizens with equal access to basic health care with reasonable quality and financial risk protection. The government has since quadrupled its funding for health. The reform's first phase (2009-11) emphasised expanding social health insurance coverage for all and strengthening infrastructure. The second phase (2012 onwards) prioritised reforming its health-care delivery system through: (1) systemic reform of public hospitals by removing mark-up for drug sales, adjusting fee schedules, and reforming provider payment and governance structures; and (2) overhaul of its hospital-centric and treatment-based delivery system. In the past 10 years, China has made substantial progress in improving equal access to care and enhancing financial protection, especially for people of a lower socioeconomic status. However, gaps remain in quality of care, control of non-communicable diseases (NCDs), efficiency in delivery, control of health expenditures, and public satisfaction. To meet the needs of China's ageing population that is facing an increased NCD burden, we recommend leveraging strategic purchasing, information technology, and local pilots to build a primary health-care (PHC)-based integrated delivery system by aligning the incentives and governance of hospitals and PHC systems, improving the quality of PHC providers, and educating the public on the value of prevention and health maintenance.
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http://dx.doi.org/10.1016/S0140-6736(19)32136-1DOI Listing
September 2019

Prevalence and income-related equity in hypertension in rural China from 1991 to 2011: differences between self-reported and tested measures.

BMC Health Serv Res 2019 Jul 1;19(1):437. Epub 2019 Jul 1.

School of Public Policy and Administration, Xi'an Jiaotong University, Xi'an, People's Republic of China.

Background: Along with economic growth and living standard improvement, hypertension has become one of the most prevalent chronic diseases in China. Self-reported measures and tested measures of hypertension may differ significantly due to the low awareness of prevalence. The objective of this study is to figure out whether and how self-reported measures differ from tested measures in terms of prevalence and equity.

Method: We have used data from the China Health and Nutrition Survey database from 1991 to 2011 and extracted the data of rural areas using hukou system. Hypertension is categorized into two groups: self-reported hypertension and tested hypertension. To evaluate the equity of self-reported hypertension and tested hypertension, we calculated their Concentration Index (C) and decomposed C based on which we have obtained the horizontal-inequity index (HI) of each year. Probit Model was deployed to analyze the key determinants of hypertension prevalence.

Results: We found that the prevalence of both self-reported hypertension and tested hypertension have sharply increased from 1991 to 2011 in rural China and the population of tested hypertension was significantly larger than that of self-reported hypertension. For self-reported hypertension, prevalence rate increased from 2.72 to 13.2% and for tested hypertension it increased from 11.01 to 25.05%. Both of the Concentration Index (C) and horizontal-inequity index (HI) of self-reported hypertension and tested hypertension appeared to be contradictory. The C and HI of self-reported hypertension in 2011 were 0.032 and 0.060 respectively while the C and HI of tested hypertension were - 0.024 and - 0.015 respectively.

Conclusion: More efforts should be put into for improving the poor's health, especially in equal access to health services. Symptom-based measures such as tested hypertension should be adopted more widely in empirical studies.
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http://dx.doi.org/10.1186/s12913-019-4289-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6604163PMC
July 2019

Urban-rural-specific trend in prevalence of general and central obesity, and association with hypertension in Chinese adults, aged 18-65 years.

BMC Public Health 2019 May 30;19(1):661. Epub 2019 May 30.

School of Public Policy and Administration, Xi'an Jiaotong University, No.28 Xianning West Road, Xi'an, 710049, Shaanxi, China.

Background: China has the largest obese population in the world, and the prevalence of central obesity is increasing dramatically in China. Moreover, the rapid economic growth of China in recent decades has led to rapid urbanization in rural China. However, studies comparing the prevalence trends of different types of obesity and the association of obesity with hypertension between urban and rural areas in China are very scarce, and most studies have focused only on the difference in the prevalence of overweight and general obesity or hypertension among rural and urban populations. Therefore, the focus of this study was to examine the shifts in the overall distribution of the prevalence of different types of obesity and to estimate the risk of hypertension in different types of obesity among urban and rural adults aged 18-65 years.

Methods: Seven iterations of the China Health and Nutrition Survey (CHNS), conducted in 1993, 1997, 2000, 2004, 2006, 2009 and 2011, were used in this study. A total of 53,636 participants aged 18-65 years were included. Obesity was classified into three types based on body mass index (BMI) and waist circumference (WC). A log-binomial model was constructed to estimate the prevalence ratio (PR) of hypertension with three types of obesity.

Results: The age-standardized prevalence of central obesity only, general obesity only, and both central and general obesity increased from 15.8, 0.2 and 2.9% in 1993 to 30.3, 0.9 and 10.3% in 2011, respectively. The prevalence of central obesity only (urban vs. rural: 20.8% vs. 13.4% in 1993, 29.6% vs. 30.6% in 2011) and both central and general obesity (urban vs. rural: 3.5% vs. 2.5% in 1993, 10.0% vs. 10.6% in 2011) in rural adults exceeded that in urban adults in 2011. Participants with both central and general obesity had the highest risk for incident hypertension compared with those with normal body measurements (adjusted PR, urban: 2.30 (95% CI, 2.01-2.63), rural: 2.50 (95% CI, 2.25-2.77)).

Conclusions: Both WC and BMI should be considered measures of obesity and targeted in hypertension prevention. More attention should be paid to the incidence of central obesity in adults in rural China.
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http://dx.doi.org/10.1186/s12889-019-7018-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6543650PMC
May 2019

Decomposing inequality in catastrophic health expenditure for self-reported hypertension household in Urban Shaanxi, China from 2008 to 2013: two waves' cross-sectional study.

BMJ Open 2019 05 9;9(5):e023033. Epub 2019 May 9.

Department of Health Policy and Management, Yale School of Public Health, New Haven, CT, USA.

Objective: Despite the latest wave of China's healthcare reform initiated in 2009 has achieved unprecedented progress in rural areas, little is known for specific vulnerable groups' catastrophic health expenditure (CHE) in urban China. This study aims to estimate the trend of incidence, intensity and inequality of CHE in hypertension households (households with one or more than one hypertension patient) in urban Shaanxi, China from 2008 to 2013.

Methods: Based on the fourth and the fifth National Health Service Surveys of Shaanxi, we identified 460 and 1289 households with hypertension in 2008 and 2013, respectively for our analysis. We classified hypertension households into two groups: simplex households (with hypertension only) and mixed households (with hypertension plus other non-communicable diseases). CHE would be identified if out-of-pocket healthcare expenditure was equal to or higher than 40% of a household's capacity to pay. Concentration index and its decomposition based on Probit regressions were employed to measure the income-related inequality of CHE.

Results: We find that CHE occurred in 11.2% of the simplex households and 22.1% of the mixed households in 2008, and the 21.5% of the simplex households and the 46.9% of mixed households incurred CHE in 2013. Furthermore, there were strong pro-poor inequalities in CHE in the simplex households (-0.279 and -0.283) and mixed households (-0.362 and -0.262) both in 2008 and 2013. The majority of observed inequalities in CHE could be associated with household economic status, household head's health status and having elderly members.

Conclusion: We find a sharp increase of CHE occurrence and the sustained strong pro-poor inequalities for simplex and mixed households in urban Shaanxi Province of China from 2008 to 2013. Our study suggests that more concerns are needed for the vulnerable groups such as hypertension households in urban areas of China.
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http://dx.doi.org/10.1136/bmjopen-2018-023033DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6528006PMC
May 2019

When more is less: What explains the overuse of health care services in China?

Soc Sci Med 2019 07 17;232:17-24. Epub 2019 Apr 17.

School of Public Policy and Administration, Xi'an Jiaotong University, No. 28 Xianning West Road, Xi'an, Shaanxi, 710049, China. Electronic address:

Overuse of health care services has become an increasingly severe problem in China. However, as both academic interests and practical efforts have mainly focused on reducing underuse, our understanding of overuse is far from complete. This study aims to analyze the status of overuse of health care services in China and explore both the supply- and demand-side factors associated with overuse. We took common cold, a self-limiting viral infection which requires no injections or infusions, as a tracer condition. Based on data from the fourth and fifth Health Service Survey of Shaanxi Province, we generated an observable indicator to measure overuse: whether or not a patient received infusion treatment for common cold during outpatient visits. The statistics showed that 58.73% and 37.56% of patients had infusion treatment for common cold during outpatient visits in 2008 and 2013, respectively. Based on this dependent variable, we employed Probit analysis to investigate factors influencing the overuse of health care services. The multivariate regression results showed that on the demand side, overuse was positively associated with low health literacy, long duration of illness, large family size, and high economic status. On the supply side, overuse was relatively high in hospitals at the county level and above as well as in cities with relatively low density of health care workforce. Our results also provided some evidence for the effectiveness of health care reform policies like the essential medicines programme in reducing overuse.
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http://dx.doi.org/10.1016/j.socscimed.2019.04.018DOI Listing
July 2019

New Health Care Reform and Impoverishment among Chronic Households in China: A Random-Intercept Approach.

Int J Environ Res Public Health 2019 03 26;16(6). Epub 2019 Mar 26.

Centre for Health Economics, Monash Business School, Monash University, Melbourne, VIC 3800, Australia.

High out-of-pocket (OOP) payments for chronic disease care often contribute directly to household poverty. Although previous studies have explored the determinants of impoverishment in China, few published studies have compared levels of impoverishment before and after the New Health Care Reform (NHCR) in households with members with chronic diseases (hereafter referred to as chronic households). Our study explored this using data from the fourth and fifth National Health Service Surveys conducted in Shaanxi Province. In total, 1938 households in 2008 and 7700 households in 2013 were included in the analysis. Rates of impoverishment were measured using a method proposed by the World Health Organization. Multilevel logistic modeling was used to explore the influence of the NHCR on household impoverishment. Our study found that the influence of NHCR on impoverishment varied by residential location. After the reform, in rural areas, there was a significant decline in impoverishment, although the impoverishment rate remained high. There was little change in urban areas. In addition, impoverishment in the poorest households did not decline after the NHCR. Our findings are important for policy makers in particular for evaluating reform effectiveness, informing directions for health policy improvement, and highlighting achievements in the efforts to alleviate the economic burden of households that have members with chronic diseases.
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http://dx.doi.org/10.3390/ijerph16061074DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6466394PMC
March 2019

Assessing the quality of primary healthcare in seven Chinese provinces with unannounced standardised patients: protocol of a cross-sectional survey.

BMJ Open 2019 02 13;9(2):e023997. Epub 2019 Feb 13.

Xiangya School of Public Health, Central South University, Changsha, China.

Introduction: Primary healthcare (PHC) serves as the cornerstone for the attainment of universal health coverage (UHC). Efforts to promote UHC should focus on the expansion of access and on healthcare quality. However, robust quality evidence has remained scarce in China. Common quality assessment methods such as chart abstraction, patient rating and clinical vignette use indirect information that may not represent real practice. This study will send standardised patients (SP or healthy person trained to consistently simulate the medical history, physical symptoms and emotional characteristics of a real patient) unannounced to PHC providers to collect quality information and represent real practice.

Methods And Analysis: 1981 SP-clinician visits will be made to a random sample of PHC providers across seven provinces in China. SP cases will be developed for 10 tracer conditions in PHC. Each case will include a standard script for the SP to use and a quality checklist that the SP will complete after the clinical visit to indicate diagnostic and treatment activities performed by the clinician. Patient-centredness will be assessed according to the Patient Perception of Patient-Centeredness Rating Scale by the SP. SP cases and the checklist will be developed through a standard protocol and assessed for content, face and criterion validity, and test-retest and inter-rater reliability before its full use. Various descriptive analyses will be performed for the survey results, such as a tabulation of quality scores across geographies and provider types.

Ethics And Dissemination: This study has been reviewed and approved by the Institutional Review Board of the School of Public Health of Sun Yat-sen University (#SYSU 2017-011). Results will be actively disseminated through print and social media, and SP tools will be made available for other researchers.
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http://dx.doi.org/10.1136/bmjopen-2018-023997DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6398795PMC
February 2019

Effects of China's urban basic health insurance on preventive care service utilization and health behaviors: Evidence from the China Health and Nutrition Survey.

PLoS One 2018 31;13(12):e0209890. Epub 2018 Dec 31.

International Business School Suzhou, Xi'an Jiaotong-Liverpool University, Suzhou, Jiangsu, People's Republic of China.

Background: Lifestyle choices are important determinants of individual health. Few studies have investigated changes in health behaviors and preventive activities brought about by the 2007 implementation of Urban Resident Basic Health Insurance (URBMI) in China. This study, therefore, aimed to explore whether URBMI has reduced individuals' incentives to adopt healthy behaviors and utilize preventive care services.

Methods: Data were drawn from two waves of the China Health and Nutrition Survey. Respondents were categorized according to their insurance situation before and after the URBMI reform in 2006 and 2011. Propensity score matching and difference-in-differences methods were used to measure levels of preventive care and behavior changes over time. Estimations were also made based on gender, self-reported health, and income.

Results: We found that URBMI implementation did not change residents' utilization of preventive care services or their smoking habits, drinking habits, or other risky behaviors overall. However, the likelihood of sedentariness did increase by five percentage points. Females tended to be more sedentary while males were less likely to drink soft drinks. Residents with poor self-reported health exercised less while those who reported good health were more likely to be sedentary. Low- and middle-income residents were likely to be sedentary while middle-income people tended to smoke after becoming insured.

Conclusion: Since URBMI implementation, some unhealthy behaviors like sedentariness have increased among those who were newly insured, and different subgroups have reacted differently. This suggests that the insurance design needs to be optimized and effective measures need to be adopted to help improve people's lifestyle choices.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0209890PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6312240PMC
May 2019

Assessing the effects of the percentage of chronic disease in households on health payment-induced poverty in Shaanxi Province, China.

BMC Health Serv Res 2018 Nov 20;18(1):871. Epub 2018 Nov 20.

Department of Health Policy and Management and Department of Economics, Yale University, 60 College Street Suite 301, New Haven, CT, 06510, USA.

Background: Chronic disease has become one of the leading causes of poverty in China, which posed heavy economic burden on individuals, households and society, and accounts for an estimated 80% of deaths and 70% of disability-adjusted life-years lost now in China. This study aims to assess the effect of chronic diseases on health payment-induced poverty in Shaanxi Province, China.

Methods: The data was from the 5th National Health Survey of Shaanxi Province, which was part of China's National Health Service Survey (NHSS) conducted in 2013. Totally, 20,700 households were selected for analysis. We used poverty headcount, poverty gap and mean positive poverty gap to assess the incidence, depth and intensity of poverty before and after health payment, respectively. Logistic regression models were further undertaken to evaluate the influence of percentage of chronic patients in households on the health payment-induced poverty with the control of other covariates.

Results: In rural areas, the incidence of poverty increased 31.90% before and after health payment in the household group when the percentage of chronic patients in the households was 0, and the poverty gap rose from 932.77 CNY to 1253.85 CNY (50.56% increased). In the group when the percentage of chronic patients in the households was 1-40% and 41-50%, the poverty gap increased 76.78 and 89.29%, respectively. In the group when the percentage of chronic patients in the households was 51~ 100%, the increase of poverty headcount and poverty gap was 49.89 and 46.24%. In the logistic model, we found that the proportion of chronic patients in the households was closely related with the health payment-induced poverty. The percentage of chronic disease in the households increased by 1 %, the incidence of poverty increased by 1.01 times. On the other hand, the male household head and the household's head with higher educational lever were seen as protective factors for impoverishment.

Conclusions: With the percentage of chronic patients in the households growing, the health payment-induced poverty increases sharply. Furthermore, the households members with more chronic diseases in rural areas were more likely to suffer poverty than those in urban areas. Our analysis emphasizes the need to protect households from the impoverishment of chronic diseases, and our findings will provide suggestions for further healthcare reforms in China and guidance for vulnerable groups.
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http://dx.doi.org/10.1186/s12913-018-3698-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6245518PMC
November 2018

Identifying Keystone Species in the Microbial Community Based on Cross- Sectional Data.

Curr Gene Ther 2018 ;18(5):296-306

School of Computer Science and Technology, Harbin Institute of Technology, WeiHai, China.

Background: In microbial communities, the keystone species have a greater impact on the performance and dynamics of ecosystem than that of other species, in which we can see from the results that losing gut microbiome causes some specific diseases. A number of ongoing studies aim at identifying links between microbial community structure and human diseases.

Method: In this paper, we have introduced a valid keystone species identification method, in which a new Spread Intensity (SI) algorithm is used. Because the accuracies of current keystone species identification algorithms are difficult to evaluate for the high diversity and uncultivated status of microbial communities, we simulated cross-sectional data of microbial communities with known interactions and set up standard keystoneness rankings using Generalized Lotka-Volterra (GLV) model. Subsequently, we compared the SI algorithm with existing methods by using simulated data and obtained an obvious better performance of SI algorithm than other methods. Also, we applied this method to gut microbiota datasets and identified some microbes having the potential association with body weight. We first assembled three correlation metrics to calculate the interspecies correlation. Then we applied network deconvolution to remove indirect correlations. Finally, we used Molecular Ecological Network Analysis (MENA) to construct the co-occurrence network. According to experimental results, SI algorithm has an excellent performance in identifying highly correlated species in gut microbiome to body weight.

Result: This result provides an effective indicator for modulating gut microbiota and thus enables the gene therapy and other gene-level treatments for losing-weight and other gut-associated diseases.
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http://dx.doi.org/10.2174/1566523218666181008155734DOI Listing
October 2019