Determinants of public malaria awareness during the national malaria elimination programme: a cross-sectional study in rural China

Factors affecting delays in seeking treatment among malaria patients during the pre-certification phase in China

BACKGROUND

Delays in malaria treatment can not only lead to severe and even life-threatening complications, but also foster transmission, putting more people at risk of infection. This study aimed to investigate the factors influencing treatment delays among malaria patients and their health-seeking behaviour.

METHODS

The medical records of 494 patients diagnosed with malaria from 6 different malaria-endemic provinces in China were analysed. A bivariate and multivariable regression model was used to investigate the association between delays in seeking treatment and various factors. A Sankey diagram was used to visualize the trajectories of malaria patients seeking medical care. Total treatment delays were categorized as patient delays and doctor delays.

RESULTS

The incidence of total delays in seeking malaria treatment was 81.6%, of which 28.4% were delayed by patients alone and 34.8% by doctors alone. The median time from the onset of symptoms to the initial healthcare consultation was 1 day. The median time from the initial healthcare consultation to the conclusive diagnosis was 2 day. After being subjected to multiple logistic regression analysis, living in central China was less likely to experience patient delays (OR = 0.43, 95% CI 0.24-0.78). The factors significantly associated with the lower likelihood of doctor delays included: age between 30 to 49 (OR = 0.43, 95% CI 0.23-0.81), being single/divorce/separated (OR = 0.48, 95% CI 0.24-0.95), first visiting a county-level health institution (OR = 0.25, 95% CI 0.14-0.45), first visiting a prefectural health institution (OR = 0.06, 95% CI 0.03-0.12) and first visiting a provincial health institution (OR = 0.05, 95%CI 0.02-0.12). Conversely, individuals with mixed infections (OR = 2.04, 95% CI 1.02-4.08) and those experiencing periodic symptoms (OR = 1.71, 95% CI 1.00-2.92) might face increased doctor delays. Furthermore, higher financial burden and complications were found to be associated with patient delays. Doctor delays, in addition to incurring these two consequences, were associated with longer hospital stays.

CONCLUSION

There was a substantial delay in access to health care for malaria patients before China was certified malaria free. Region, marital status, periodic symptoms and the level of health institutions were factors contributing to delays in treatment-seeking among malaria patients.

Using social media for health education and promotion: a pilot of WeChat-based prize quizzes on China national malaria day

BACKGROUND

Imported malaria cases remains a key health concern, especially during the COVID-19 pandemic. Providing accurate health information is important to improving people's awareness of malaria. WeChat is an excellent social media tool for health information dissemination, especially during the pandemic. This study explored the effect of malaria knowledge dissemination via a WeChat public account.

METHODS

A questionnaire for data collection was constructed using the online survey tool Sojump. Questionnaires were sent to users who followed the Jiangsu institute of Parasitic Disease WeChat public account during the National Malaria Day 2021 period. A small incentive (WeChat Red Packet) was distributed to everyone who answered the questionnaire correctly on time.

RESULTS

A total of 13,169 valid questionnaires were collected during the China National Malaria Day period. Questions in which participants focused mainly on information pertaining to themselves, such as infection, symptoms, and epidemic areas, reached highest accuracy (above 90%). Questionnaires were submitted through smartphones and most of them were completed during the period of 4 days from April 23 to April 26, 2021 when a WeChat Red Packet was offered. The accuracy of responses was related to bolded words and location and number of knowledge points that were shown at the beginning of the questionnaire. The number of users of the WeChat public account in question increased from 5961 to 12,339 in just 4 days of the activity.

CONCLUSION

A WeChat public account is a convenient and accessible tool for spreading malaria-related health information to the public. Distribution of incentives (Red Packets) can effectively increase public attention to popular science and health information and activities.

The economic burden of malaria inpatients and its determinants during China's elimination stage

Background

Malaria burden is still worrisome, while empirical evidence from malaria-eliminated countries including China may provide inspiration for the world.

Objective

This study aimed to investigate China's malaria hospitalization costs and explore its determinants.

Methods

Stratified multistage sampling across provincial, municipal, and county hospitals was conducted in 2017. All the malaria medical records were retrieved from 2014 to 2016 in 70 hospitals. Parametric and non-parametric methods were employed to estimate hospitalization costs, and the non-parametric bootstrap was used to compare hospitalization costs among sample areas and assessed the uncertainty of its differences. Quantile regressions were conducted to identify the determinants of hospitalization costs.

Results

The median hospitalization costs of 1633 malaria inpatients were 628 USD. Medication and laboratory tests accounted for over 70% of total expenditure. The median reimbursement rate was 41.87%, and this number was even lower in higher-level hospitals (<35%) and among the New Rural Cooperative Medical Scheme (<40%). Finally, health insurance type, hospital tier, clinical units, unknown fever, and comorbidity were the main determinants of hospitalization costs.

Conclusion

The disparity of health protection for malaria hospitalization between rural and urban areas was noteworthy. Equivocal diagnosis and comorbidity are contributors of high cost as well. A reasonable payment system and enhanced capacities to treat malaria in a cost-effective way are suggested to reassure malaria economic burden.

Ethnic Variation and Its Association With Malaria Awareness: A Cross-sectional Study in East Nusa Tenggara Province, Indonesia

Objectives

This study investigated associations between ethnicity and malaria awareness in East Nusa Tenggara Province (ENTP), Indonesia.

Methods

A community-based cross-sectional study was conducted upon 1503 adults recruited by multi-stage cluster random sampling. A malaria awareness questionnaire was used to collect data, according to which participants were classified as aware or unaware of malaria. Logistic regression was applied to quantify the strength of associations of factors with malaria awareness.

Results

The participation rate in this study was high (99.5%). The participants were distributed relatively evenly among the Manggarai, Atoni, and Sumba ethnicities (33.0, 32.3, and 30.2%, respectively). Malaria awareness was significantly different amongst these groups; it was most common in the Manggarai ethnicity (65.1%; 95% confidence interval [CI], 59.9 to 70.3) and least common in the Sumba ethnicity (35.0%; 95% CI, 27.6 to 42.4). The most prominent factor influencing the malaria awareness in the Sumba and Manggarai ethnicities was education level, whilst it was socioeconomic status (SES) in the Atoni ethnicity. The likelihood of malaria awareness was significantly higher in adults with an education level of diploma or above (adjusted odds ratio [aOR], 21.4; 95% CI, 3.59 to 127.7 for Manggarai; aOR, 6.94; 95% CI, 1.81 to 26.6 for Sumba). Malaria awareness was significantly more common amongst high-SES adults in the Atoni group (aOR, 24.48; 95% CI, 8.79 to 68.21).

Conclusions

Low education levels and low SES were prominent contributors to lower levels of malaria awareness in rural ENTP. Interventions should focus on improving malaria awareness to these groups to support the Indonesian government’s national commitment to achieve a malaria elimination zone by 2030.

Exploring Factors Associated with Self-Management Compliance among Rural Elders with Diabetes

The purpose of the study was to examine the social-ecological factors associated with diabetic self-management compliance among elders with diabetes in China. A total of 2,586 rural elderly residents who were 60-years-old or above participated in the survey. Socio-demographic factors, social support, healthcare accessibility and health risk factors were measured, along with self-reported medication and blood glucose monitoring data. Among the 117 individuals with diabetes, the medication compliance rate was 79.49%. The elderly who had high economic status were more likely to meet medication treatment compliance. Only 58.97% of study participants monitored blood glucose once a month. Younger age (<70-year-old), higher economic status, more social support and better healthcare accessibility were associated with higher blood glucose monitoring compliance odds. Diabetic medication and blood glucose testing tools should be more comprehensively covered by the national insurance program. Healthcare accessibility should be increased through transportation support, building more local facilities, such as mobile labs, and promoting affordable home-visit care. Self-management education programs about diabetes for rural elders should be promoted.

Regularity of Clinical Visits and Medication Adherence of Patients with Hypertension or Diabetes in Rural Yunnan Province of China

Chronic diseases can be controlled through effective self-management. The purpose of this study is to explore the regularity of clinical visits and medication adherence of patients with hypertension or diabetes (PWHD), and its association with the first experience with care and individual factors in rural Southwestern China. This cross-sectional study was carried out in Yunnan province in 2018 and recruited 292 PWHD and 122 village clinics from 122 villages in 10 counties. Participants were interviewed using a structured questionnaire. Results show around 39% of hypertensive and 25% of diabetic patients neither visited physicians nor took medicine regularly during the preceding three months of the interview date. The regression results further indicated that individual characteristics of the PWHD, including patient age, health status, and economic level, as well as their first experience with care, were significantly associated with their regular healthcare behavior. In addition to providing medical services, on average each sample village clinic, with around two physicians, simultaneously managed 180 hypertensive and 45 diabetic patients. This study revealed the need for further reforms in terms of improving self-management and thus recommends an increase in the quantity and the quality of human resources in the primary healthcare realm in rural China.

The Elderly's Demand for Community-Based Care Services and Its Determinants: A Comparison of the Elderly in the Affordable Housing Community and Commercial Housing Community of China

With the rapid aging of the world population, great pressure has been placed on the provision of community-based care in China. This paper aimed to compare the demand and its determinants for various community-based care services among the elderly in the affordable housing community (AHC) and commercial housing community (CHC) of China. Two community-based surveys were conducted separately in the AHC and CHC of Nanjing City, China. In total, 408 valid questionnaires were returned from the Daishan AHC while 8422 valid questionnaires were received from the CHCs. The chi square test indicated that the respondents in the AHC had significantly higher demands for five types of services (the meal-aid service, the cleaning-aid service, the bath-aid service, the rehabilitation therapy service, and the first-aid service) than those in the CHCs of Nanjing. Further, the Cochran–Mantel–Haenszel test showed that factors influencing the elderly's demands for these services varied across communities. Several policy implications could be obtained to improve the efficiency of community-based care provision.

Beyond Altruism: Framing Organ Donation in a 19-year Review of Chinese News Coverage

Despite a significant legal transformation of the organ donation system in China, the public's willingness to become organ donors remains low. This study provides the first empirical examination of how Chinese newspaper coverage reflects the complex interplay among multifaceted factors associated with the stagnant donation rate. Using framing as the primary theoretical lens, we analyzed 923 organ donation newspaper articles from 2000 to 2018 in terms of topics, facilitators and barriers, valence, and policy development. The three most common topics emphasized were: a new official information release regarding organ donation promotion; the challenges of promoting organ donation in social, cultural, and legal contexts; and the positive emotional appeals of organ donors, coordinators, and transplant surgeons. Findings suggest that the values that facilitators of and barriers to organ donation represent can be culturally favored but in conflict with each other. Sharp increases in the presence of policy development framing are associated with the official announcements of new legislation. A better understanding of trending topics and interacting influence from facilitators and barriers is imperative for developing culturally tailored messages to raise awareness about organ donation promotion.

Do Mothers with Lower Socioeconomic Status Contribute to the Rate of All-Cause Child Mortality in Kazakhstan?

Background

This study aimed to explore whether or not mothers with higher educational and wealth status report lower rate of child mortality compared to those with less advantageous socioeconomic situation.

Methods

Data used were cross-sectional and collected from Multiple Indicator Cluster Survey in Kazakhstan conducted in 2015. Subjects experiencing childbirth were 9278 women aging between 15 and 49 years. The associations between maternal education and household wealth status with child mortality were examined by multivariate analytical methods.

Results

The overall prevalence of child mortality was 6.7%, with noticeable variations across the different regions. Compared with women who had the highest educational status, those with upper and lower secondary were 1.47 and 1.89 times more likely to experience child death. Women in the lowest and second lowest wealth quintile had 2.74 and 2.68 times higher odds of experiencing child death compared with those in the richest wealth status households.

Conclusions

Policy makers pay special attention to improving socioeconomic status of the mothers in an effort to reduce child mortality in the country. Women living in the disadvantaged regions with poor access to quality health care services should be regarded as a top priority.

Does having a usual primary care provider reduce patient self-referrals in rural China's rural multi-tiered medical system? A retrospective study in Qianjiang District, China

INTRODUCTION

Within China's multi-tiered medical system, many patients seek care in higher-tiered hospitals without a referral by a primary-care provider. This trend, generally referred to as patient self-referral behavior, may reduce the efficiency of the health care system. This study seeks to test the hypothesis that having a usual primary care provider could reduce patients' self-referral behavior.

METHODS

We obtained medical records of 832 patients who were hospitalized for common respiratory diseases from township hospitals in Qianjiang District of Chongqing City during 2012-2014. Logit regressions were performed to examine the association between having a township hospital as a usual provider and self-referring to a county hospital after being discharged from a township hospital, while controlling for patients' gender, age, income, education, severity of disease, distance to the nearest county hospital and the general quality of the township hospitals in their community. A propensity score weighting approach was applied.

RESULTS

We found that having a usual primary care provider was associated with a lower likelihood of self-referral (odds ratio = 0.58, 95% confidence interval [CI] =0.41-0.82), and a 9% (95% CI: -14%, - 3%) reduction in the probability of patients' self-referral behavior.

DISCUSSION/CONCLUSION

The results suggest that establishing a long-term relationship between patients and primary care providers may enhance the patient-physician relationship and reduce patients' tendency for unnecessary use of medical resources.

Economic burden of malaria inpatients during National Malaria Elimination Programme: estimation of hospitalization cost and its inter-province variation

BACKGROUND

Apart from its direct impact on public health and well-being, malaria had placed significant socioeconomic burden on both individuals and whole health systems. This study was conducted to investigate the hospitalization cost of malaria and explore the inter-province variation during the National Malaria Elimination Programme in China.

METHODS

Information on medical expenditure for malaria treatment was extracted from inpatient medical records in Henan, Hainan and Guangxi Province. The costs were adjusted to the price in 2014 and converted to USD (United States Dollars). Non-parametric and parametric methods were employed to estimate hospitalization costs and non-parametric bootstrap method was used for the comparison of hospitalization costs among sample provinces and to estimate the uncertainty of differences in inter-province hospitalization costs.

RESULTS

The hospitalization cost and daily cost of 426 malaria inpatients were 929.8 USD and 143.12 USD respectively. The average length of stay was 11.95 days. The highest cost of hospitalization services occurred in tertiary hospitals (956 USD per episode). Whereas the lowest ones occurred in internal departments (424 USD). Medications, laboratory tests and supportive resources for treatment were the most important components of hospitalization costs, respectively responsible for 45.31, 24.70, and 20.09% of the total hospitalization costs. The hospitalization cost per episode in Henan Province was significantly higher than that in Hainan an in Guangxi Province, with incremental costs of 713 USD (95% confidence interval 419.70, 942.50) and of 735.58 USD (95% CI 606.50, 878.00), respectively. The differences in the daily costs between Henan and Hainan along with Guangxi provinces were 75.33 USD (95% CI 40.33, 96.67) and 93.56 USD (95% CI 83.58, 105.28), respectively.

CONCLUSIONS

Although the prevalence of malaria cases has considerably declined, the direct hospitalization costs of malaria in the household remain high and the inter-province variations need to be seriously considered in the formulation the further interventions regarding hospitalization cost control. This study suggests that economic risk protection mechanisms targeting at malaria inpatients should be redesigned. The drug price addition policy in public hospitals should be gradually reformed or abolished coupling with increasing government subsidies along with the charges for treatment services to reduce the hospitalization cost. The policy for cost control in the provincial hospitals should be implemented in comparison with the policy in other provinces, where the status of economic and geography are similar.

Improving local health workers' knowledge of malaria in the elimination phase-determinants and strategies: a cross-sectional study in rural China

BACKGROUND

The current stage of malaria elimination in China requires experienced local health workers with sufficient knowledge of malaria who help to keep the public health system vigilant about a possible resurgence. However, the influencing factors of local health workers' knowledge level are not fully comprehended. This study aims to explore the factors with heavy impact on local health worker's knowledge of malaria and propose corresponding suggestions.

METHODS

Underpinned by stratified sampling method, a cross-sectional survey was carried out between November 2014 and April 2016. Chi square test was performed to identify the factors with potential influence on health workers' knowledge level of malaria. Bivariate logistic regression was employed to explore the relationship between the predictors and local health workers' knowledge level of malaria. Layered Chi square test was used to calculate the homogeneity of the interaction between training approaches and the percentage of participants with high-level knowledge.

RESULTS

The endemic type of county and type of organization played the most significant role in influencing local health workers' knowledge level regarding malaria in the sample population. The participants from Type 1 and Type 2 counties were 4.3 times (4.336 and 4.328, respectively) more likely to have high-level knowledge of malaria than those who work in Type 3 counties. The probability of having high-level knowledge amongst the participants from county-level facilities (county hospitals and CDCs) were more than 2.2 times higher than those who work in villages. Other socio-demographic factors, such as education and work experience, also affected one's knowledge regarding malaria. Amongst the six most-used training approaches, electronic material (OR = 2.356, 95% CI 1.112-4.989), thematic series (OR = 1.784, 95% CI 0.907-3.508) and supervision (OR = 2.788, 95% CI 1.018-7.632) were proven with significant positive impact on local health workers' knowledge of malaria.

CONCLUSION

Village doctors and who served in Type 3 counties were identified as the ones in urgent need of effective training. Three types of training approaches, including electronic material, thematic series and supervision, were proven to be effective in improving local health workers' knowledge. Nevertheless, the coverage of these training approaches was still limited. This study suggests expanding the coverage of training, especially the three particular types of training, to local health workers, particularly to the target populations (village doctors and who served in Type 3 counties). Online training, small group discussion and targeted skill development may be the directions for the future development of training programmes.

What Contributes to the Regularity of Patients with Hypertension or Diabetes Seeking Health Services? A Pilot Follow-Up, Observational Study in Two Sites in Hubei Province, China

Regular maintenance of non-communicable chronic diseases can constrain disease progression in diabetic and hypertensive patients. To identify the individual and social factors that are associated with positive health-seeking behaviors and regular maintenance of chronic diseases, we have conducted a follow up study in 2015 on diabetic and hypertensive patients in Hubei Province. We used binary logistic regression models to determine specific factors associated with diabetic and hypertensive patients that sought healthcare services for their conditions in accordance with current Chinese Centers for Disease Prevention and Control (CDC) guidelines. Our findings show that 42.16% of 510 people living with chronic conditions (PLCDs) sought health services in line with existing guidelines. Findings also show a higher probability (8.418 times) for PLCDs seeking healthcare services at higher-tiered hospitals (secondary and tertiary hospitals) than for PLCDs seeking care at primary hospitals (odds ratio (OR) = 8.418, 95% confidence interval (CI) = 4.82, 14.27, p < 0.001). These analyses underscore the importance of having patient advocates who can provide support, where necessary, and encourage positive health-seeking behavior. The study also shows a negative impact on regular maintenance for PLCDs in households with high financial constraints. In contrast, the study shows positive impacts for increased household income, age, and residency in rural locations. In sum, this study underscores the importance of primary hospitals as key points of care and critical players in care coordination for PLCDs. The study provides more evidence for Chinese policymakers seeking to contain costs and improve population health. The findings also underscore the need for community-based interventions, specifically interventions that link local primary hospitals, friends/family members, and PLCDs.