Characteristics and Workload of Pediatricians in China

Impact Analysis of COVID-19 Pandemic on Hospital Reviews on Dianping Website in Shanghai, China: Empirical Study

BACKGROUND

In the era of the internet, individuals have increasingly accustomed themselves to gathering necessary information and expressing their opinions on public web-based platforms. The health care sector is no exception, as these comments, to a certain extent, influence people's health care decisions. During the onset of the COVID-19 pandemic, how the medical experience of Chinese patients and their evaluations of hospitals have changed remains to be studied. Therefore, we plan to collect patient medical visit data from the internet to reflect the current status of medical relationships under specific circumstances.

OBJECTIVE

This study aims to explore the differences in patient comments across various stages (during, before, and after) of the COVID-19 pandemic, as well as among different types of hospitals (children's hospitals, maternity hospitals, and tumor hospitals). Additionally, by leveraging ChatGPT (OpenAI), the study categorizes the elements of negative hospital evaluations. An analysis is conducted on the acquired data, and potential solutions that could improve patient satisfaction are proposed. This study is intended to assist hospital managers in providing a better experience for patients who are seeking care amid an emergent public health crisis.

METHODS

Selecting the top 50 comprehensive hospitals nationwide and the top specialized hospitals (children's hospitals, tumor hospitals, and maternity hospitals), we collected patient reviews from these hospitals on the Dianping website. Using ChatGPT, we classified the content of negative reviews. Additionally, we conducted statistical analysis using SPSS (IBM Corp) to examine the scoring and composition of negative evaluations.

RESULTS

A total of 30,317 pieces of effective comment information were collected from January 1, 2018, to August 15, 2023, including 7696 pieces of negative comment information. Manual inspection results indicated that ChatGPT had an accuracy rate of 92.05%. The F1-score was 0.914. The analysis of this data revealed a significant correlation between the comments and ratings received by hospitals during the pandemic. Overall, there was a significant increase in average comment scores during the outbreak (P<.001). Furthermore, there were notable differences in the composition of negative comments among different types of hospitals (P<.001). Children's hospitals received sensitive feedback regarding waiting times and treatment effectiveness, while patients at maternity hospitals showed a greater concern for the attitude of health care providers. Patients at tumor hospitals expressed a desire for timely examinations and treatments, especially during the pandemic period.

CONCLUSIONS

The COVID-19 pandemic had some association with patient comment scores. There were variations in the scores and content of comments among different types of specialized hospitals. Using ChatGPT to analyze patient comment content represents an innovative approach for statistically assessing factors contributing to patient dissatisfaction. The findings of this study could provide valuable insights for hospital administrators to foster more harmonious physician-patient relationships and enhance hospital performance during public health emergencies.

Pediatric health service utilization at tertiary hospitals in Denmark 2000-2018

Pediatric health service differs between and within countries. To prioritize limited resources, data-driven studies on pediatric tertiary hospital contacts are warranted. This population-based register study identified all contacts with four Danish tertiary hospitals 2000-2018 by 0-17-year-old patients. During 2000-2018, 2,496,001 individuals resided in Denmark while 0-17 years old, and the study described 829,562 inpatient and 3,932,744 outpatient contacts at tertiary hospitals by hospital, sex, age, diagnosis, department, and residence. Male patients accounted for more contacts overall (inpatient 55.51%, outpatient 52.40%) and more contacts with severe chronic disease (inpatient 56.24%, outpatient 54.41%). Median (interquartile range) patient age was 3.09 (0.26-9.96) and 8.48 (2.78-13.70) years for in- and outpatient contacts. Overall, 28.23% and 21.02% of in- and outpatient contacts included a diagnosis of a severe chronic disease, but the proportions differed across hospitals. A pattern of pediatric healthcare directed towards less severe diseases was observed: While the total number of outpatient visits at tertiary hospitals increased from 2000 to 2018, the proportion of these contacts which had a diagnosis of a severe chronic disease decreased. Future comparisons between hospitals regarding pediatric outcomes should consider potential differences in terms of uptake and diagnosis severity. Such findings may have implications for future pediatric organization, nationally and internationally.

Characteristics analysis of Internet pharmacy consultation services for children in southwest China during the post-epidemic era: A cross-sectional study

AIM

This study aims to examine the features of online pediatric pharmacy consultations in Southwest China, an area with limited medical resources during the post-epidemic era and to explore the factors affecting the dialogue volume in online consultations.

METHODS

A cross-sectional study was conducted in southwest China from April 2022 to March 2023. The study encompassed a cohort of 2,526 children, ranging from 0 to 18 years old. The collected data encompassed patient gender, age, weight, department, drugs involved in consultation services, types of questions consulted, consultation start time, and the dialogue volume in online consultations. Descriptive statistics and an ordered multicategorical logistic regression analysis were performed. SPSS 26.0 software was used for data analysis.

RESULTS

Among the total Internet pharmacy consultation services offered, the infant group constituted the largest portion (n = 1021). Children with internal medicine concerns have greater online consultation needs (n = 455). The peak usage of Internet pharmacy consultation occurred in the fall at 11:00 a.m. (n = 73). Factors influencing the dialogue volume in online consultations include the non-availability of Chinese medications [P = 0.033, OR = 0.81, 95 % CI (0.67-0.98)], consultation initiation during the spring [P = 0.002, OR = 1.52, 95 % CI(1.17-1.97)] or afternoon [P = 0.012, OR = 1.36, 95 % CI (1.07-1.72)] and weight＜15 kg group [P = 0.038, OR = 2.19, 95 % CI (1.04-4.58)].

CONCLUSION

Our findings provide important information for peers to carry out their work. In the post-epidemic era, emphasis should be placed on addressing concerns related to children's internal medicine and otolaryngology. Optimizing healthcare resource allocation should take into account the time-seasonal variability of children's consultation behaviors. Furthermore, it is recommended to focus on weight＜15 kg children in inquiries, absorb sufficient knowledge about Chinese medicines, and schedule more pharmacists to participate in consultation services during the spring or in every afternoon. These findings help the authorities of online platforms and the National Health Commission to rationalize the allocation of healthcare resources, optimize the quality of service delivery, and develop new policies.

Estimating the Economic Impact of Levalbuterol's Potential Transition From the National Reimbursement Drug List for the Treatment of Pediatric Asthma in China: A Budget Impact Analysis

Background Levalbuterol is a short-acting β2-agonist (SABA) indicated for treating or preventing asthma exacerbation. It was included in the 2020 Chinese National Reimbursement Drug List (NRDL). This study estimates the economic impact of levalbuterol's status change within and withdrawal from the NRDL in treating pediatric asthma from a publicly funded medical insurance perspective. Methodology A prevalence-based budget impact model was developed. The analysis compared a world with a levalbuterol scenario to a world without levalbuterol. Epidemiological data were obtained from the existing literature. Cost data were estimated based on the drug dosage in clinical trials, real-world settings, and expert opinions. Scenario analysis considered the same length of stay (LOS) in the two groups. One-way sensitivity analyses were carried out to show the impact of varying individual parameters. Results In the base-case analysis, compared to the world without scenario, the preservation of levalbuterol resulted in cost savings of ¥82.8 million in China over three years. In the scenario analysis, savings decreased to ¥76.1 million over three years. Sensitivity analysis showed that, for the most part, the results were robust to changes in input parameter values. Conclusions Using levalbuterol may lead to substantial cost savings for Chinese society.

Prognostic factors for intermediate- or high-risk neuroblastomas in children in China

BACKGROUND

Evidence regarding the characteristics and prognosis of neuroblastoma (NBL) in China is limited. We aimed to investigate the characteristics and prognosis of intermediate- or high-risk NBL in children in China.

METHODS

We included 147 patients with intermediate- or high-risk NBL evaluated from January 2006 to March 2015. The patients were aged 1 month to 15.5 years, 66% of them were boys, and 117 (79.6%) were diagnosed with high-risk NBL.

RESULTS

After a median follow-up of 32.5 months, 80 (45.6%) patients survived, with a median survival time of 48 months (95% confidence interval [CI]: 36.41-59.59). High-risk patients (hazard ratio [HR]: 12.467; 95% CI: 11.029-12.951), partial response (PR) (HR: 1.200; 95% CI: 1.475-2.509) or progression disease (PD) (HR: 1.924; 95% CI: 1.623-3.012) after induction chemotherapy, and intracranial metastasis (HR: 3.057; 95% CI: 0.941-4.892) were independent risk factors for survival (p < 0.05) and postrelapse survival (p < 0.05). NBL relapse, male sex, and PR or PD after induction chemotherapy were risk factors for event-free survival (p < 0.05).

CONCLUSIONS

In addition to previously established independent risk factors, such as age, risk group, and relapse, efficacy of induction chemotherapy and intracranial metastasis play significant roles in the prognosis of NBL.

Universal health coverage in China part 1: progress and gaps

Over the past 2 decades, China has made remarkable progress in health-care service coverage, especially in the areas of reproductive, maternal, newborn, and child health, infectious diseases, and service capacity and access. In these areas, coverage is comparable to those in high-income countries. Inequalities of service coverage in these areas have been reduced. However, there remain large gaps in the service coverage of chronic diseases. There has been little progress in controlling risk factors of chronic diseases in the past 10 years. Service coverage for most chronic conditions is lower than in high-income countries. Moreover, China has disproportionately high incidences of catastrophic health expenditure compared with countries with similar economic development. This paper comprehensively evaluates China's progress towards universal health coverage by identifying the achievements and gaps in service coverage and financial risk protection that are crucial to achieve universal health coverage goals by 2030.

Characteristics and Admission Preferences of Pediatric Emergency Patients and Their Waiting Time Prediction Using Electronic Medical Record Data: Retrospective Comparative Analysis

BACKGROUND

The growing number of patients visiting pediatric emergency departments could have a detrimental impact on the care provided to children who are triaged as needing urgent attention. Therefore, it has become essential to continuously monitor and analyze the admissions and waiting times of pediatric emergency patients. Despite the significant challenge posed by the shortage of pediatric medical resources in China's health care system, there have been few large-scale studies conducted to analyze visits to the pediatric emergency room.

OBJECTIVE

This study seeks to examine the characteristics and admission patterns of patients in the pediatric emergency department using electronic medical record (EMR) data. Additionally, it aims to develop and assess machine learning models for predicting waiting times for pediatric emergency department visits.

METHODS

This retrospective analysis involved patients who were admitted to the emergency department of Children's Hospital Capital Institute of Pediatrics from January 1, 2021, to December 31, 2021. Clinical data from these admissions were extracted from the electronic medical records, encompassing various variables of interest such as patient demographics, clinical diagnoses, and time stamps of clinical visits. These indicators were collected and compared. Furthermore, we developed and evaluated several computational models for predicting waiting times.

RESULTS

In total, 183,024 eligible admissions from 127,368 pediatric patients were included. During the 12-month study period, pediatric emergency department visits were most frequent among children aged less than 5 years, accounting for 71.26% (130,423/183,024) of the total visits. Additionally, there was a higher proportion of male patients (104,147/183,024, 56.90%) compared with female patients (78,877/183,024, 43.10%). Fever (50,715/183,024, 27.71%), respiratory infection (43,269/183,024, 23.64%), celialgia (9560/183,024, 5.22%), and emesis (6898/183,024, 3.77%) were the leading causes of pediatric emergency room visits. The average daily number of admissions was 501.44, and 18.76% (34,339/183,204) of pediatric emergency department visits resulted in discharge without a prescription or further tests. The median waiting time from registration to seeing a doctor was 27.53 minutes. Prolonged waiting times were observed from April to July, coinciding with an increased number of arrivals, primarily for respiratory diseases. In terms of waiting time prediction, machine learning models, specifically random forest, LightGBM, and XGBoost, outperformed regression methods. On average, these models reduced the root-mean-square error by approximately 17.73% (8.951/50.481) and increased the R2 by approximately 29.33% (0.154/0.525). The SHAP method analysis highlighted that the features "wait.green" and "department" had the most significant influence on waiting times.

CONCLUSIONS

This study offers a contemporary exploration of pediatric emergency room visits, revealing significant variations in admission rates across different periods and uncovering certain admission patterns. The machine learning models, particularly ensemble methods, delivered more dependable waiting time predictions. Patient volume awaiting consultation or treatment and the triage status emerged as crucial factors contributing to prolonged waiting times. Therefore, strategies such as patient diversion to alleviate congestion in emergency departments and optimizing triage systems to reduce average waiting times remain effective approaches to enhance the quality of pediatric health care services in China.

Prevalence of post-traumatic stress disorder among residents of Shanghai standardized training programs during the COVID-19 outbreak: a cross-sectional study

Background

The COVID-19 pandemic may have increased the prevalence of psychiatric disorders, such as anxiety, depressive disorders, and post-traumatic stress disorder (PTSD), among healthcare workers.

Purpose

This study aims to investigate the prevalence of PTSD and its risk factors among residents in the standardized residency training programs (SRTPs) in Shanghai during the COVID-19 outbreak.

Participants and methods

An online cross-sectional survey was conducted between December 17, 2021, and January 7, 2022, among SRPT residents from 15 hospitals in Shanghai, China. Questionnaires comprising general information, medical-related traumatic event experiences, the PTSD Checklist (PCL-5), and the perceived social support scale (PSSS) were distributed to the participants using the online Questionnaire Star electronic system.

Results

We included 835 valid responses for the analysis. In total, 654 residents (78.3%) had experienced at least one traumatic event, and 278 residents (33.3%) were found to have PTSD symptoms. The age 26-30 years old, female sex, and increased resident working hours were identified as the risk factors for PTSD (p < 0.05), and perceived social support had a significant negative association with PTSD (p < 0.05).

Conclusion

During the COVID-19 pandemic, there was a high prevalence of PTSD among SRTPs residents in Shanghai. The age 26-30 years old, female sex, and increased resident working hours were identified as risk factors for PTSD, while perceived social support was identified as a protective factor against PTSD. The present findings can be applied in STRPs management and provide useful information for designing special interventions and protocols for SRTPs residents.

The role of different educational programs in specialty preference among Chinese medical students: a cross-sectional study

BACKGROUND

The imbalanced supply of physicians in different specialties and the decreasing number of young doctors in China have made it important to understand specialty preference and influencing factors and to evaluate the role of different programs in specialty choice and career planning among Chinese medical students to help shape the social healthcare system and ensure adequate medical practitioners in each specialty.

METHOD

A cross-sectional study comprising medical students from 5-year and 8-year program was conducted online. Demographics, specialty preferences and influencing factors, and career planning situations were collected and analysed by the chi-square test. Binary logistic regression analysis was performed in each program to identify the association between influencing factors and each specialty.

RESULTS

A total of 128 students (57.03% 5-year, 42.97% 8-year) responded to our survey. More 8-year students had a doctor in their household than 5-year students (25.45% vs. 10.96%, p < 0.05). The most preferred specialty among 5-year students was surgery, followed by others and internal medicine, while that most preferred by 8-year students was surgery, followed by internal medicine, obstetrics/gynecology and anesthesiology. Compared with 5-year students, more 8-year students considered 'personal competencies' (66.67% vs. 40.85%, p < 0.05), 'the reputation of the specialty' (18.52% vs. 7.04%, p ≤ 0.05), 'fewer doctor‒patient disputes' (27.78% vs. 11.27%, p < 0.05) and 'advice from family members' (24.07% vs. 7.04%, p < 0.05) influential. Among 5-year students, 'personal competencies' was positively associated with preference for surgery and 'work-life balance' was negatively associated. Among 8-year students, 'personal competencies' and 'work-life balance' were positively associated with internal medicine, while 'interests in the specialty' and 'broad career prospects' were negatively related. Many students need further career guidance, and personalized tutoring was the most wanted method.

CONCLUSIONS

There was no difference between 5-year and 8-year students regarding specialty preference, but bias existed, possibly due to the influence of the real-world situation. Improving the working environment and welfare might be beneficial for developing a balanced distribution of the workforce among different medical departments. It is necessary for medical schools to develop programs accordingly to help them better plan their future careers.

Current treatment outcomes of congenital heart disease and future perspectives

China has the largest number of individuals with congenital heart disease (CHD) in the world and a heavy burden of CHD. Therefore, understanding current CHD treatment outcomes and patterns in China will contribute to global progress in CHD treatment and be a valuable experience. Generally, CHD treatment in China has satisfactory outcomes owing to the joint efforts by all relevant stakeholders across the country. However, efforts are needed to overcome the remaining challenges: management of mitral valve disease and paediatric end-stage heart failure needs to be improved; cohesive paediatric cardiology teams should be established and collaboration between hospitals enhanced; CHD-related medical resources need to be more accessible and equitable; and nationwide CHD databases should be enhanced. In the second paper of this Series, we aim to systematically summarise the current CHD treatment outcomes in China, discuss potential solutions, and provide future perspectives.

Who consumes curative care expenditure of medical institutions in Beijing: a case study based on System of Health Accounts 2011

BACKGROUND

China's health system is challenged by complex health problems experienced by different population groups and caused by multiple diseases. This study examined the distribution of curative care expenditure (CCE) of medical institutions in Beijing using beneficiary characteristics such as residency, gender, age, and disease. Suggestions are presented for the development of health policies.

METHODS

A total of 81 medical institutions with approximately 80 million patients in Beijing, China, were selected via a multistage stratified cluster random sampling approach. Based on this sample, the System of Health Accounts 2011 was used to estimate the CCE of medical institutions.

RESULTS

The CCE of medical institutions in Beijing was ¥246.93 billion in 2019. The consumption of patients from other provinces was ¥60.04 billion, accounting for 24.13% of the total CCE. The CCE of female consumption (52.01%/¥128.42 billion) exceeded that of male consumption (47.99%/¥118.51 billion). Almost half of the CCE (45.62%/¥112.64 billion) was consumed by patients aged 60 or above. Adolescent patients up to an age of 14 (including those aged 14) mainly chose secondary or tertiary hospitals for treatment. Chronic non-communicable diseases accounted for the largest share of CCE consumption, with circulatory diseases accounting for the highest proportion.

CONCLUSIONS

This study identified significant differences in CCE consumption in Beijing according to region, gender, age, and disease. Currently, the utilization of resources in medical institutions is not reasonable, and the hierarchical medical system is not sufficiently effective. Therefore, the government needs to optimize the allocation of resources according to the needs of different groups and rationalize the institutional process and functions.

The Pediatrician Workforce in the United States and China

From 2019 to 2022, the For Our Children project gathered a team of Chinese and American pediatricians to explore the readiness of the pediatric workforce in each country to address pressing child health concerns. The teams compared existing data on child health outcomes, the pediatric workforce, and education and combined qualitative and quantitative comparisons centered on themes of effective health care delivery outlined in the World Health Organization Workforce 2030 Report. This article describes key findings about pediatric workload, career satisfaction, and systems to assure competency. We discuss pediatrician accessibility, including geographic distribution, practice locations, trends in pediatric hospitalizations, and payment mechanisms. Pediatric roles differed in the context of each country's child health systems and varied teams. We identified strengths we could learn from one another, such as the US Medical Home Model with continuity of care and robust numbers of skilled clinicians working alongside pediatricians, as well as China's Maternal Child Health system with broad community accessibility and health workers who provide preventive care.In both countries, notable inequities in child health outcomes, evolving epidemiology, and increasing complexity of care require new approaches to the pediatric workforce and education. Although child health systems in the United States and China have significant differences, in both countries, a way forward is to develop a more inclusive and broad view of the child health team to provide truly integrated care that reaches every child. Training competencies must evolve with changing epidemiology as well as changing health system structures and pediatrician roles.

Diagnostic consistency between admission and discharge of pediatric cases in a tertiary teaching hospital in China

BACKGROUND

Patient-centered, high-quality health care relies on accurate and timely diagnosis. Diagnosis is a complex, error-prone process. Prevention of errors involves understanding the cause of errors. This study investigated diagnostic discordance between admission and discharge in pediatric cases.

METHODS

We retrospectively reviewed the electronic medical records of 5381 pediatric inpatients during 2017-2018 in a tertiary teaching hospital. We analyzed diagnostic consistency by comparing the first 4 digits of admission and discharge ICD-10 codes of the cases and classified them as concordant for "complete and partial match" or discordant for "no match".

RESULTS

Diagnostic discordance was observed in 49.2% with the highest prevalence in infections of the nervous and respiratory systems (Ps < 0.001). Multiple (multivariable) logistic regression analysis predicted a lower risk of diagnostic discordance with older children (aOR, 95%CI: 0.94, 0.93-0.96) and a higher risk with infectious diseases (aOR, 95%CI: 1.49, 1.33-1.66) and admission by resident and attending pediatricians (aOR, 95%CI: 1.41, 1.30-1.54). Discordant cases had a higher rate of antibiotic prescription (OR, 95%CI: 2.09, 1.87-2.33), a longer duration of antibiotic use (P = 0.02), a longer length of hospital stay (P < 0.001), and higher medical expenses (P < 0.001).

CONCLUSIONS

This study denotes a considerably high rate of discordance between admission and discharge diagnoses with an associated higher and longer prescription of antibiotics, a longer length of stay, and higher medical expenses among Chinese pediatric inpatient cases. Infectious diseases were identified as high-risk clinical conditions for discordance. Considering potential diagnostic and coding errors, departmental investigation of preventable diagnostic discordance is suggested for quality health care and preventing potential medicolegal consequences.

Development and evaluation of an artificial intelligence system for children intussusception diagnosis using ultrasound images

Accurate identification of intussusception in children is critical for timely non-surgical management. We propose an end-to-end artificial intelligence algorithm, the Children Intussusception Diagnosis Network (CIDNet) system, that utilizes ultrasound images to rapidly diagnose intussusception. 9999 ultrasound images of 4154 pediatric patients were divided into training, validation, test, and independent reader study datasets. The independent reader study cohort was used to compare the diagnostic performance of the CIDNet system to six radiologists. Performance was evaluated using, among others, balance accuracy (BACC) and area under the receiver operating characteristic curve (AUC). The CIDNet system performed the best in diagnosing intussusception with a BACC of 0.8464 and AUC of 0.9716 in the test dataset compared to other deep learning algorithms. The CIDNet system compared favorably with expert radiologists by outstanding identification performance and robustness (BACC:0.9297; AUC:0.9769). CIDNet is a stable and precise technological tool for identifying intussusception in ultrasound scans of children.

Labour-Market Characteristics and Self-Rated Health: Evidence from the China Health and Retirement Longitudinal Study

In the face of labour-force ageing, understanding labour-market characteristics and the health status of middle-aged and older workers is important for sustainable social and economic development. Self-rated health (SRH) is a widely-used instrument to detect health problems and predict mortality. This study investigated labour-market characteristics that may have an impact on the SRH among Chinese middle-aged and older workers, using data from the national baseline wave of the China Health and Retirement Longitudinal Study. The analytical sample included 3864 individuals who at the time held at least one non-agricultural job. Fourteen labour-market characteristics were clearly defined and investigated. Multiple logistic regression models of the associations of each labour-market characteristic with SRH were estimated. Seven labour-market characteristics were associated with higher odds of poor SRH when controlled for age and sex. Employment status and earned income remained significantly associated with poor SRH, when controlling for all the sociodemographic factors and health behaviours. Doing unpaid work in family businesses is associated with 2.07 (95% CI, 1.51-2.84) times probability of poor SRH, compared with employed individuals. Compared with more affluent individuals (highest quintile of earned income), people in the fourth and fifth quintiles had 1.92 (95% CI, 1.29-2.86) times and 2.72 (95% CI, 1.83-4.02) times higher chance, respectively, of poor SRH. In addition, residence type and region were important confounders. Measures improving adverse working conditions should be taken to prevent future risk of impaired health among the Chinese middle-aged and older workforce.

Association between social supports and negative emotions among pediatric residents in China: The chain-mediating role of psychological resilience and burnout

Background

Chinese pediatricians are facing challenges, and there is a need to examine the issue of negative emotions, namely, stress, anxiety and depression, among front-line pediatric residents in clinical settings. Understanding the current situation and influencing factors of negative emotions among pediatric residents in China and exploring the formation mechanism can lay a foundation for psychological interventions.

Methods

A total of 138 pediatric residents in the Children's Hospital, Zhejiang University School of Medicine, China, were surveyed using the Depression Anxiety Stress Scale-21 (DASS-21), Social Support Rating Scale (SSRS), Connor-Davidson Resilience Scale (CD-RISC), and Maslach Burnout Inventory-General Survey (MBI-GS).

Results

(1) The incidence of abnormal stress, anxiety, and depression among pediatric residents was 18.8%, 47.8%, and 47.8% respectively. (2) Negative emotions were significantly negatively correlated with social supports and psychological resilience, and positively correlated with burnout. (3) The chain-mediating effect of resilience and burnout between social supports and negative emotions was significant.

Conclusion

Psychological resilience and burnout played a chain-mediating role between social supports and negative emotions. Measures should be taken to improve the mental health of Chinese pediatric residents.

How to become an excellent pediatric resident: a qualitative comparative study from China

BACKGROUND

Competency-oriented medical education has become a global trend. However, most current studies focus on the independent effects of various competencies and lack an examination of the combined effects. Therefore, the purpose of this study was to explore the competency configurations of excellent pediatric residents and general pediatric residents and to provide a scientific reference for the talent training and career development of pediatric residents.

METHODS

Behavioral event interviews were conducted with 23 pediatric residents at a children's hospital in Beijing in July and August 2019. Two researchers coded the interview data to summarize the competency of pediatric residents. The research group scored the performance of 23 pediatric residents in various aspects of competency and used the crisp-set qualitative comparative analysis method to explore the competency configurations of excellent pediatric residents and general pediatric residents.

RESULTS

This study concludes that pediatric residents should have six core competencies: professional spirit, clinical skills, communication ability, learning ability, mental capacity and research ability. There are 4 combinations of competencies for becoming an excellent pediatric resident: the clinical type, scientific research type, all-around development type and high emotional intelligence type. In addition, there are 3 combinations of competencies for becoming a general pediatric resident: the comprehensive ability deficiency type, lack of professionalism and mental capacity type, lack of communication ability type.

CONCLUSIONS

There are differences in competence between excellent and general pediatric residents. Excellent pediatric residents do not need to possess all competencies but should specialize in clinical practice, scientific research or communication skills. This study suggests that training in mental capacity, professional spirit and communication ability should be strengthened during pediatric resident training. Pediatric residents should make career development plans according to their actual situation, and hospitals should arrange suitable positions according to the characteristics of pediatric residents.

Translation and validation of the STARx questionnaire in transitioning Chinese adolescents and young adults with chronic health conditions

BACKGROUND

Adolescent/young adults (AYAs) with chronic conditions must undergo healthcare transition (HCT) preparation until their mid-twenties. Valid HCT readiness measures are lacking in China.

METHODS

The present study translated, back-translated, and adapted the Self-Management and Transition to Adulthood with Rx = Treatment (STAR_x) Questionnaire. We examined the psychometric properties of this tool in a relatively large in-patient sample of AYAs with various chronic health conditions at a Chinese tertiary general hospital.

RESULTS

We enrolled 624 AYAs aged 10-25 years (19.66 ± 3.64) with various chronic health conditions. The Chinese version of the STAR_x Questionnaire demonstrated excellent internal consistency (Cronbach's alpha = 0.83) and reliability with a two-week test-retest (ICC = 0.88, p < .001). Furthermore, the Chinese version revealed a three-factor structure (self-management, disease knowledge, and provider communication) consistent with the revised English version of the STAR_x Questionnaire. In terms of discriminant validity, the total score of the Chinese STAR_x Questionnaire showed a significant positive correlation with age but no gender differences were found. In terms of predictive validity, the Chinese STAR_x Questionnaire was significantly correlated with shorter length of hospitalization and higher frequency of emergency room visit, but the correlations became insignificant after controlling for age.

CONCLUSIONS

The results suggest that the Chinese version of the STAR_x Questionnaire is a robust HCT readiness tool in AYAs with chronic conditions and clinicians may find it useful to develop individualized interventions.

Economic value and characteristics of cloud pharmacy for children based on internet hospital in western China during the COVID-19 pandemic: Cross-sectional survey study

Background

Online health care services have been encouraged by the Chinese government in recent years, and the COVID-19 pandemic catalyzed the rapid growing of internet hospitals. As an integral part of online health care services, little is known about the economic value and characteristics of cloud pharmacy especially for children. This study aimed to reveal the economic value and comprehensive characteristics of pediatric cloud pharmacy during the COVID-19 pandemic in a tertiary children's hospital in western China.

Methods

A total of 33,254 online prescriptions over the course of February 2020 through December 2021 were analyzed with respect to the user profiles, diseases, consulting behaviors, distribution of departments, delivery region and distance, drug information and degree of satisfaction. The cost savings for patients calculated lost wages and the high-speed railway fees for transport to and from hospital.

Results

A total of 33,254 prescriptions, including 56,216 drugs were delivered to 27 provinces and municipalities of China. The internet cloud pharmacy saved a total of more than RMB 11.17 million in financial costs for patients. Of the 33,254 delivered prescriptions, 50.40% were sent to Chongqing Province, the top 5 provinces for out-of-province prescription deliveries were Sichuan (37.77%), Guizhou (8.00%), Yunnan (1.18%), Hubei (0.66%) and Guangdong (0.42%). In terms of department distribution, neurology (31.7%), respiratory (15.0%) and endocrinology (14.6%) were the top three departments. Epilepsy (16.2%), precocious puberty (10.3%) and asthma (8.7%) were the top three frequently consulted diseases. The peak times of day for online prescriptions occurred at 9 AM and 8 PM. 99.67% of users gave full marks for their internet counseling.

Conclusion

The pediatric cloud pharmacy is efficient, cost-saving and convenient for children with chronic disease or mild symptoms during the COVID-19 pandemic. The widespread use of this pediatric cloud pharmacy can help alleviating pressure on offline hospitals and facilitated people's lives beyond geographical and time-related limitations. Further efforts are needed to be made to improve the quality and acceptance of pediatric cloud pharmacy, as well as to regulate and standardize the management of this novel online health care service.

Assessment of Transcatheter or Surgical Closure of Atrial Septal Defect using Interpretable Deep Keypoint Stadiometry

Automated echocardiogram interpretation with artificial intelligence (AI) has the potential to facilitate the serial diagnosis of heart defects by primary clinician. However, the fully automated and interpretable analysis pipeline for suggesting a treatment plan is largely underexplored. The present study targets to build an automatic and interpretable assistant for the transthoracic echocardiogram- (TTE-) based assessment of atrial septal defect (ASD) with deep learning (DL). We developed a novel deep keypoint stadiometry (DKS) model, which learns to precisely localize the keypoints, i.e., the endpoints of defects and followed by the absolute distance measurement with the scale. The closure plan and the size of the ASD occluder for transcatheter closure are derived based on the explicit clinical decision rules. A total of 3,474 2D and Doppler TTE from 579 patients were retrospectively collected from two clinical groups. The accuracy of closure classification using DKS (0.9425 ± 0.0052) outperforms the "black-box" model (0.7646 ± 0.0068; p < 0.0001) for within-center evaluation. The results in cross-center cases or using the quadratic weighted kappa as an evaluation metric are consistent. The fine-grained keypoint label provides more explicit supervision for network training. While DKS can be fully automated, clinicians can intervene and edit at different steps of the process as well. Our deep learning keypoint localization can provide an automatic and transparent way for assessing size-sensitive congenital heart defects, which has huge potential value for application in primary medical institutions in China. Also, more size-sensitive treatment planning tasks may be explored in the future.

Socioeconomic inequalities in cancer incidence and access to health services among children and adolescents in China: a cross-sectional study

BACKGROUND

Despite the substantial burden caused by childhood cancer globally, childhood cancer incidence obtained in a nationwide childhood cancer registry and the accessibility of relevant health services are still unknown in China. We comprehensively assessed the most up-to-date cancer incidence in Chinese children and adolescents, nationally, regionally, and in specific population subgroups, and also examined the association between cancer incidence and socioeconomic inequality in access to health services.

METHODS

In this national cross-sectional study, we used data from the National Center for Pediatric Cancer Surveillance, the nationwide Hospital Quality Monitoring System, and public databases to cover 31 provinces, autonomous regions, and municipalities in mainland China. We estimated the incidence of cancer among children (aged 0-14 years) and adolescents (aged 15-19 years) in China through stratified proportional estimation. We classified regions by socioeconomic status using the human development index (HDI). Incidence rates of 12 main groups, 47 subgroups, and 81 subtypes of cancer were reported and compared by sex, age, and socioeconomic status, according to the third edition of the International Classification of Childhood Cancer. We also quantified the geographical and population density of paediatric oncologists, pathology workforce, diagnoses and treatment institutions of paediatric cancer, and paediatric beds. We used the Gini coefficient to assess equality in access to these four health service indicators. We also calculated the proportions of cross-regional patients among new cases in our surveillance system.

FINDINGS

We estimated the incidence of cancer among children (aged 0-14 years) and adolescents (aged 15-19 years) in China from Jan 1, 2018, to Dec 31, 2020. An estimated 121 145 cancer cases were diagnosed among children and adolescents in China between 2018 and 2020, with world standard age-standardised incidence rates of 122·86 (95% CI 121·70-124·02) per million for children and 137·64 (136·08-139·20) per million for adolescents. Boys had a higher incidence rate of childhood cancer (133·18 for boys vs 111·21 for girls per million) but a lower incidence of adolescent cancer (133·92 for boys vs 141·79 for girls per million) than girls. Leukaemias (42·33 per million) were the most common cancer group in children, whereas malignant epithelial tumours and melanomas (30·39 per million) surpassed leukaemias (30·08 per million) in adolescents as the cancer with the highest incidence. The overall incidence rates ranged from 101·60 (100·67-102·51) per million in very low HDI regions to 138·21 (137·14-139·29) per million in high HDI regions, indicating a significant positive association between the incidence of childhood and adolescent cancer and regional socioeconomic status (p<0·0001). The incidence in girls showed larger variation (48·45% from the lowest to the highest) than boys (36·71% from lowest to highest) in different socioeconomic regions. The population and geographical densities of most health services also showed a significant positive correlation with HDI levels. In particular, the geographical density distribution (Gini coefficients of 0·32-0·47) had higher inequalities than population density distribution (Gini coefficients of 0·05-0·19). The overall proportion of cross-regional patients of childhood and adolescent cancer was 22·16%, and the highest proportion occurred in retinoblastoma (56·54%) and in low HDI regions (35·14%).

INTERPRETATION

Our study showed that the burden of cancer in children and adolescents in China is much higher than previously nationally reported from 2000 to 2015. The distribution of the accessibility of health services, as a social determinant of health, might have a notable role in the socioeconomic inequalities in cancer incidence among Chinese children and adolescents. With regards to achieving the Sustainable Development Goals, policy approaches should prioritise increasing the accessibility of health services for early diagnosis to improve outcomes and subsequently reduce disease burdens, as well as narrowing the socioeconomic inequalities of childhood and adolescent cancer.

FUNDING

National Major Science and Technology Projects of China, National Natural Science Foundation of China, Chinese Academy of Engineering Consulting Research Project, Wu Jieping Medical Foundation, Beijing Municipal Administration of Hospitals Incubating Program.

Working in hospitals during a pandemic: investigating the resilience among medical staff during COVID-19 outbreak through qualitative and quantitative research

Background:

Medical staff in hospitals were faced with great stress as a result of COVID-19’s sudden and severe occurrence, which makes investigating their resilience essential.

Aims and methods:

Using qualitative and quantitative research methods, this research studied medical staff (n = 403) working in a hospital during the COVID-19 pandemic and followed four main goals: First was evaluating the psychometric properties of the Persian version of Adult Resilience Measure-Revised (ARM-R). The second goal was investigating the personal, relational, social, and organizational issues facing the medical staff during the COVID-19 using semi-structural interviews. The third goal was to determine predictive effects of demographic and work-related variables on resilience using stepwise regression analysis. And the fourth was comparing resilience of three groups of the medical staff (coronavirus group consisted of the medical staff in direct contact with COVID-19 patients; emergency group who work in the emergency department who deal with both COVID and non-COVID patients; and non-coronavirus group who had no contact with COVID-19 patients) using one-way ANOVA.

Findings:

Results showed that internal reliability/consistency, content, and face validity of the Persian version of the ARM-R are acceptable. The construct validity of the test was also verified using exploratory factor analysis and indicated the two factors of personal and relational resilience. The content of the interviews was analyzed using manifest content analysis, and the results were divided into 27 subcategories and 3 main categories including personal, organizational, and family categories. Moreover, regression analysis revealed that the marital status and age of children can explain resilience variance in some medical staff groups. The results of ANOVA and post hoc test also showed that the total resilience of the non-coronavirus group was greater than the coronavirus and emergency groups; the relational resilience of the coronavirus and non-coronavirus groups was greater than the emergency, and non-coronavirus group’s personal resilience was greater than the emergency group.

The Relationship between the Unmet Needs of Chinese Family Caregivers and the Quality of Life of Childhood Cancer Patients Undergoing Inpatient Treatment: A Mediation Model through Caregiver Depression

A large proportion of the global burden of childhood cancer arises in China. These patients have a poor quality of life (QoL) and their family caregivers have high unmet needs. This paper examined the association between the unmet needs of family caregivers and the care recipient’s QoL. A total of 286 childhood cancer caregivers were included in this cross-sectional study. Unmet needs and depression among caregivers were assessed by the Comprehensive Needs Assessment Tool for Cancer Caregivers (CNAT-C) and the Patient Health Questionnaire (PHQ-9), respectively. The patient’s QoL was proxy-reported by the Pediatric Quality of Life Inventory Measurement Models (PedsQL 3.0 scale Cancer Module). Descriptive analyses, independent Student’s t-tests, one-way ANOVA, and mediation analyses were performed. The mean scores (standard deviations) for unmet needs, depression, and QoL were 65.47 (26.24), 9.87 (7.26), and 60.13 (22.12), respectively. A caregiver’s unmet needs (r = −0.272, p < 0.001) and depression (r = −0.279, p < 0.001) were negatively related to a care recipient’s QoL. Depression among caregivers played a mediating role in the relationship between a caregiver’s unmet needs and a care recipient’s QoL. As nursing interventions address depression among caregivers, it is important to standardize the programs that offer psychological support to caregivers.

An Assessment Framework for the Training of General Practitioners and Specialists Based on EPAs

Purpose

The purpose of this study is to explore the practicality and feasibility of EPA (level 4 theory) for establishing medical training and service model in China.

Method

We opted for a mixed qualitative and quantitative research method, considering both explanatory and exploratory sequential designs. The qualitative research comprehended focus groups and interviews conducted with two panels of experts. The quantitative research was conducted to collect data about the applicability of international entrustable professional activities (EPAs) pediatrics standards in the Chinese context by organizing a seminar with a sample of 60 pediatricians. A questionnaire was designed with EPAs and distributed within professional networks. Structural equation modeling and statistical analysis were used to process the data.

Results

In this study, Medical Service-Groups Model (MSGM) with four levels was successfully established to measure the correlation between specialized and general EPAs. As expected, results showed that specialized EPAs were built on top of general EPAs. There may be a mediating mechanism that general EPAs contribute to the lower level of specialization EPAs. In addition, levels 1 and 2 were primarily needed to lay the groundwork for levels 3 and 4, and these higher levels of EPAs were still the most informative for specialized Gastroenterology EPAs.

Conclusions

The diagnosis and treatment level of primary general practitioners, as the basis of the pediatric medical service chain, affected the clinical disposal ability of specialists. The establishment of MSGM provided a theoretical basis for the linkage training of general practitioners and specialist physicians. In future studies, scholars must explore China's EPAs based on unique national conditions.

Effects of bedside team-based learning on pediatric clinical practice in Chinese medical students

BACKGROUND

Bedside teaching is a primary educational tool to improve the clinical practice of medical students. As a new medical pedagogical approach, team-based learning (TBL) is gradually being integrated into Chinese medical education programmes to promote clinical reasoning, knowledge application, teamwork and collaboration. The aim of this controlled study is to investigate the effects of TBL on pediatric bedside teaching in medical students.

METHODS

Thirty medical students in pediatric clinical practice were randomly assigned to an intervention and a control group. Students in the intervention group exposed bedside teaching activity with TBL while students in the control group received traditional bedside teaching. Teaching for the two groups was conducted biweekly, and the same clinical cases were selected for both groups with the same instructors. After six months of clinical practice, the differences of learning outcomes between the two groups were compared through assessments by computer-based case simulations (CCS) and mini-Clinical Evaluation Exercise (mini-CEX). Student feedback following completion of bedside teaching was collected by questionnaire.

RESULTS

The CCS scores in the intervention group were significantly higher than that in the control group (p < 0.05). The mini-CEX results showed that clinical judgment and counseling skills of the intervention group were higher than those in the control group (p < 0.01). Medical interviewing skills and overall clinical competence in the intervention group were better than those in the control group (p < 0.05). In the questionnaire survey, students in the intervention group believed that bedside teaching activity with TBL could promote active learning ability, improve counseling skills and strengthen teamwork.

CONCLUSIONS

Application of TBL in bedside teaching not only enhanced clinical practice skills among medical students but also improved their clinical reasoning and counseling skills.

Current situation of pediatric clinical trials in China: focus on trials for drug marketing application and administrative approval

Background

Research and development of pediatric drug faces many difficulties and pediatric clinical trials remain a challenge. Since 2011, a series of measures have been taken to encourage research, development of drugs for pediatric patients in China. In this study, we analyzed pediatric clinical trials conducted in China to provide reference for research and development of pediatric drugs and formulation of relevant policies.

Methods

We conducted a cross-sectional observational study of pediatric trials registered in the Drug Trial Registration and Information Publication Platform before Oct. 31, 2021. All trials that recruited children (under 18 years old as defined in China) were retrieved and general characteristics of the trials and the research drugs were extracted and analyzed. The data were extracted and statistically analyzed by excel 2010 and SPSS 22.0, respectively.

Results

There were 588 registered pediatric clinical trials, which accounted for 3.94% of the total registered trials. The overall average annual growth rate of the number of trials from 2013 to 2020 was 14.47% (P < 0.01). Of the 588 trials included, there were 312 trials (53.06%) with only children as subjects, 127 trials (21.60%) with research drugs only for children use, and the median of target subject number was 320 with the range of 8 to 600,000. The sponsors and the principal investigators were mainly located in the eastern and northern China. 325 trials were vaccine trials, and the dosage form was mainly injection. There were 98 non-vaccine biological product trials (mainly injections), 135 chemical compound drug trials (mainly tablets), 30 traditional Chinese medicine/natural drugs (mainly granules). Indications of the non-vaccine drugs were mainly diseases of the blood and blood-forming organs and certain disorders involving the immune mechanism.

Conclusion

The number of pediatric clinical trials in China has increased these years. To further promote pediatric clinical trials and motivate pediatric appropriate drug marketing application and administrative approval, conducting large pediatric clinical trials, further development of dosage forms suitable for children with special attention to neonates and prematurity, and improving uneven geographical distribution of sponsors and researchers are the current challenges.

Estimates of inpatient admission rates and associated costs for infants before and after China's universal two-child policy

Background

China implemented a universal two-child policy in 2015. It is important to understand infants’ medical utilization in the context of this policy to inform health policies and resource allocation.

Methods

This study utilized a 20% random sample of administrative data from China’s Urban and Rural Basic Medical Insurance (URBMI) in one of the largest southern Chinese cities from January 2015 to June 2018. Ordinary least squares models were used to estimate changes in inpatient admission rates and costs for infants between 0 and 6 months old after the implementation of China’s universal two-child policy.

Results

The overall inpatient admission rate was 27.2% in 2015 and 31.3% in 2017. Compared with 2015, there was an increase in inpatient admission rates for infants 1 month old or younger (coef = 0.038, 95% CI = 0.029 to 0.047, p < .001) and infants 6 months old or younger (coef = 0.041, 95% CI = 0.030 to 0.052, p < .001) in 2017. The increase was larger for male infants than for female ones. The average inpatient admission cost was 8412.3 RMB ($1320.61) (SD = 15,088.2). There was no increase in inpatient admission costs overall. The average length of hospital stay was 7.3 days, the probability of going to a tertiary hospital was 76.2%, and the share of out-of-pocket costs was 53.0% for all diseases.

Conclusion

After the implementation of the universal two-child policy in China, there was a significant increase in inpatient admission rates, especially for male infants. The overall associated costs did not change, but the increase in admission rates caused additional economic burdens for families and for social health insurance. Understanding the healthcare utilization of infants in the universal two-child period can provide insight for healthcare resource allocation in a time of dramatic changes in population policy.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-07571-9.

The intervention dilemma and high burden of children with autism in Guizhou province, Southwest China

BACKGROUND

Autism spectrum disorder (ASD) is a highly disabling neurodevelopmental disorder, and the burden is high. Data on the burden of ASD are limited in China, especially in the southwest. Therefore, the aims of this study were to investigate the intervention status and burden of children with ASD in Southwest China.

MATERIALS AND METHODS

Families of children with ASD were recruited from hospitals, special education schools, and private rehabilitation centers; they participated in the survey and completed the questionnaire. Descriptive analysis was conducted on the questionnaire results, which included basic demographic characteristics, rehabilitation status, and burden. Multivariate analysis was used to analyze the association of basic family demographic characteristics, rehabilitation status, and costs of ASD.

RESULTS

A total of 231 families of children with ASD participated in this survey, and 78.35% (181/231) of the children with ASD were male. The mean age was 4.34 ± 2.09 years. A total of 55.84% (129/231) of the children with ASD had an intellectual disability. Only 46.32% (107/231) started receiving intervention within 1 month after diagnosis. The institutions for rehabilitation interventions for children with ASD were mainly tertiary hospitals (39.39%), special education schools (29.87%) and private rehabilitation institutions (21.64%). For a total of 42.86% (99/231) of the children with ASD, the duration of the intervention was less than 10 h per week. A total of 74.89% (173/231) of the children with ASD received a rehabilitation intervention at home. A total of 66.67% of the parents were satisfied with the treatment. The monthly cost of medical intervention for the patients of children with autism was 7,225 ± 474 RMB ($1,134 ± 74), and the non-medical intervention cost was 2,133 ± 107 RMB ($334 ± 17). The annual burden of patients with autism was 86,700 ± 5,688 RMB ($13,596 ± 892). The estimated total annual burden of ASD was 5.548 billion RMB ($870 million) in Guizhou province.

CONCLUSION

The results revealed that rehabilitation resources are limited and that the burden of ASD is high in Guizhou province; therefore, improving the rehabilitation status and easing the burden of children with ASD is urgent in these regions.

Attitudes and perspectives of 534 Chinese pediatricians toward internet hospitals

BACKGROUND

Internet hospitals introduced in China have effectively reduced service time and space, promoted high-quality pediatric medical resources to grassroots areas, solved the contradiction between supply and demand of pediatric medical resources, and met patients' increasing multi-level and diversified medical service needs. However, pediatricians' attitudes toward and satisfaction with the use of internet hospitals remain unknown.

OBJECTIVE

This study aimed to investigate pediatricians' knowledge of, use of, and satisfaction with internet hospitals in order to identify major issues in internet hospital development, and to understand pediatricians' attitudes and opinions on the construction, development, and use of internet hospitals.

MATERIALS AND METHODS

A total of 625 pediatricians in 17 public tertiary hospitals in Shanghai were surveyed from November 1-30, 2021. Five hundred and thirty four pediatricians completed the survey, and the response rate was 85.44%. Pediatricians' baseline demographic data were collected and information about their use of and satisfaction with internet hospitals.

RESULTS

About 70.22% (375/534) of pediatricians knew about internet hospitals and about 54.68% (292/534) use internet hospitals for patient consultation, diagnosis, and treatment. Utilized services mainly focused on online consultation (271/292, 92.81%), online follow-up consultation (174/292, 59.59%), and health sciences (111/292, 38.01%). Online services were provided by 69.18% (202/292) of pediatricians for less than 1 h a day, and 75.00% (219/292) responded to fewer than five patient consultations online every day. Pediatricians' overall satisfaction with internet hospitals was low (3.59 ± 0.92 points), user experience, systems functions, operation processes, service prices, and performance rewards of internet hospitals were main influencing factors. Pediatricians are enthusiastic about further development of internet hospitals, with 87.83% (469/534) willing to provide services on the internet hospital platform.

CONCLUSION

Most pediatricians view internet hospitals favorably and are eager to contribute to the development of online diagnosis and treatment services. The development of internet hospitals will be more strongly supported by improving pediatricians' satisfaction and mobilizing their enthusiasm and initiative to participate in internet medical services.

Validation of the accuracy of the childhood asthma model for clinical decision support: a study protocol

Background

In China, the average prevalence of asthma in children aged 0-14 years increased by approximately 50% every 10 years. Hence, a specific decision support system that fits China's situation is needed for childhood asthma. This prospective, multicenter, observational study aims to assess the accuracy of the Childhood Asthma Model for Clinical Decision Support (CAMCDS) in clinical practice in four hospitals in Shanghai in China.

Methods

The study will be conducted in two phases. Phase I of the study aims to evaluate the accuracy of the CAMCDS for diagnosis, while phase II of the study aims to examine the treatment predicting accuracy of the CAMCDS model. In total, 817 children diagnosed with stable asthma and 545 suspected asthma will be enrolled. The accuracy of the CAMCDS model will be calculated using the receiver operating characteristic (ROC) curve compared with the results of pediatrician's diagnosis. Besides, the treatment patterns from CAMCDS and real-world environment for Chinese children with stable asthma will be assessed, and the factors that affect the CAMCDS implementation in routine clinical practice will be explored.

Conclusions

This will be the first study to examine the diagnostic accuracy and treatment predicting accuracy of a clinical decision support system in children with asthma in China. We hope that the CAMCDS will be help pediatricians in basic-level hospitals to improve the diagnosis and treatment strategy of asthma.

Trial Registration

Chinese Clinical Trial Registry Identifier: ChiCTR2100045283.

A systematic review of the profile and density of the maternal and child health workforce in China

BACKGROUND

To track progress in maternal and child health (MCH), understanding the health workforce is important. This study seeks to systematically review evidence on the profile and density of MCH workers in China.

METHODS

We searched 6 English and 2 Chinese databases for studies published between 1 October 1949 and 20 July 2020. We included studies that reported on the level of education or the certification status of all the MCH workers in one or more health facilities and studies reporting the density of MCH workers per 100 000 population or per 1000 births. MCH workers were defined as those who provided MCH services in mainland China and had been trained formally or informally.

RESULTS

Meta-analysis of 35 studies found that only two-thirds of obstetricians and paediatricians (67%, 95% CI: 59.6-74.3%) had a bachelor or higher degree. This proportion was lower in primary-level facilities (28% (1.5-53.9%)). For nurses involved in MCH care the proportions with a bachelor or higher degree were lower (20.0% (12.0-30.0%) in any health facility and 1% (0.0-5.0%) in primary care facilities). Based on 18 studies, the average density of MCH doctors and nurses was 11.8 (95% CI: 7.5-16.2) and 11.4 (7.6-15.2) per 100 000 population, respectively. The average density of obstetricians was 9.0 (7.9-10.2) per 1000 births and that of obstetric nurses 16.0 (14.8-17.2) per 1000 births. The density of MCH workers is much higher than what has been recommended internationally (three doctors and 20 midwives per 3600 births).

CONCLUSIONS

Our review suggests that the high density of MCH workers in China is achieved through a mix of workers with high and low educational profiles. Many workers labelled as "obstetricians" or "paediatrician" have lower qualifications than expected. China compensates for these low educational levels through task-shifting, in-service training and supervision.

Can a Multi-Component Intervention Improve Pediatric Service Delivery in Guangzhou?

Background: Accessible, equitable, and efficient pediatric service is critical to achieve optimal child health. This study aimed to evaluate the effectiveness of a multi-component intervention on the pediatric health system over two different periods in Guangzhou. Methods: Based on the World Health Organization (WHO) "six building blocks" model and Donabedian's "Structure-Process-Outcomes" framework, an intervention package was developed to increase financial and human resouce investment to strengthen basic health care and strive for a better quality of pediatric care. This multi-component intervention package was conducted in Guangzhou to improve the pediatric service delivery during two stages (2011-2014 and 2016-2019). The main outcome indicators were the changes in the allocation of pediatricians and pediatric beds, pediatric service efficiency, and the impact of pediatricians on child mortality. Results: We found that pediatricians per 1,000 children (PPTC) and pediatric beds per 1,000 children (PBPTC) increased from 1.07 and 2.37 in 2010 to 1.37 and 2.39 in 2014, then to 1.47 and 2.93 in 2019, respectively. Infant mortality rate (IMR) and under-5 mortality rate (U5MR) dropped from 5.46‰ and 4.04‰ in 2010 to 4.35‰ and 3.30‰ in 2014 then to 3.26‰ and 2.37‰ in 2019. The Gini coefficients of PPTC and PBPTC decreased from 0.48 and 0.38 in 2010, to 0.35 and 0.28 in 2014, then to 0.35 and 0.22 in 2019, respectively, representing the improvement of pediatric resources distribution according to service population. However, equalities in the spatial distribution were not improved much. The average efficiency of pediatric service fluctuated from 2010 to 2019. A unit increase in PPTC was associated with an 11% reduction in IMR and a 16% reduction in U5MR. Conclusions: Findings suggest this multi-component intervention strategy is effective, particularly on the reduction of child mortality. In future, more rigorous and multi-faceted indicators should be integrated in a comprehensive evaluation of the intervention.

A Cross-Sectional Nationwide Study on Accessibility and Availability of Neonatal care Resources in Hospitals of China: Current Situation, Mortality and Regional Differences: Neonatal Care Resources and Newborn Mortality in China

Background

To investigate the current situation of neonatal care resources (NCR), newborn mortality rates (NMR), regional differences and existing challenges in China.

Methods

By using a self-designed questionnaire form and the cross-sectional method, we conducted a survey of all hospitals equipped with neonatal facilities in China from March 2019 to March 2020 with respect to the level and nature of these hospitals, the number of newborn beds and NICU beds, the number of neonatal pediatricians, and the development of therapeutic techniques. The data about the newborn births and deaths were retrieved from the annual statistics of the health commissions of the related provinces, autonomous regions and municipalities.

Finding

Included in this nationwide survey were 3,020 hospitals from all 22 provinces, 5 autonomous regions and 4 municipalities directly under the Central Government of Mainland China, with a 100% response rate. They included 1,183 (39.2%) level-3 (L3) hospitals, 1629 (53.9%) L-2 hospitals and 208 (6.9%) L-1 hospitals. Geographically, 848 (31.4%) hospitals were distributed in Central China, 983 (32.5%) hospitals in East China, and 1,089 (36.1%) in West China. The 3,020 included hospitals were altogether equipped with 75,679 newborn beds, with a median of 20 (2-350) beds, of which 2,286 hospitals (75.7%) were equipped with neonatal intensive care units (NICU), totaling 28,076 NICU beds with a median of 5 (1-160) beds. There were altogether 27,698 neonatal pediatricians in these hospitals, with an overall doctor-bed ratio of 0.366. There were 48.18 newborn beds and 17.87 NICU beds per 10,000 new births in China. In East, Central and West China, the number of neonatal beds, NICU beds, neonatal pediatricians, and attending pediatricians or pediatricians with higher professional titles per 10,000 newborns was 42.57, 48.64 and 55.67; 17.07, 18.66 and 18.17; 16.26, 16.51 and 20.81; and 10.69, 10.81 and 11.29, respectively. However, when the population and area are taken into consideration and according to the health resources density index (HRDI), the number of newborn beds, NICU beds and neonatal pediatricians in West China was significantly lower than that in Central and East China. In addition, only 10.64% of the neonatal pediatricians in West China possessed the Master or higher degrees, vs. 31.7% in East China and 20.14% in Central China. On the contrary, the number of neonatal pediatricians with a lower than Bachelor degree in West China was significantly higher than that in Central and East China (13.28% vs. 7.36% and 4.28%). Technically, the application rate of continuous positive airway pressure (CPAP) and conventional mechanical ventilation (CMV) in L-1 hospitals of West China was lower than that in Central and East China. According to the statistics in 2018, the newborn mortality rate (NMR) in West China was significantly higher than that in Central and East China.

Interpretation

China has already possessed relatively good resources for neonatal care and treatment, which is the primary reason for the rapid decrease in the NMR in China. However, there are still substantial regional differences. The density of health resources, the level of technical development and educational background of neonatal pediatricians in West China still lag behind those in other regions of China and need to be further improved and upgraded.

Funding

This research work was funded by National Natural Science Foundation of China (81671504) and United Nations International Children's Emergency Fund (CHINA-UNICEF501MCH).

Toward the Cure of Acute Lymphoblastic Leukemia in Children in China

This study explored results of therapy of children with acute lymphoblastic leukemia (ALL) in China, recent progress, and challenges. Included are a survey of therapy outcomes of ALL in Chinese children nationwide, comparison of these data with global ALL therapy outcomes, analyses of obstacles to improving outcomes, and suggestions of how progress can be achieved. Therapy outcomes at many Chinese pediatric cancer centers are approaching those of resource-rich countries. However, nationwide outcomes still need improvement. Obstacles include suboptimal clinical trials participation, children without adequate health care funding, human resource shortages, especially physicians expert in pediatric hematology and oncology, and social-economic disparities. We suggest how these obstacles have been and continue to be remedied including expanded access to protocol-based therapy, improved supportive care, health care reforms, recruitment of trained personnel, and international collaborations. China has made substantial progress treating children with ALL. We envision even better outcomes in the near future.

Associations between measures of pediatric human resources and the under-five mortality rate: a nationwide study in China in 2014

BACKGROUND

To quantify the associations between the under-five mortality rate (U5MR) and measures of pediatric human resources, including pediatricians per thousand children (PPTC) and the geographical distribution of pediatricians.

METHODS

We analyzed data from a national survey in 2015-2016 in 2636 counties, accounting for 31 mainland provinces of China. We evaluated the associations between measures of pediatric human resources and the risk of a high U5MR (≥ 18 deaths per 1000 live births) using logistic regression and restricted cubic spline regression models with adjustments for potential confounders. PPTC and pediatricians per 10,000 km2 were categorized into quartiles. The highest quartiles were used as reference.

RESULTS

The median values of PPTC and pediatricians per 10,000 km2 were 0.35 (0.20-0.70) and 150 (50-500), respectively. Compared to the counties with the highest PPTC (≥ 0.7), those with the lowest PPTC (< 0.2) had a 52% higher risk of a high U5MR, with an L-shaped relationship. An inverted J-shaped relationship was found that the risk of a high U5MR was 3.74 [95% confidence interval (CI) 2.55-5.48], 3.07 (95% CI 2.11-4.47), and 2.25 times (95% CI 1.52-3.31) higher in counties with < 50, 50-149, and 150-499 pediatricians per 10,000 km2, respectively, than in counties with ≥ 500 physicians per 10,000 km2. The joint association analyses show a stronger association with the risk of a high U5MR in geographical pediatrician density than PPTC.

CONCLUSION

Both population and geographical pediatrician density should be considered when planning child health care services, even in areas with high numbers of PPTC.

Association of Child Mental Health with Child and Family Characteristics in Rural China: A Cross-Sectional Analysis

Assessing the mental health problems encountered by school children and understanding the contributing factors are crucial to inform strategies aimed at improving mental health in low-resource contexts. However, few studies have investigated the mental health problems among disadvantaged children in poorer countries. This study examines the prevalence of mental health problems in rural China and their association with child and family characteristics. The study uses survey data from 9696 children in 120 rural primary schools and measures child mental health using the Strengths and Difficulties Questionnaire (SDQ). Overall, 17.9% of the sample children were found to be in the abnormal range of the SDQ total difficulties scores. The mean score was 12.93 (SD = 4.94). Abnormal scores were associated with child and family characteristics, including older child age (Odds Ratio, OR = 0.704, 95% CI: 0.611, 0.810; p < 0.001), gender (OR = 1.235, 95% CI: 1.112, 1.371; p < 0.001), and academic performance (OR = 0.421, 95% CI: 0.369, 0.480; p < 0.001). Reading time was found to be protective for mental health. Risk factors include excessive screen time (OR = 1.685, 95% CI: 1.409, 2.016; p < 0.001) and being bullied (OR = 3.695, 95% CI: 3.301, 4.136; p < 0.001). Our study suggests that future mental health illness prevention programs in rural China should consider targeting different aspects of children's social contexts.

Prevalence of antibiotic self-medication behavior and related factors among children aged 0 to 5 years

Background: Self-medication behavior has great adverse effects on children. The aims of this study were to assess the prevalence of self-medication with antibiotics (SMA) among children aged 0-5 years and explore the related factors.Methods: A cross-sectional survey was conducted from 1 July 2019 to 31 July 2019 in Wuhan, Hubei Province (Central China). A structured questionnaire was used to collect data from 1188 parents of children aged 0-5 years on sociodemographic characteristics, SMA among children, antibiotic knowledge and health beliefs of SMA.Results: Of the 1188 participants, 14.32% had self-medicated their children with antibiotics in the past 6 months. The higher the degree of perceived threat (OR = 0.94, 95%CI: 0.89-1.00) and self-efficacy (OR = 0.94, 95%CI: 0.89-0.98), the less likely parents were to self-medicate their children. On the contrary, the higher the degree of perceived barriers, the more likely parents were to self-medicate their children with antibiotics (OR = 1.058, 95%CI: 1.01-1.11).Conclusions: Health beliefs of parents were significantly associated with SMA among children. In addition to extensive health education, the Chinese government should also improve the accessibility and quality of health services to reduce the barriers of parental behavior change.

Occupational identity, job satisfaction and their effects on turnover intention among Chinese Paediatricians: a cross-sectional study

Background

This study contributes to research on the paediatrician shortage by examining occupational identity, job satisfaction and their effects on turnover intention among paediatricians in China.

Methods

A multi-stage stratified random sampling method was employed to conduct a questionnaire survey. Of the 4906 survey recipients, valid data were collected from 4198 of the respondents (85.6%). The participants were from seven geographic regions of China (south, central, north, east, northwest, southwest, and northeast). Paediatricians who volunteered and provided written informed consent participated. All variables including basic socio-demographics and work-related characteristics, occupational identity, job satisfaction and turnover intention were based on available literature, and measured on a 5- point Likert scale. Statistical methods such as exploratory factor analysis (EFA), descriptive analysis, common method bias, one-way ANOVA test, Pearson correlation analysis and mediation analysis were used.

Results

Significant differences were observed among the respondents in terms of turnover intention based on age, education level, marital status, region, the type and grade of practice setting, professional title, years in practise, workload, rest days, and monthly income. Occupational identity and job satisfaction were both negatively related to turnover intention, and occupational identity was positively correlated with job satisfaction (r₁ = − 0.601, p < 0.01; r₂ = − 0.605, p < 0.01). The results also showed that job satisfaction played a mediating role in the association between occupational identity and turnover intention among Chinese paediatricians.

Conclusions

Work conditions, workload and salary are crucial factors of turnover intention among paediatricians in China. Therefore, we suggest that healthcare managers should increase investment in paediatrics, implement salary reforms and dedicate more attention to female and young paediatricians, thus reducing turnover intention among Chinese paediatricians.

The Current Landscape of Congenital Heart Surgery in Northern China: A Geographic and Population-Based Analysis

Background: Congenital heart disease (CHD) is the leading birth defect in China, and many patients require congenital heart surgery (CHS) to achieve optimal outcomes. However, the current landscape and population accessibility to specialist resources for CHS in China are unclear. Methods: Care facilities performing CHS were identified from the 2018 white book of Chinese cardiovascular surgery and were categorized as full or limited facilities based on specialist capacity. Census-based population data and road data were obtained from administrative sources. Service area analysis of all facilities was performed to estimate geographic accessibility. Results: Of 93 facilities in 14 provinces and municipalities in northern China, only 30.1% had full specialist capacity. The shortage of pediatric cardiologists and mechanical circulatory support was the primary limiting factor. In 2018, 61.3% of facilities performed <200 CHS cases, and 31.6% of all CHS cases (N = 30,921) were performed in limited facilities with substantially lower volume than full-capacity facilities (median value: 85.0 vs. 368.0). Beijing had a disproportionately higher CHS volume (367 cases per million population) than other provinces. Of all children under 5 in northern China, only 12.9% live within 30 km (a typical half-day visit) of the service areas of all facilities. Compared to children from the eastern region (31.4%), 71.8% of children from the central region and 70.2% of children from the western region needed to travel >180 km (a typical overnight visit) to receive care in full-capacity facilities. Conclusions: Many facilities for CHS in northern China had limited specialist capacity, and many CHD patients received suboptimal surgical care. Policy measures should address the significant geographic disparities to receive high-quality surgical care among disadvantaged patients.

Prevalence and Risk Factors of Burnout Among Chinese Pediatric Orthopedic Surgeons

BACKGROUND

Burnout is an occupational hazard among Chinese pediatric orthopedists, characterized by extreme physical and emotional exhaustion, and reduced professional efficacy; however, it has yet to be studied among this group of professionals in China. Our study aimed to assess the levels of burnout in Chinese pediatric orthopedists, and to identify the potential risk factors for burnout.

METHODS

A 32-question, anonymous, cross-sectional survey was conducted from August to September 2019. Overall, 1392 Chinese pediatric orthopedists participated in the survey.

RESULTS

Seven hundred valid questionnaires (50.3% response rate) were retrieved from 387 (55.3%) and 313 (44.7%) full-time and part-time pediatric orthopedists, respectively. Overall, 73.7% of the participants experienced burnout, of which 64.7% and 9.0% had some and severe burnout symptoms, respectively. The burnout levels significantly differed based on age (P=0.005), years in service (P=0.006), professional rank (P=0.03), weekly working hours (P<0.001), and monthly income (P=0.03). A binary logistic regression model showed that longer weekly working hours (adjusted odds ratio=1.29, 95% confidence interval: 1.09-1.52, P=0.004) was a risk factor for burnout, while higher monthly income (adjusted odds ratio=0.78, 95% confidence interval: 0.64 to 0.95, P=0.02) was protective against burnout, suggesting that younger pediatric orthopedists were more susceptible. No significant difference between full-time and part-time pediatric orthopedists or between sexes was detected in the adjusted analysis.

CONCLUSIONS

Chinese pediatric orthopedists have a relatively high rate of burnout. Younger pediatric orthopedists have a greater chance of experiencing burnout. These results highlight the need for further policies, especially focused on younger pediatric orthopedists, to assist in better developing Chinese pediatric orthopedics.

LEVEL OF EVIDENCE

Level: IV.

Effects on applying micro-film case-based learning model in pediatrics education

BACKGROUND

In view of the harsh reality Chinese paediatricians face, the challenge of paediatric education is about instilling not only knowledge and clinical skills but also resilience and beliefs. The aim of the study is to explore a more effective method than the traditional lecture-based learning (LBL) model for optimizing educational outcomes by establishing an innovative, comprehensive, case-based learning (CBL) model combined with the micro-film technique (MF + CBL). This approach has four important components: interests (attraction), knowledge application, competency, and scenario coping skills.

METHODS

Experimental research was conducted via a controlled parallel group study. The total sample of 104 senior-year students (Chinese) majoring in clinical medicine was randomly divided into two groups. The experimental group was exposed to the MF + CBL model and the control group to the LBL model. Overall, the results were assessed after an 8-week course via a student self-assessment questionnaire, a satisfaction survey and the final examination.

RESULTS

The experimental group generally performed better than the control group on the student self-assessment (P<0.05), satisfaction survey (P<0.05), and final examination (80.02 ± 3.77 vs 73.65 ± 3.69, P = 0.000). The open question at the end of the questionnaire revealed that a small number of students did not favour the MF + CBL model due to its time- and energy-consuming features.

CONCLUSIONS

Compared with LBL, the MF + CBL model was an innovative teaching method that promoted more comprehensive quality development. It represents an alternative model for optimizing the capacity of future paediatric doctors.

Global Gaps in Training Opportunities for Pediatricians and Pediatric Subspecialists

OBJECTIVE

A comprehensive, well-trained pediatric workforce is needed to ensure high-quality child health interventions around the globe. Further understanding of pediatric workforce training capacity would assist planning at the global and country level. The purpose of this study was to better understand the availability and process of training programs for pediatricians and pediatric subspecialists worldwide, as well as in-country presence of subspecialists.

METHODS

A survey was developed and distributed by e-mail to national pediatric leaders across the globe. The survey asked about the number of pediatric training programs, duration and logistics of training, and whether practicing pediatric subspecialists and subspecialty training programs were available in their country.

RESULTS

We received responses from 121 of the 166 countries contacted (73%). Of these, 108 countries reported the presence of one or more general pediatric postgraduate training programs, ranging from 1 to 500 programs per country. The number of training programs did not vary significantly by gross domestic product but did vary by region, with the fewest in Africa (P < .001). Most countries identified national guidelines for training (82% of countries) and accreditation (84% of countries). Availability of pediatric subspecialists varied significantly by income and region, from no subspecialties available in 4 countries to all 26 queried subspecialties available in 17 countries. Neonatology was most common, available in 88% of countries. Subspecialty training programs were less available overall, significantly correlating with country income.

CONCLUSION

Education for general pediatrics and pediatric subspecialties is quite limited in many of the countries surveyed, particularly in Africa. The creation of additional educational capacity is a critical issue challenging the adequate provision of pediatrics and pediatric subspecialty services.

Positive impact of COVID-19 on career choice in pediatric medical students: a longitudinal study

BACKGROUND

On March 11^th, 2020, the WHO made the assessment that coronavirus disease 2019 (COVID-19) could be characterized as a pandemic. Medical students experienced a greater degree of anxiety and psychological stress than during previous pandemics. Negative emotions were related to decreased medical career interest, increased career choice regret and dropout rates in medical students, which affected academic and professional development. The goal of this study was to investigate the impact of the current COVID-19 outbreak on the career preferences of pediatric medical students and to explore the underlying factors contributing to it.

METHODS

A prospective, longitudinal study was conducted among all 120 pediatric medical students from Shanghai Medical College of Fudan University on November 23^rd, 2019, and February 21^st, 2020 using a 7-item online questionnaire about career choice.

RESULTS

A total of 106 (41 male and 65 female) students with a mean age of 21 years consented to participate in this study. The response rate was 100% in November 2019 and 98.1% in February 2020. Since the outbreak, career choices to practice medicine or pediatrics did not drop significantly, decreasing by only 4.3% and 2.2%, respectively. There was a positive impact of the COVID-19 outbreak on strengthening 66.7% of students' beliefs and choices to become good pediatricians (P<0.001). Only 14 students (13.5%) thought that COVID-19 had a negative impact on their career choices, but the majority of them were in the 3^rd (28.6%) and 4^th (64.3%) years of medical education and had insufficient knowledge about the hospital environment and clinics.

CONCLUSIONS

The outbreak of COVID-19 might have an overall positive impact on career choice by strengthening students' belief and choice to become good doctors and may decrease the choice regret and drop rates of the next generation of doctors. Special attention should be paid to students with insufficient clinical experience. Good protection for students, sharing outstanding stories regarding fighting the pandemic, and innovations of needs-based curriculum could be helpful during this pandemic. Future studies are warranted to confirm these findings.

Health care reform in China from the perspective of physicians

Health care reform is a worldwide problem. To address the problems of costs, access, quality, efficiency, and equity, China initiated healthcare reform in 2009. The progress of China's healthcare reform has been internationally recognized as the reform has expanded insurance coverage and improved access to and reduced the costs of care over the ten-year period from 2008 to 2018. To achieve sustainable goals, attention must be focused on whether and how the reform encourages physicians. This paper highlights the role of physicians, the challenges that need to be addressed, and the direction in which to advance health reform in China from the perspective of physicians. The slow-growing and aging physician population cannot meet the ever-increasing medical demand. Physicians have a heavy workload, work long hours, have unsatisfactory income, and have a fraught relationship with patients. The situation calls for rethinking the value of physicians and rebuilding trust between physicians and patients. Further healthcare reform is needed to equitably allocate physicians with adequate training, time, and resources to deliver evidence-based practices and patient-centered care.

Parent and Teacher Training Increases Medication Adherence for Primary School Children With Attention-Deficit/Hyperactivity Disorder

Objective: Attention-deficit/hyperactivity disorder (ADHD) is a common neurobiological disorder for which effective and safe medication is recommended as first-line treatment. However, many parents and teachers do not believe that ADHD is a disorder or do not accept medication treatment in China. Treatment is often short term or intermittent. Our study aimed to investigate the clinical effect of employing a 4-week, session-based training for both parents and teachers in improving medication adherence for primary school children with ADHD. Methods: From January 2018 to December 2018, a total of 5,118 primary school children were screened. Among 211 children diagnosed with ADHD, 116 were assigned to the intervention group and 95 to the control group. This study provided systematic training for parents and teachers in the intervention group. The training consisted of education about the disorder and ADHD behavioral intervention for both parents and teachers as well as classroom management techniques for just the teachers. A cluster randomized controlled trial (RCT) was conducted to investigate the effect of this training at 6 months follow-up. The study determined medication adherence using a questionnaire and scoring with a rating scale at baseline and at the 6 month follow-up endpoint. The questionnaire was self-report. Results: The study population had a relatively low rate of attention deficit hyperactivity disorder (4.1%) compared to the generally accepted prevalence. After the training, more parents and teachers believed that ADHD is a neurobiological disorder and that medication is the first line treatment. At 6 months follow-up, the Medication Adherence Report Scale (MARS) score for the intervention group was 22.8 ± 0.75 and 16.5 ± 1.63 for the control group (t = 5.217, P < 0.01). Based on parents' reports and medical records, 82 children (70.69%) were continuously taking medication for 6 months in the intervention group, while only 35 children (36.84%) were doing so in the control group. In the intervention group, the mean SNAP-IV score was 1.98 ± 0.42 at baseline but 0.99 ± 0.31 at 6-month follow-up. In the control group, the mean SNAP-IV score was 1.89 ± 0.47 at baseline but 1.37 ± 0.42 at 6-months follow-up (F = 2.67, P = 0.009). Factors influencing medication adherence for children with ADHD were parent's beliefs, teacher's beliefs, socioeconomic status, adverse effect, insurance coverage, gender, and trust of the medical system. Conclusions: Our findings indicate that comprehensive training programs improve the understanding of ADHD and medication adherence for both children's parents and teachers, providing a promising approach for improving clinical efficacy for children with ADHD.