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Wu Y, Liang Y, Cai Z, Li L, Sun C, Sylvia S, Zhou H, Feng J, Rozelle S. Process quality, diagnosis quality, and patient satisfaction of primary care in Rural Western China: A study using standardized patients. Patient Educ Couns 2024; 123:108208. [PMID: 38377708 DOI: 10.1016/j.pec.2024.108208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Revised: 12/26/2023] [Accepted: 02/12/2024] [Indexed: 02/22/2024]
Abstract
OBJECTIVES Patient satisfaction is an essential indicator of the doctor-patient relationship. This study aimed to investigate the relationship between primary care quality and patient satisfaction for non-communicable diseases (NCDs) in rural western China. METHODS The study utilized the standardized patients (SPs) approach to present typical symptoms of unstable angina and diabetes to rural healthcare providers. After the consultations, the SPs completed a satisfaction survey. Ordinary least squares and quantile regression were used to examine the association between quality of primary care and patient satisfaction. RESULTS We examined 178 anonymous SPs visits. The results showed that higher process quality for angina SPs was correlated with stronger satisfaction for provider ability at a low quantile of ability satisfaction. For diabetes SPs, higher process quality increased overall satisfaction at a low quantile of overall satisfaction, whereas a correct diagnosis significantly contributed to communication satisfaction at a high quantile of communication satisfaction. CONCLUSIONS The study found positive associations between process and diagnosis quality and SPs satisfaction. Notably, the influence of process quality was most significant among patients with lower satisfaction levels. PRACTICE IMPLICATIONS Provider's process quality could be a key area of improving the satisfaction levels, especially for patients with lower levels of satisfaction.
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Affiliation(s)
- Yuju Wu
- Department of Health Behavior and Social Science,West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Yizhi Liang
- Department of Global Health and Population, Harvard Chan School of Public Health, 677 Huntington Ave, Boston 02115, MA, USA
| | - Zhengjie Cai
- Department of Health Behavior and Social Science,West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Linhua Li
- Department of Health Behavior and Social Science,West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Chang Sun
- Department of Health Behavior and Social Science,West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Sean Sylvia
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Huan Zhou
- Department of Health Behavior and Social Science, West China School of Public Health and West China Fourth Hospital, Sichuan University, No. 16, Section 3, South Renmin Road, Chengdu 610041, Sichuan, China.
| | - Jieyuan Feng
- Stanford Center on China's Economy and Institutions, Stanford University, Stanford, CA, USA
| | - Scott Rozelle
- Stanford Center on China's Economy and Institutions, Stanford University, Stanford, CA, USA
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Cheng TC, Sylvia S, Yip W. Innovative approaches of measuring care quality in China's market for telemedicine. Lancet Reg Health West Pac 2024; 46:101070. [PMID: 38645740 PMCID: PMC11033135 DOI: 10.1016/j.lanwpc.2024.101070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/03/2024] [Accepted: 04/07/2024] [Indexed: 04/23/2024]
Affiliation(s)
- Terence C. Cheng
- Department of Global Health and Population, Harvard TH Chan School of Public Health, USA
| | - Sean Sylvia
- Department of Health Policy and Management, University of North Carolina at Chapel Hill, USA
| | - Winnie Yip
- Department of Global Health and Population, Harvard TH Chan School of Public Health, USA
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Si Y, Xue H, Liao H, Xie Y, Xu DR, Smith MK, Yip W, Cheng W, Tian J, Tang W, Sylvia S. The quality of telemedicine consultations for sexually transmitted infections in China. Health Policy Plan 2024; 39:307-317. [PMID: 38113375 DOI: 10.1093/heapol/czad119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Revised: 12/06/2023] [Accepted: 12/16/2023] [Indexed: 12/21/2023] Open
Abstract
The burden of sexually transmitted infections (STIs) continues to increase in developing countries like China, but the access to STI care is often limited. The emergence of direct-to-consumer (DTC) telemedicine offers unique opportunities for patients to directly access health services when needed. However, the quality of STI care provided by telemedicine platforms remains unknown. After systemically identifying the universe of DTC telemedicine platforms providing on-demand consultations in China in 2019, we evaluated their quality using the method of unannounced standardized patients (SPs). SPs presented routine cases of syphilis and herpes. Of the 110 SP visits conducted, physicians made a correct diagnosis in 44.5% (95% CI: 35.1% to 54.0%) of SP visits, and correctly managed 10.9% (95% CI: 5.0% to 16.8%). Low rates of correct management were primarily attributable to the failure of physicians to refer patients for STI testing. Controlling for other factors, videoconference (vs SMS-based) consultation mode and the availability of public physician ratings were associated with higher-quality care. Our findings suggest a need for further research on the causal determinants of care quality on DTC telemedicine platforms and effective policy approaches to promote their potential to expand access to STI care in developing countries while limiting potential unintended consequences for patients.
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Affiliation(s)
- Yafei Si
- Centre for International Studies on Development and Governance, Zhejiang University, No. 688 Yuhangtang Road, Hangzhou, Zhejiang 310058, China
- School of Risk & Actuarial Studies and CEPAR, The University of New South Wales, 223 Anzac Parade, Kensington, NSW 2033, Australia
- Global Health Research Center, Duke Kunshan University, No. 8 Duke Avenue Kunshan, Jiangsu 215316, China
- University of North Carolina Project-China, No313 Huanshizhong Road Guangzhou, Guangdong 510000, China
| | - Hao Xue
- Stanford Center for China's Institutions and Economy, Stanford University, 616 Jane Stanford Way, Stanford, CA 94305, USA
| | - Huipeng Liao
- University of North Carolina Project-China, No313 Huanshizhong Road Guangzhou, Guangdong 510000, China
| | - Yewei Xie
- University of North Carolina Project-China, No313 Huanshizhong Road Guangzhou, Guangdong 510000, China
- Programme for Health Services & Systems Research, Duke-NUS Medical School, 8 College Road, Singapore 169857, Singapore
| | - Dong Roman Xu
- Center for World Health Organization Studies and Department of Health Management, School of Health Management of Southern Medical University, 1023 South Shatai Road, Guangzhou, Guangdong 510515, China
- Acacia Labs, SMU Institute for Global Health (SIGHT), Dermatology Hospital of Southern Medical University (SMU), 1023 South Shatai Road, Guangzhou, Guangdong 510515, China
| | - M Kumi Smith
- Division of Epidemiology and Community Health, University of Minnesota Twin Cities, 1300 South 2nd Street, Minneapolis, MN 55454, USA
| | - Winnie Yip
- Department of Global Health and Population, Harvard University, 665 Huntington Ave, Cambridge, MA 02115, USA
| | - Weibin Cheng
- Institute for Healthcare Artificial Intelligence Application, Guangdong Second Provincial General Hospital, No. 466 Xingangzhong Road, Guangzhou, Guangdong 510330, China
- School of Data Science, City University of Hong Kong, Tat Chee Avenue Kowloon, Hong Kong 0000, China
| | - Junzhang Tian
- Institute for Healthcare Artificial Intelligence Application, Guangdong Second Provincial General Hospital, No. 466 Xingangzhong Road, Guangzhou, Guangdong 510330, China
| | - Weiming Tang
- University of North Carolina Project-China, No313 Huanshizhong Road Guangzhou, Guangdong 510000, China
- Institute for Healthcare Artificial Intelligence Application, Guangdong Second Provincial General Hospital, No. 466 Xingangzhong Road, Guangzhou, Guangdong 510330, China
- Institute for Global Health and Infectious Disease, University of North Carolina at Chapel Hill, 123 W Franklin St, Chapel Hill, NC 27516, USA
| | - Sean Sylvia
- Department of Health Policy and Management, University of North Carolina at Chapel Hill, 1101 McGavran-Greenberg Hall, Chapel Hill, NC 27516, USA
- Carolina Population Center, University of North Carolina at Chapel Hill, 123 W Franklin St, Chapel Hill, NC 27516, USA
- Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, 25 M.L.K. Jr Blvd, Chapel Hill, NC 27516, USA
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Zhang S, Wang L, Luo R, Rozelle S, Sylvia S. The medium-term impact of a micronutrient powder intervention on anemia among young children in Rural China. BMC Public Health 2024; 24:426. [PMID: 38336627 PMCID: PMC10858501 DOI: 10.1186/s12889-024-17895-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Accepted: 01/26/2024] [Indexed: 02/12/2024] Open
Abstract
BACKGROUND Poor development of young children is a common issue in developing countries and it is well established that iron deficiency anemia is one of the risk factors. Research has shown that iron deficiency is a common micronutrient deficiency among children in rural China and can result in anemia. A previous paper using data from the same trial as those used in the current study, but conducted when sample children were younger, found that after 6 months of providing caregivers of children 6-11 months of age free access to iron-rich micronutrient powder (MNP) increased the hemoglobin concentrations (Hb) of their children. However, no effects were found 12 and 18 months after the intervention. The current study followed up the children four years after the start of the original intervention (when the children were 4-5 years old) and aims to assess the medium-term impacts of the MNP program on the nutritional status of the sample pre-school-aged children, including their levels of Hb, the prevalence of anemia, and the dietary diversity of the diets of the children. METHODS At baseline, this study sampled 1,802 children aged 6-11 months in rural Western China. The intervention lasted 18 months. In this medium-term follow-up study that successfully followed 81% (n = 1,464) of children (aged 49-65 months) from the original study population 4 years after the start of the intervention, we used both intention-to-treat (ITT) effect and average treatment on the treated effect (ATT) analyses to assess the medium-term impacts of the MNP distribution program on the nutritional status of sample children. RESULTS The ITT analysis shows that the MNP intervention decreased the prevalence of anemia of young children in the medium run by 8% (4 percentage points, p < 0.1). The ATT analysis shows that consuming 100 (out of 540) MNP sachets during the initial intervention led to a decrease in anemia of 4% (2 percentage points, p < 0.1). Among children with moderate anemia at baseline (Hb < 100 g/L), the intervention reduced the probability of anemia by 45% (9 percentage points, p < 0.1), and, for those families that complied by consuming 100 (out of 540) sachets, a 25% (5 percentage points, p < 0.05) reduction in the anemia rate was found. The MNP intervention also led to a persistent increase in dietary diversity among children that were moderately anemic at baseline. The results from the quantile treatment effect analysis demonstrated that children with lower Hb levels at baseline benefited relatively more from the MNP intervention. CONCLUSIONS The findings of the current study reveal that the MNP intervention has medium-term effects on the nutritional status of children in rural China. The impacts of the MNP program were relatively higher for children that initially had more severe anemia levels. Hence, the implications of this study are that programs that aim to increase caregiver knowledge of nutrition and improve their feeding practices should be encouraged across rural China. Families, policymakers, and China's society overall need to continue to pay more attention to problems of childhood anemia in rural areas. This is particularly crucial for families with moderately anemic children at an early age as it can significantly contribute to improving the anemia status of children across rural areas of China. TRIAL REGISTRATION ISRCTN44149146 (15/04/2013).
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Affiliation(s)
- Siqi Zhang
- International Business School, Shaanxi Normal University, Xi'an, China
| | - Lei Wang
- International Business School, Shaanxi Normal University, Xi'an, China.
| | - Renfu Luo
- Center for Agricultural Policy, School of Advanced Agricultural Sciences, Peking University, Beijing, China
| | - Scott Rozelle
- Stanford Center On China's Economy and Institutions, Stanford University, Stanford, CA, USA
| | - Sean Sylvia
- Department of Health Policy and Management, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- Carolina Population Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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Liu L, Wu Y, Xian X, Feng J, Mao Y, Balakrishnan S, Weber AM, Darmstadt GL, Chen Y, Sylvia S, Zhou H, Rozelle S. In-Hospital Formula Feeding Hindered Exclusive Breastfeeding: Breastfeeding Self-Efficacy as a Mediating Factor. Nutrients 2023; 15:5074. [PMID: 38140332 PMCID: PMC10746093 DOI: 10.3390/nu15245074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2023] [Revised: 12/04/2023] [Accepted: 12/08/2023] [Indexed: 12/24/2023] Open
Abstract
Breastfeeding self-efficacy (BSE), defined as a mother's confidence in her ability to breastfeed, has been confirmed to predict the uptake of exclusive breastfeeding (EBF). Early experiences during the birth hospital stay, especially in-hospital formula feeding (IHFF), can impact both EBF and maternal breastfeeding confidence. Therefore, our objective was to examine the association between IHFF and EBF outcomes and investigate whether this association is influenced by BSE. The study included 778 infants from a larger cohort study conducted in 2021, with a one-year follow-up in rural areas of Sichuan Province, China. We used a causal mediation analysis to estimate the total effect (TE), natural direct (NDE), and nature indirect effects (NIE) using the paramed command in Stata. Causal mediation analyses revealed that IHFF was negatively associated with EBF (TE odds ratio = 0.47; 95% CI, 0.29 to 0.76); 28% of this association was mediated by BSE. In the subgroup analysis, there were no significant differences in the effects between parity subgroups, as well as between infant delivery subgroups. Our study found that IHFF hindered later EBF and that BSE mediated this association. Limiting the occurrence of in-hospital formula feeding or improving maternal breastfeeding self-efficacy is likely to improve exclusive breastfeeding outcomes.
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Affiliation(s)
- Lu Liu
- Department of Health Behavior and Social Medicine, West China School of Public Health and West China Fourth Hospital, Sichuan University, No. 16 South Renmin Road 3 Section, Chengdu 610041, China; (L.L.); (Y.W.); (X.X.)
| | - Yuju Wu
- Department of Health Behavior and Social Medicine, West China School of Public Health and West China Fourth Hospital, Sichuan University, No. 16 South Renmin Road 3 Section, Chengdu 610041, China; (L.L.); (Y.W.); (X.X.)
| | - Xiannan Xian
- Department of Health Behavior and Social Medicine, West China School of Public Health and West China Fourth Hospital, Sichuan University, No. 16 South Renmin Road 3 Section, Chengdu 610041, China; (L.L.); (Y.W.); (X.X.)
| | - Jieyuan Feng
- Stanford Center on China’s Economy and Institutions, Freeman Spogli Institute for International Studies, Stanford University, Stanford, CA 94305, USA; (J.F.); (S.R.)
| | - Yuping Mao
- Department of Communication Studies, College of Liberal Arts, California State University Long Beach, Long Beach, CA 90840, USA;
| | - Siva Balakrishnan
- Department of Biostatistics, Epidemiology and Environmental Health, School of Public Health, University of Nevada, Reno, NV 89503, USA; (S.B.)
| | - Ann M. Weber
- Department of Biostatistics, Epidemiology and Environmental Health, School of Public Health, University of Nevada, Reno, NV 89503, USA; (S.B.)
| | - Gary L. Darmstadt
- Department Pediatrics, Stanford University School of Medicine, Stanford, CA 94305, USA;
| | - Yunwei Chen
- Health Policy and Management, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA; (Y.C.); (S.S.)
| | - Sean Sylvia
- Health Policy and Management, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA; (Y.C.); (S.S.)
| | - Huan Zhou
- Department of Health Behavior and Social Medicine, West China School of Public Health and West China Fourth Hospital, Sichuan University, No. 16 South Renmin Road 3 Section, Chengdu 610041, China; (L.L.); (Y.W.); (X.X.)
| | - Scott Rozelle
- Stanford Center on China’s Economy and Institutions, Freeman Spogli Institute for International Studies, Stanford University, Stanford, CA 94305, USA; (J.F.); (S.R.)
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Chen Y, Wu Y, Dill SE, Guo Y, Westgard CM, Medina A, Weber AM, Darmstadt GL, Zhou H, Rozelle S, Sylvia S. Effect of the mHealth-supported Healthy Future programme delivered by community health workers on maternal and child health in rural China: study protocol for a cluster randomised controlled trial. BMJ Open 2023; 13:e065403. [PMID: 36669837 PMCID: PMC9872510 DOI: 10.1136/bmjopen-2022-065403] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Accepted: 01/04/2023] [Indexed: 01/22/2023] Open
Abstract
INTRODUCTION Millions of young rural children in China still suffer from poor health and malnutrition, partly due to a lack of knowledge about optimal perinatal and child care among rural mothers and caregivers. Meanwhile, there is an urgent need to improve maternal mental health in rural communities. Comprehensive home visiting programmes delivered by community health workers (CHWs) can bridge the caregiver knowledge gap and improve child health and maternal well-being in low-resource settings, but the effectiveness of this approach is unknown in rural China. Additionally, grandmothers play important roles in child care and family decision-making in rural China, suggesting the importance of engaging multiple caregivers in interventions. The Healthy Future programme seeks to improve child health and maternal well-being by developing a staged-based curriculum that CHWs deliver to mothers and caregivers of young children through home visits with the assistance of a tablet-based mHealth system. This protocol describes the design and evaluation plan for this programme. METHODS AND ANALYSIS We designed a cluster-randomised controlled trial among 119 rural townships in four nationally designated poverty counties in Southwestern China. We will compare the outcomes between three arms: one standard arm with only primary caregivers participating in the intervention, one encouragement arm engaging primary and secondary caregivers and one control arm with no intervention. Families with pregnant women or infants under 6 months of age are invited to enrol in the 12-month study. Primary outcomes include children's haemoglobin levels, exclusive breastfeeding rates and dietary diversity in complementary feeding. Secondary outcomes include a combination of health, behavioural and intermediate outcomes. ETHICS AND DISSEMINATION Ethical approval has been provided by Stanford University, Sichuan University and the University of Nevada, Reno. Trial findings will be disseminated through national and international peer-reviewed publications and conferences. TRIAL REGISTRATION NUMBER ISRCTN16800789.
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Affiliation(s)
- Yunwei Chen
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Yuju Wu
- West China School of Public Health, Sichuan University, Chengdu, China
| | - Sarah-Eve Dill
- Stanford Center on China's Economy and Institutions, Stanford University, Stanford, CA, USA
| | - Yian Guo
- Stanford Center on China's Economy and Institutions, Stanford University, Stanford, CA, USA
| | - Christopher Michael Westgard
- Department of Maternal and Child Health, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Alexis Medina
- Stanford Center on China's Economy and Institutions, Stanford University, Stanford, CA, USA
| | - Ann M Weber
- Department of Biostatistics, Epidemiology and Environmental Health, School of Public Health, University of Nevada, Reno, Reno, NV, USA
| | - Gary L Darmstadt
- Department of Pediatrics, Stanford University School of Medicine, Stanford, CA, USA
| | - Huan Zhou
- West China School of Public Health, Sichuan University, Chengdu, China
| | - Scott Rozelle
- Stanford Center on China's Economy and Institutions, Stanford University, Stanford, CA, USA
| | - Sean Sylvia
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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Marley G, Zou X, Nie J, Cheng W, Xie Y, Liao H, Wang Y, Tao Y, Tucker JD, Sylvia S, Chou R, Wu D, Ong J, Tang W. Improving cascade outcomes for active TB: A global systematic review and meta-analysis of TB interventions. PLoS Med 2023; 20:e1004091. [PMID: 36595536 PMCID: PMC9847969 DOI: 10.1371/journal.pmed.1004091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Revised: 01/18/2023] [Accepted: 12/13/2022] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND To inform policy and implementation that can enhance prevention and improve tuberculosis (TB) care cascade outcomes, this review aimed to summarize the impact of various interventions on care cascade outcomes for active TB. METHODS AND FINDINGS In this systematic review and meta-analysis, we retrieved English articles with comparator arms (like randomized controlled trials (RCTs) and before and after intervention studies) that evaluated TB interventions published from January 1970 to September 30, 2022, from Embase, CINAHL, PubMed, and the Cochrane library. Commentaries, qualitative studies, conference abstracts, studies without standard of care comparator arms, and studies that did not report quantitative results for TB care cascade outcomes were excluded. Data from studies with similar comparator arms were pooled in a random effects model, and outcomes were reported as odds ratio (OR) with 95% confidence interval (CI) and number of studies (k). The quality of evidence was appraised using GRADE, and the study was registered on PROSPERO (CRD42018103331). Of 21,548 deduplicated studies, 144 eligible studies were included. Of 144 studies, 128 were from low/middle-income countries, 84 were RCTs, and 25 integrated TB and HIV care. Counselling and education was significantly associated with testing (OR = 8.82, 95% CI:1.71 to 45.43; I2 = 99.9%, k = 7), diagnosis (OR = 1.44, 95% CI:1.08 to 1.92; I2 = 97.6%, k = 9), linkage to care (OR = 3.10, 95% CI = 1.97 to 4.86; I2 = 0%, k = 1), cure (OR = 2.08, 95% CI:1.11 to 3.88; I2 = 76.7%, k = 4), treatment completion (OR = 1.48, 95% CI: 1.07 to 2.03; I2 = 73.1%, k = 8), and treatment success (OR = 3.24, 95% CI: 1.88 to 5.55; I2 = 75.9%, k = 5) outcomes compared to standard-of-care. Incentives, multisector collaborations, and community-based interventions were associated with at least three TB care cascade outcomes; digital interventions and mixed interventions were associated with an increased likelihood of two cascade outcomes each. These findings remained salient when studies were limited to RCTs only. Also, our study does not cover the entire care cascade as we did not measure gaps in pre-testing, pretreatment, and post-treatment outcomes (like loss to follow-up and TB recurrence). CONCLUSIONS Among TB interventions, education and counseling, incentives, community-based interventions, and mixed interventions were associated with multiple active TB care cascade outcomes. However, cost-effectiveness and local-setting contexts should be considered when choosing such strategies due to their high heterogeneity.
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Affiliation(s)
- Gifty Marley
- Dermatology Hospital of Southern Medical University, Guangzhou, China
- University of North Carolina Project-China, Guangzhou, China
| | - Xia Zou
- Global Health Research Center, Guangdong Provincial People’s Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, China
| | - Juan Nie
- Department of Research and Education, Guangzhou Concord Cancer Center, Guangzhou, China
| | - Weibin Cheng
- Institute for Healthcare Artificial Intelligence Application, Guangdong Second Provincial General Hospital, Guangzhou, China
- School of Data Science, City University of Hong Kong, Hong Kong, China
| | - Yewei Xie
- University of North Carolina Project-China, Guangzhou, China
| | - Huipeng Liao
- University of North Carolina Project-China, Guangzhou, China
| | - Yehua Wang
- University of North Carolina Project-China, Guangzhou, China
| | - Yusha Tao
- University of North Carolina Project-China, Guangzhou, China
| | - Joseph D. Tucker
- University of North Carolina Project-China, Guangzhou, China
- Faculty of Infectious and Tropical Diseases, London School of Health and Tropical Medicine, London, United Kingdom
| | - Sean Sylvia
- University of North Carolina Project-China, Guangzhou, China
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina, United States of America
| | - Roger Chou
- Oregon Health & Science University, Portland, Oregon, United States of America
| | - Dan Wu
- University of North Carolina Project-China, Guangzhou, China
- Faculty of Infectious and Tropical Diseases, London School of Health and Tropical Medicine, London, United Kingdom
| | - Jason Ong
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Weiming Tang
- Dermatology Hospital of Southern Medical University, Guangzhou, China
- University of North Carolina Project-China, Guangzhou, China
- * E-mail:
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Du Y, Zhou Q, Cheng W, Zhang Z, Hoelzer S, Liang Y, Xue H, Ma X, Sylvia S, Tian J, Tang W. Factors Influencing Adoption and Use of Telemedicine Services in Rural Areas of China: Mixed Methods Study. JMIR Public Health Surveill 2022; 8:e40771. [PMID: 36563026 PMCID: PMC9823570 DOI: 10.2196/40771] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Revised: 10/06/2022] [Accepted: 10/18/2022] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND The shortage of medical resources in rural China reflects the health inequity in resource-limited settings, whereas telemedicine could provide opportunities to fill this gap. However, evidence of patient acceptance of telemedicine services from low- and middle-income countries is still lacking. OBJECTIVE We aimed to understand the profile of patient end-user telemedicine use and identify factors influencing telemedicine service use in rural China. METHODS Our study followed a mixed methods approach, with a quantitative cross-sectional survey followed by in-depth semistructured interviews to describe telemedicine use and its associated factors among rural residents in Guangdong Province, China. In the quantitative analysis, explanatory variables included environmental and context factors, household-level factors, individual sociodemographic factors, access to digital health care, and health needs and demand factors. We conducted univariate and multivariate analyses using Firth logistic regression to examine the correlations of telemedicine uptake. A thematic approach was used, guided by the Social Cognitive Theory for the qualitative analysis. RESULTS A total of 2101 households were recruited for the quantitative survey. With a mean age of 61.4 (SD 14.41) years, >70% (1364/2101, 72.94%) of the household respondents were male. Less than 1% (14/2101, 0.67%) of the respondents reported experience of using telemedicine. The quantitative results supported that villagers living with family members who had a fever in the past 2 weeks (adjusted odds ratio 6.96, 95% CI 2.20-21.98; P=.001) or having smartphones or computers (adjusted odds ratio 3.71, 95% CI 0.64-21.32; P=.14) had marginally higher telemedicine uptake, whereas the qualitative results endorse these findings. The results of qualitative interviews (n=27) also supplemented the potential barriers to telemedicine use from the lack of knowledge, trust, demand, low self-efficacy, and sufficient physical and social support. CONCLUSIONS This study found extremely low use of telemedicine in rural China and identified potential factors affecting telemedicine uptake. The main barriers to telemedicine adoption among rural residents were found, including lack of knowledge, trust, demand as well as low self-efficacy, and insufficient physical and social support. Our study also suggests strategies to facilitate telemedicine engagement in low-resource settings: improving digital literacy and self-efficacy, building trust, and strengthening telemedicine infrastructure support.
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Affiliation(s)
- Yumeng Du
- Institute for Healthcare Artificial Intelligence Application, Guangdong Second Provincial General Hospital, Guangzhou, China
| | - Qiru Zhou
- Internet Hospital, Guangdong Second Provincial General Hospital, Guangzhou, China
| | - Weibin Cheng
- Institute for Healthcare Artificial Intelligence Application, Guangdong Second Provincial General Hospital, Guangzhou, China
- School of Data Science, City University of Hong Kong, Hong Kong, China
| | - Zhang Zhang
- Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
- Carolina Population Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Samantha Hoelzer
- Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Yizhi Liang
- University of North Carolina at Chapel Hill Project-China, Guangzhou, China
- Department of Global Health and Population, Harvard University, Boston, MA, United States
| | - Hao Xue
- Stanford Center for China's Economy and Institutions, Stanford University, Stanford, CA, United States
| | - Xiaochen Ma
- China Center for Health Development Studies, Peking University, Beijing, China
| | - Sean Sylvia
- Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
- Carolina Population Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Junzhang Tian
- Institute for Healthcare Artificial Intelligence Application, Guangdong Second Provincial General Hospital, Guangzhou, China
| | - Weiming Tang
- Institute for Healthcare Artificial Intelligence Application, Guangdong Second Provincial General Hospital, Guangzhou, China
- University of North Carolina at Chapel Hill Project-China, Guangzhou, China
- Institute for Global Health and Infectious Disease, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
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9
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Wu Y, Ye R, Sun C, Meng S, Cai Z, Li L, Sylvia S, Zhou H, Pappas L, Rozelle S. Using standardized patients to assess the quality of type 2 diabetes care among primary care providers and the health system: Evidence from rural areas of western China. Front Public Health 2022; 10:1081239. [PMID: 36620284 PMCID: PMC9815030 DOI: 10.3389/fpubh.2022.1081239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Accepted: 12/08/2022] [Indexed: 12/24/2022] Open
Abstract
Background Improving type 2 diabetes (T2D) care is key to managing and reducing disease burden due to the growing prevalence of diabetes worldwide, but research on this topic, specifically from rural areas, is limited. This study uses standardized patients (SPs) to assess T2D care quality among primary care providers to access the healthcare system in rural China. Methods Using multi-stage random sampling, health facilities, providers, and households were selected. SPs were used to evaluate providers' T2D care quality and a questionnaire survey was used to collect patient sorting behaviors from households. Logistic regression was used to explore factors correlated with T2D care quality. Provider referral and treatment rates were combined with patient sorting behaviors to assess the overall quality of T2D management by rural China's healthcare system. Results A total of 126 providers, 106 facilities, and 750 households were enrolled into this study. During SP interactions, 20% of rural providers followed the national guidelines for T2D consultation, 32.5% gave correct treatment, and 54.7% provided lifestyle suggestions. Multi-variable regression results showed that providers who had earned practicing certificates (β = 1.56, 95% CI: 0.44, 2.69) and saw more patients (β = 0.77, 95%: 0.25, 1.28) were more likely to use a higher number of recommended questions and perform better examinations, whereas providers who participated in online training were less likely to practice these behaviors (β = -1.03, 95%: -1.95, -0.11). The number of recommended questions and examination (NRQE) was the only significant correlated factor with correct treatment (marginal effect = 0.05, 95%: 0.01, 0.08). Throughout the rural healthcare system, 23.7% of T2D patients were treated correctly. Conclusion The quality of T2D care in rural western China, especially throughout the consultation and treatment process during a patient's first visit, is poor. Online training may not improve T2D care quality and low patient volume was likely to indicate poor care quality. Further research is needed to explore interventions for improving T2D care quality in rural China's healthcare system.
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Affiliation(s)
- Yuju Wu
- West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Ruixue Ye
- West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Chang Sun
- West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Sha Meng
- Department of Operation Management, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Zhengjie Cai
- West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Linhua Li
- West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Sean Sylvia
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Huan Zhou
- West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, Sichuan, China,*Correspondence: Huan Zhou ✉
| | - Lucy Pappas
- Freeman Spogli Institute for International Studies, Stanford University, Stanford, CA, United States
| | - Scott Rozelle
- Freeman Spogli Institute for International Studies, Stanford University, Stanford, CA, United States
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10
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Tang W, Si Y, Xue H, Liao H, Xie Y, Xu D(R, Smith MK, Yip W, Cheng W, Tian J, Sylvia S. The quality of direct-to-consumer telemedicine consultations for sexually transmitted infections in China: An analysis of visits by standardized patients (Preprint). Interact J Med Res 2022. [DOI: 10.2196/44190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
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11
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Chen Y, Sylvia S, Dill SE, Rozelle S. Structural Determinants of Child Health in Rural China: The Challenge of Creating Health Equity. Int J Environ Res Public Health 2022; 19:13845. [PMID: 36360724 PMCID: PMC9654689 DOI: 10.3390/ijerph192113845] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/04/2022] [Revised: 10/20/2022] [Accepted: 10/20/2022] [Indexed: 06/16/2023]
Abstract
Over the past two decades, the literature has shown a clear gradient between child health and wealth. The same health-wealth gradient is also observed among children in China, with a large gap in health between rural and urban children. However, there are still unanswered questions about the main causes of China's rural-urban child health inequality. This paper aims to review the major factors that have led to the relatively poor levels of health among China's rural children. In addition to the direct income effect on children's health, children in rural areas face disadvantages compared with their urban counterparts from the beginning of life: Prenatal care and infant health outcomes are worse in rural areas; rural caregivers have poor health outcomes and lack knowledge and support to provide adequate nurturing care to young children; there are large disparities in access to quality health care between rural and urban areas; and rural families are more likely to lack access to clean water and sanitation. In order to inform policies that improve health outcomes for the poor, there is a critical need for research that identifies the causal drivers of health outcomes among children. Strengthening the pediatric training and workforce in rural areas is essential to delivering quality health care for rural children. Other potential interventions include addressing the health needs of mothers and grandparent caregivers, improving parenting knowledge and nurturing care, improving access to clean water and sanitation for remote families, and most importantly, targeting poverty itself.
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Affiliation(s)
- Yunwei Chen
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
| | - Sean Sylvia
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
| | - Sarah-Eve Dill
- Stanford Center on China’s Economy and Institutions, Stanford University, Stanford, CA 94305, USA
| | - Scott Rozelle
- Stanford Center on China’s Economy and Institutions, Stanford University, Stanford, CA 94305, USA
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12
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Meng S, Wang Q, Wu Y, Xue H, Li L, Ye R, Chen Y, Pappas L, Akhtar M, Dill SE, Sylvia S, Zhou H, Rozelle S. The know-do gap in quality of health for chronic non-communicable diseases in rural China. Front Public Health 2022; 10:953881. [PMID: 36062129 PMCID: PMC9435052 DOI: 10.3389/fpubh.2022.953881] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Accepted: 07/25/2022] [Indexed: 01/24/2023] Open
Abstract
Proper management of non-communicable diseases (NCDs) is a severe challenge to China's rural health system. This study investigates what influences the poor medical treatment of NCDs (diabetes and angina) by evaluating the "know-do gap" between provider knowledge and practice. To determine whether low levels of provider knowledge low quality of patient care is the primary constraint on the quality of NCDs diagnosis and treatment in rural China. Providers from Village Clinics (VC) and Township Health Centers (THC), and Standardized Patients (SP) were selected by a multi-stage random sampling method. Clinical vignettes were administered to 306 providers from 103 VCs and 50 THCs in rural Sichuan Province. SPs presented diabetes symptoms completed 97 interactions with providers in 46 VCs and 51 THCs; SPs presented angina symptoms completed 100 interactions with providers in 50 VCs and 50 THCs. Process quality, diagnosis quality, and treatment quality were assessed against national standards for diabetes and angina. Two-tailed T-tests and tests of proportions for continuous outcomes and tests of proportions for binary dependent variables were used to compare vignette and SP results. Differences between vignette and SP data calculated the know-do gap. Regression analyses were used to examine the providers/facility characteristics and knowledge/practice associations. THC providers demonstrated significantly more knowledge in vignettes and better practices in SP visits than VC providers. However, levels of knowledge were low overall: 48.2% of THC providers and 28.2% of VC providers properly diagnosed type 2 diabetes, while 23.8% of THC providers and 14.7% of VC providers properly diagnosed angina. With SPs, 2.1% of THC providers and 6.8% of VC providers correctly diagnosed type 2 diabetes; 25.5% of THC providers and 12.8% of VC providers correctly diagnosed angina. There were significant know-do gaps in diagnosis process quality, diagnosis quality, and treatment quality for diabetes (p < 0.01), and in diagnosis process quality (p < 0.05) and treatment quality for angina (p < 0.01). Providers in rural China display low levels of knowledge when treating diabetes and angina. Despite low knowledge, evidence of the know-do gap indicates that low-quality healthcare is the primary constraint on the quality of NCD diagnosis and treatment in rural China. Our research findings provide a new perspective for the evaluation of the medical quality and a technical basis for the development of new standardized cases in the future.
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Affiliation(s)
- Sha Meng
- Department of Health Behavior and Social Medicine, West China School of Public Health, West China Fourth Hospital, West China Hospital, Sichuan University, Chengdu, China,Department of Operation Management, West China Hospital, Sichuan University, Chengdu, China
| | - Qingzhi Wang
- Department of Health Behavior and Social Medicine, West China School of Public Health, West China Fourth Hospital, West China Hospital, Sichuan University, Chengdu, China
| | - Yuju Wu
- Department of Health Behavior and Social Medicine, West China School of Public Health, West China Fourth Hospital, West China Hospital, Sichuan University, Chengdu, China
| | - Hao Xue
- Stanford Center on China's Economy and Institutions, Freeman Spogli Institute for International Studies, Stanford University, Stanford, CA, United States
| | - Linhua Li
- Department of Health Behavior and Social Medicine, West China School of Public Health, West China Fourth Hospital, West China Hospital, Sichuan University, Chengdu, China
| | - Ruixue Ye
- Department of Health Behavior and Social Medicine, West China School of Public Health, West China Fourth Hospital, West China Hospital, Sichuan University, Chengdu, China
| | - Yunwei Chen
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Lucy Pappas
- Stanford Center on China's Economy and Institutions, Freeman Spogli Institute for International Studies, Stanford University, Stanford, CA, United States
| | - Muizz Akhtar
- Stanford Center on China's Economy and Institutions, Freeman Spogli Institute for International Studies, Stanford University, Stanford, CA, United States
| | - Sarah-Eve Dill
- Stanford Center on China's Economy and Institutions, Freeman Spogli Institute for International Studies, Stanford University, Stanford, CA, United States
| | - Sean Sylvia
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Huan Zhou
- Department of Health Behavior and Social Medicine, West China School of Public Health, West China Fourth Hospital, West China Hospital, Sichuan University, Chengdu, China,*Correspondence: Huan Zhou
| | - Scott Rozelle
- Stanford Center on China's Economy and Institutions, Freeman Spogli Institute for International Studies, Stanford University, Stanford, CA, United States
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13
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Wu Y, Ye R, Wang Q, Sun C, Meng S, Sylvia S, Zhou H, Friesen D, Rozelle S. Provider competence in hypertension management and challenges of the rural primary healthcare system in Sichuan province, China: a study based on standardized clinical vignettes. BMC Health Serv Res 2022; 22:849. [PMID: 35778732 PMCID: PMC9248120 DOI: 10.1186/s12913-022-08179-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Accepted: 06/01/2022] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Improving primary care providers' competence is key to detecting and managing hypertension, but evidence to guide this work has been limited, particularly for rural areas. This study aimed to use standardized clinical vignettes to assess the competence of providers and the ability of the primary healthcare system to detect and manage hypertension in rural China. METHODS A multi-stage random sampling method was administered to select target health facilities, providers, and households. The clinical vignette script was developed to evaluate provider competence in managing first-visit patients with symptoms of hypertension. Logistic regression was used to explore the factors correlated with provider competence. Provider referral and management rates were combined with patients' facility sorting behaviors to assess the ability of the rural healthcare system to manage hypertension in three policy scenarios. RESULTS A total of 306 providers and 153 facilities were enrolled in our study. In the 306 clinical vignette interactions, 25.9% of providers followed the national guidelines for hypertension consultation. The correct diagnosis was achieved by only 10.1% of providers, and 30.4% of providers were able to prescribe the correct treatment. Multi-variable regression results showed that younger providers (OR = 0.85, 95%CI: 0.73, 0.98) and those who work in township health centers (OR = 4.47, 95%: 1.07, 18.67) were more likely to provide a correct diagnosis. In a free-selection scenario, 29.8% of patients with hypertension were managed correctly throughout the rural system. When all patients first visit village clinics, system-level correct management is reduced to 20.5% but increases to 45.0% when all patients first visit township health centers. CONCLUSIONS Rural primary care providers do not have enough competence to detect and treat hypertension cases in China to an acceptable degree. Policy constraints may limit the competence of the rural healthcare system. Research to improve detection and treatment competence in hypertension and optimize health policy is needed.
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Affiliation(s)
- Yuju Wu
- Department of Health Behavior and Social Science, West China School of Public Health and West China Fourth Hospital, Sichuan University, No. 16, Section 3, South Renmin Road, Chengdu, 610041, Sichuan, People's Republic of China
| | - Ruixue Ye
- Department of Health Behavior and Social Science, West China School of Public Health and West China Fourth Hospital, Sichuan University, No. 16, Section 3, South Renmin Road, Chengdu, 610041, Sichuan, People's Republic of China
| | - Qingzhi Wang
- Department of Health Behavior and Social Science, West China School of Public Health and West China Fourth Hospital, Sichuan University, No. 16, Section 3, South Renmin Road, Chengdu, 610041, Sichuan, People's Republic of China
| | - Chang Sun
- Department of Health Behavior and Social Science, West China School of Public Health and West China Fourth Hospital, Sichuan University, No. 16, Section 3, South Renmin Road, Chengdu, 610041, Sichuan, People's Republic of China
| | - Sha Meng
- Department of Operation Management, West China Hospital, Sichuan University, Chengdu, 610041, Sichuan, China
| | - Sean Sylvia
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Huan Zhou
- Department of Health Behavior and Social Science, West China School of Public Health and West China Fourth Hospital, Sichuan University, No. 16, Section 3, South Renmin Road, Chengdu, 610041, Sichuan, People's Republic of China.
| | - Dimitris Friesen
- Freeman Spogli Institute for International Studies, Stanford University, California, Stanford, USA
| | - Scott Rozelle
- Freeman Spogli Institute for International Studies, Stanford University, California, Stanford, USA
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14
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Chen Y, Sylvia S, Wu P, Yi H. Explaining the declining utilization of village clinics in rural China over time: A decomposition approach. Soc Sci Med 2022; 301:114978. [PMID: 35461080 DOI: 10.1016/j.socscimed.2022.114978] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Revised: 04/11/2022] [Accepted: 04/12/2022] [Indexed: 11/19/2022]
Abstract
With a goal of improving health system quality and efficiency, reforms of China's health system over the past decade have sought to strengthen primary healthcare in lower-level clinics and health centers. Despite these wide-ranging reforms and initiatives, population-based studies have documented dramatic declines in patients' use of primary care facilities during this period. In this paper, we explore the determinants of this trend in China's rural areas using detailed longitudinal data following a nationally-representative sample of rural households and village clinics from 2011 to 2018. We estimate that between 2011 and 2018, the probability that individuals sought care at village clinics when ill dropped by 44%. At the same time, the utilization of outpatient services in county hospitals increased by 56% and patient self-treatment increased by 20%. Detailed Kitagawa-Oaxaca-Blinder decompositions suggest four primary drivers of this trend: the shifting burden of disease in rural areas, changes in how patients choose to seek care given different disease conditions, declining drug inventory in village clinics, and the decreasing importance of remoteness as a determinant of healthcare seeking behavior. Our results highlight the deteriorating role of village clinics in the rural healthcare system and the increasing importance of self-treatment and higher-tier primary care services.
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Affiliation(s)
- Yunwei Chen
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
| | - Sean Sylvia
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
| | - Paiou Wu
- School of Advanced Agricultural Sciences, Peking University, Beijing, China.
| | - Hongmei Yi
- School of Advanced Agricultural Sciences, Peking University, Beijing, China; Institute for Global Health and Development, Peking University, Beijing, China.
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15
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Jiang Q, Dill SE, Sylvia S, Singh MK, She X, Wang E, Medina A, Rozelle S. Parenting centers and caregiver mental health: Evidence from a large-scale randomized controlled trial in China. Child Dev 2022; 93:1559-1573. [PMID: 35481708 DOI: 10.1111/cdev.13782] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
This study conducts an exploratory analysis of the impacts of a center-based early childhood development intervention on the mental health of caregivers, using data from a cluster-randomized controlled trial of 1664 caregivers (Mage = 36.87 years old) of 6- to 24-month-old children in 100 villages in rural China. Caregivers and children in 50 villages received individual parenting training, group activities and open play space in village parenting centers. The results show no significant overall change in caregiver-reported mental health symptoms after 1 year of intervention. Subgroup analyses reveal heterogeneous effects by caregiver socioeconomic status and identity (mother vs. grandmother). Findings suggest that early childhood development interventions without targeted mental health components may not provide sufficient support to improve caregiver mental health.
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Affiliation(s)
- Qi Jiang
- Freeman Spogli Institute for International Studies, Stanford University, Stanford, California, USA
| | - Sarah-Eve Dill
- Freeman Spogli Institute for International Studies, Stanford University, Stanford, California, USA
| | - Sean Sylvia
- Gillings school of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Manpreet K Singh
- School of Medicine, Stanford University, Stanford, California, USA.,Stanford Pediatric Mood Disorders Program, Stanford University, Stanford, California, USA
| | - Xinshu She
- School of Medicine, Stanford University, Stanford, California, USA
| | - Eric Wang
- Freeman Spogli Institute for International Studies, Stanford University, Stanford, California, USA
| | - Alexis Medina
- Freeman Spogli Institute for International Studies, Stanford University, Stanford, California, USA
| | - Scott Rozelle
- Freeman Spogli Institute for International Studies, Stanford University, Stanford, California, USA
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16
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Durosinmi-Etti O, Fried B, Dubé K, Sylvia S, Greene S, Ikpeazu A, Nwala EK. Sustainability of Funding for HIV Treatment Services: A Cross-Sectional Survey of Patients' Willingness to Pay for Treatment Services in Nigeria. Glob Health Sci Pract 2022; 10:GHSP-D-21-00550. [PMID: 35487556 PMCID: PMC9053145 DOI: 10.9745/ghsp-d-21-00550] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Accepted: 02/14/2022] [Indexed: 02/04/2023]
Abstract
BACKGROUND About 50% of individuals needing HIV treatment are unable to access required services primarily due to the inability of the Nigerian HIV treatment program to meet patient needs. We explored patient willingness to pay for HIV treatment, which can inform the feasibility of cost recovery through patient fees to contribute to the funding of HIV treatment services in Nigeria. METHODS We conducted a cross-sectional survey of 400 people living with HIV randomly selected from 15 health care facilities providing free HIV treatment services in 2 medium and high HIV burden states (Lagos, Enugu) and the Federal Capital Territory Abuja. We calculated the elasticity of the price that patients were willing to pay per month relative to the estimated current cost of providing HIV treatment services per patient and determined the patient coverage and potential cost recovery at each price point. RESULTS We found that 92% of patients were willing to pay for HIV treatment. The mean amount patients were willing to pay was 3,000 naira (US$7.50) per month with about 18% of patients willing to pay the current monthly price of 5000 naira (US$12.50). The availability of financial support from family and friends (odds ratio [OR]=14.209; P=.001; 95% confidence interval [CI]=0.151, 0.285), lack of employment (OR=0.190; P=.02; 95% CI=0.015, 0.202), monthly income (OR=2.476; P<.001; 95% CI=84.698, 737.233), and change in monthly income (OR=2.015; P<.001; 95% CI=0.003, 0.229) were associated with willingness to pay. CONCLUSION Many Nigerian patients are willing to contribute to funding for HIV treatment and this can enhance domestic funding for HIV treatment and equitable access to treatment through proper segmentation of patients based on willingness and capacity to pay. Measures must be put in place to reduce the cost of accessing HIV treatment and promote financial empowerment of people living with HIV to improve willingness to pay for treatment.
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Affiliation(s)
- Olawale Durosinmi-Etti
- Health Leadership Program, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, NC, USA.,Correspondence to Olawale Durosinmi-Etti ()
| | - Bruce Fried
- Health Leadership Program, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, NC, USA
| | - Karine Dubé
- Health Leadership Program, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, NC, USA
| | - Sean Sylvia
- Health Leadership Program, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, NC, USA
| | - Sandra Greene
- Health Leadership Program, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, NC, USA
| | - Akudo Ikpeazu
- National AIDS and Sexually Transmitted Illnesses Control Program, Federal Ministry of Health, Abuja, Nigeria
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17
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Wang Q, Adhikari SP, Wu Y, Sunil TS, Mao Y, Ye R, Sun C, Shi Y, Zhou C, Sylvia S, Rozelle S, Zhou H. Consultation length, process quality and diagnosis quality of primary care in rural China: A cross-sectional standardized patient study. Patient Educ Couns 2022; 105:902-908. [PMID: 34391601 DOI: 10.1016/j.pec.2021.08.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Revised: 08/01/2021] [Accepted: 08/04/2021] [Indexed: 06/13/2023]
Abstract
OBJECTIVE Consultation length, the time spent between patient and health care provider during a visit, is an essential element in measuring quality of health care patients receive from a primary care facility. However, the linkage between consultation length and process quality and diagnosis quality of primary care is still uncertain. This study aims to examine the role consultation length plays in delivering process quality and diagnosis quality, two central components of overall primary care quality, in rural China. METHODS We recruited unannounced standardized patients (SPs) to present classic symptoms of angina and tuberculosis in selected healthcare facilities in three provinces of China. The consultation length and primary care quality of SPs were measured and compared with both international and national standards of care. Ordinary Least Squares (OLS) regressions for process quality (continuous dependent variable) and Logistic regressions for diagnosis quality (binary dependent variable) were performed to investigate the relationship between consultation length and primary care quality. RESULTS The average consultation lengths among patients with classic symptoms of angina and those with symptoms of tuberculosis were approximately 4.33 min and 6.28 min, respectively. Providers who spent more time with patients were significantly more likely to complete higher percentage of recommended checklist items of both questions and examinations for angina (β = 1.39, 95%CI 1.01-1.78) and tuberculosis (β = 0.89, 95%CI 0.69-1.08). Further, providers who spent more time with patients were more likely to make correct diagnosis for angina (marginal effect = 0.014, 95%CI 0.002-0.026) and for tuberculosis (marginal effect = 0.013, 95%CI 0.005-0.021). CONCLUSIONS The average consultation length is extremely short among primary care providers in rural China. The longer consultation leads to both better process and diagnosis quality of primary care. PRACTICE IMPLICATIONS We recommend primary care providers to increase the length of their communication with patients. To do so, government should implement healthcare reforms to clarify the requirements of affordable and reliable consultation length in medical care services. Moreover, such an experience can also be extended to other developing countries.
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Affiliation(s)
- Qingzhi Wang
- Department of Health Behavior and Social Medicine, West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, China
| | - Sasmita Poudel Adhikari
- Department of Health Behavior and Social Medicine, West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, China
| | - Yuju Wu
- Department of Health Behavior and Social Medicine, West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, China
| | - Thankam S Sunil
- Department of Public Health, University of Tennessee, TN, USA
| | - Yuping Mao
- Department of Communication Studies, California State University, California, USA
| | - Ruixue Ye
- Department of Health Behavior and Social Medicine, West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, China
| | - Chang Sun
- Department of Health Behavior and Social Medicine, West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, China
| | - Yaojiang Shi
- Center for Experimental Economics in Education, Shaanxi Normal University, Xi'an, China
| | - Chengchao Zhou
- Institute of Social Medicine and Health Administration, School of Public Health, Shandong University, Jinan, China
| | - Sean Sylvia
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, NC, USA
| | - Scott Rozelle
- Freeman Spogli Institute, Stanford University, California, USA
| | - Huan Zhou
- Department of Health Behavior and Social Medicine, West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, China.
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18
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Tan RKJ, Wu D, Day S, Zhao Y, Larson HJ, Sylvia S, Tang W, Tucker JD. Digital approaches to enhancing community engagement in clinical trials. NPJ Digit Med 2022; 5:37. [PMID: 35338241 PMCID: PMC8956701 DOI: 10.1038/s41746-022-00581-1] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Accepted: 02/23/2022] [Indexed: 11/11/2022] Open
Abstract
Digital approaches are increasingly common in clinical trial recruitment, retention, analysis, and dissemination. Community engagement processes have contributed to the successful implementation of clinical trials and are crucial in enhancing equity in trials. However, few studies focus on how digital approaches can be implemented to enhance community engagement in clinical trials. This narrative review examines three key areas for digital approaches to deepen community engagement in clinical trials—the use of digital technology for trial processes to decentralize trials, digital crowdsourcing to develop trial components, and digital qualitative research methods. We highlight how digital approaches enhanced community engagement through a greater diversity of participants, and deepened community engagement through the decentralization of research processes. We discuss new possibilities that digital technologies offer for community engagement, and highlight potential strengths, weaknesses, and practical considerations. We argue that strengthening community engagement using a digital approach can enhance equity and improve health outcomes.
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Affiliation(s)
- Rayner K J Tan
- University of North Carolina Project-China, Guangzhou, China. .,Dermatology Hospital of Southern Medical University, Guangzhou, China. .,Saw Swee Hock School of Public Health, National University of Singapore, Singapore, Singapore.
| | - Dan Wu
- Clinical Research Department, Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, UK
| | - Suzanne Day
- Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Yang Zhao
- School of Social Science, University of Queensland, Brisbane, QLD, Australia
| | - Heidi J Larson
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
| | - Sean Sylvia
- Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Weiming Tang
- Dermatology Hospital of Southern Medical University, Guangzhou, China.,Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Joseph D Tucker
- University of North Carolina Project-China, Guangzhou, China.,Clinical Research Department, Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, UK
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19
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Liu H, Li H, Teuwen DE, Sylvia S, Shi H, Rozelle S, Yi H. Irrational Use of Medicine in the Treatment of Presumptive Asthma Among Rural Primary Care Providers in Southwestern China. Front Pharmacol 2022; 13:767917. [PMID: 35242030 PMCID: PMC8885990 DOI: 10.3389/fphar.2022.767917] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Accepted: 01/19/2022] [Indexed: 12/02/2022] Open
Abstract
Poor knowledge, scarce resources, and lack of or misaligned incentives have been widely documented as drivers of the irrational use of medicine (IUM), which significantly challenges the efficiency of health systems across the globe. However, there is limited understanding of the influence of each factor on IUM. We used detailed data on provider treatment of presumptive asthma cases in rural China to assess the contributions of provider knowledge, resource constraints, and provider behavior on IUM. This study enrolled 370 village providers from southwest China. All providers responded to a clinical vignette to test their knowledge of how to treat presumptive asthma. Resource constraints (“capacity”) were defined as the availability of the prescribed medicines in vignette. To measure provider behavior (“performance”), a subset of providers (104 of 370) were randomly selected to receive unannounced visits by standardized patients (SPs) who performed of presumptive asthma symptoms described in the vignette. We found that, 54% (201/370) of providers provided the vignette-based patients with prescriptions. Moreover, 67% (70/104) provided prescriptions for the SPs. For the vignette, only 10% of the providers prescribed the correct medicines; 38% prescribed only unnecessary medicines (and did not provide correct medicine); 65% prescribed antibiotics (although antibiotics were not required); and 55% prescribed polypharmacy prescriptions (that is, they prescribed five or more different types of drugs). For the SP visits, the numbers were 12%, 51%, 63%, and 0%, respectively. The lower number of medicines in the SP visits was due, in part, to the injections’ not being allowed based on ethical considerations (in response to the vignette, however, 65% of providers prescribed injections). The difference between provider knowledge and capacity is insignificant, while a significant large gap exists between provider performance and knowledge/capacity (for 11 of 17 indicators). Our analysis indicated that capacity constraints play a minor role in driving IUM compared to provider performance in the treatment of asthma cases in rural China. If similar findings hold for other disease cases, this suggests that policies to reduce the IUM in rural China have largely been unsuccessful, and alternatives for improving aligning provider incentives with appropriate drug use should be explored.
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Affiliation(s)
- Huidi Liu
- China Center for Agricultural Policy, School of Advanced Agricultural Sciences, Peking University, Beijing, China
| | - Huibo Li
- Department of Pharmacy, Peking University Third Hospital, Beijing, China.,Institute for Drug Evaluation, Peking University Health Science Center, Beijing, China
| | - Dirk E Teuwen
- Department of Neurology, Ghent University Hospital, Ghent, Belgium
| | - Sean Sylvia
- Department of Health Policy and Management and the Carolina Population Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Haonan Shi
- Business Development Center, Red Cross Society of China, Beijing, China
| | - Scott Rozelle
- Center on China's Economy and Institution, Stanford University, Stanford, CA, United States
| | - Hongmei Yi
- China Center for Agricultural Policy, School of Advanced Agricultural Sciences, Peking University, Beijing, China
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20
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Sylvia S, Ma X, Shi Y, Rozelle S. Ordeal mechanisms, information, and the cost-effectiveness of strategies to provide subsidized eyeglasses. J Health Econ 2022; 82:102594. [PMID: 35193056 PMCID: PMC9811338 DOI: 10.1016/j.jhealeco.2022.102594] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Revised: 01/26/2022] [Accepted: 01/26/2022] [Indexed: 05/14/2023]
Abstract
The cost-effectiveness of policies providing subsidized health goods is often compromised by limited use of the goods provided. Through a randomized trial involving 251 primary schools in western China, we tested two approaches to improve the cost-effectiveness of a program distributing free eyeglasses to myopic children. Relative to delivery of free eyeglasses to schools, we find that providing vouchers redeemable in local optical shops modestly improved the targeting of eyeglasses to those who would use them without reducing effective coverage. Information provided through a health education campaign increased eyeglass use when eyeglasses were delivered to schools, but had no effect when requiring voucher redemption or when families were only given a prescription for eyeglasses to be purchased on the market. Though most expensive, free delivery to schools with a health education campaign was the most socially cost-effective approach tested and increased effective coverage of eyeglasses by 18.5 percentage points after seven months.
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Affiliation(s)
- Sean Sylvia
- University of North Carolina at Chapel Hill, 135 Dauer Drive, 1101 McGavran-Greenberg Hall, CB #7411, Chapel Hill, NC 27599, United States.
| | - Xiaochen Ma
- Peking University, 112 Shu Wahh Building, 38 XueYuan Road, Haidian District, Beijing 100191, China.
| | - Yaojiang Shi
- Shaanxi Normal University, 620 Chang'an Road West, Xi'an 710119, China.
| | - Scott Rozelle
- Stanford University, 616 Serra Street, Encina Hall East Wing, Room 401, Stanford, CA 94305, United States.
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21
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Cheng W, Zhang Z, Hoelzer S, Tang W, Liang Y, Du Y, Xue H, Zhou Q, Yip W, Ma X, Tian J, Sylvia S. Evaluation of a village-based digital health kiosks program: A protocol for a cluster randomized clinical trial. Digit Health 2022; 8:20552076221129100. [PMID: 36211797 PMCID: PMC9537487 DOI: 10.1177/20552076221129100] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Accepted: 09/09/2022] [Indexed: 11/16/2022] Open
Abstract
Background To address disparities in healthcare quality and access between rural and
urban areas in China, reforms emphasize strengthening primary care and
digital health utilization. Yet, evidence on digital health approaches in
rural areas is lacking. Objective This study will evaluate the effectiveness of Guangdong Second Provincial
General Hospital's Digital Health Kiosk program, which uses the Dingbei
telemedicine platform to connect rural clinicians to physicians in
upper-level health facilities and provide access to artificial
intelligence-enabled diagnostic support. We hypothesize that our
interventions will increase healthcare utilization and patient satisfaction,
decrease out-of-pocket costs, and improve health outcomes. Methods This cluster randomized control trial will enroll clinics according to a
partial factorial design. Clinics will be randomized to either a control arm
with clinician medical training, a second arm additionally receiving Dingbei
telemedicine training, or a third arm with monetary incentives for patient
visits conducted through Dingbei plus all prior interventions. Clinics in
the second and third arm will then be orthogonally randomized to a social
marketing arm that targets villager awareness of the kiosk program. We will
use surveys and Dingbei administrative data to evaluate clinic utilization,
revenue, and clinician competency, as well as patient satisfaction and
expenses. Results We have received ethical approval from Guangdong Second Provincial General
Hospital (IRB approval number: GD2H-KY IRB-AF-SC.07-01.1), Peking University
(IRB00001052-21007), and the University of North Carolina at Chapel Hill
(323385). Study enrollment began April 2022. Conclusions This study has the potential to inform future telemedicine approaches and
assess telemedicine as a method to address disparities in healthcare
access. Trial registration number: ChiCTR2100053872
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Affiliation(s)
- Weibin Cheng
- Institute for the Application of Artificial Intelligence in Healthcare, Guangdong Second Provincial General Hospital, Guangzhou, China.,School of Data Science, City University of Hong Kong, Kowloon, Hong Kong
| | - Zhang Zhang
- Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, USA.,Carolina Population Center, University of North Carolina at Chapel Hill, Chapel Hill, USA
| | - Samantha Hoelzer
- Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, USA
| | - Weiming Tang
- Institute for the Application of Artificial Intelligence in Healthcare, Guangdong Second Provincial General Hospital, Guangzhou, China.,Carolina Population Center, University of North Carolina at Chapel Hill, Chapel Hill, USA.,Institute for Global Health and Infectious Disease, University of North Carolina at Chapel Hill, Chapel Hill, USA
| | - Yizhi Liang
- University of North Carolina at Chapel Hill Project-China, Guangzhou, China.,Department of Global Health and Population, Harvard University, Boston, USA
| | - Yumeng Du
- Institute for the Application of Artificial Intelligence in Healthcare, Guangdong Second Provincial General Hospital, Guangzhou, China.,University of North Carolina at Chapel Hill Project-China, Guangzhou, China
| | - Hao Xue
- Stanford Center for China's Economy and Institutions, Stanford University, Stanford, USA
| | - Qiru Zhou
- Internet Hospital, Guangdong Second Provincial General Hospital, Guangzhou, China
| | - Winnie Yip
- Department of Global Health and Population, Harvard University, Boston, USA
| | - Xiaochen Ma
- China Center for Health Development Studies, Peking University, Beijing, China
| | - Junzhang Tian
- Institute for the Application of Artificial Intelligence in Healthcare, Guangdong Second Provincial General Hospital, Guangzhou, China
| | - Sean Sylvia
- Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, USA.,Carolina Population Center, University of North Carolina at Chapel Hill, Chapel Hill, USA
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22
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Sylvia S, Luo R, Zhong J, Dill SE, Medina A, Rozelle S. Passive versus active service delivery: Comparing the effects of two parenting interventions on early cognitive development in rural China. World Dev 2022; 149:105686. [PMID: 34980940 PMCID: PMC8566276 DOI: 10.1016/j.worlddev.2021.105686] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Accepted: 08/27/2021] [Indexed: 06/14/2023]
Abstract
We present the results of a cluster-randomized controlled trial that evaluates the effects of a free, center-based parenting intervention on early cognitive development and parenting practices in 100 rural villages in China. We then compare these effects to a previous trial of a home-based intervention conducted in the same region, using the same parenting curriculum and public service system, accounting for potential differences between the studies. We find that the center-based intervention did not have a significant impact on child development outcomes, but did lead to increases in the material investments, time investments, and parenting skills of caregivers. The average impact of the center-based intervention on child skills and investments in children was significantly smaller than the home-visiting intervention. Analysis of the possible mechanisms suggests that the difference in effects was driven primarily by different patterns of selection into program participation.
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Affiliation(s)
- Sean Sylvia
- Gillings School of Global Public Health and Carolina Population Center, 1101-D McGavran-Greenberg Bldg., University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
| | - Renfu Luo
- China Center for Agricultural Policy, School of Advanced Agricultural Science, 409 Wangkezhen Bldg., Peking University, No. 5 Yiheyuan, Haidian District, Beijing, China
| | - Jingdong Zhong
- School of Economics, Peking University, No. 5 Yiheyuan, Haidian District, Beijing, China
| | - Sarah-Eve Dill
- Rural Education Action Program, Freeman Spogli Institute for International Studies, 616 Jane Stanford Way, Stanford University, Stanford, CA, USA
| | - Alexis Medina
- Rural Education Action Program, Freeman Spogli Institute for International Studies, 616 Jane Stanford Way, Stanford University, Stanford, CA, USA
| | - Scott Rozelle
- Rural Education Action Program, Freeman Spogli Institute for International Studies, 616 Jane Stanford Way, Stanford University, Stanford, CA, USA
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23
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Domino ME, Sylvia S, Green S. Nudging primary care providers to expand the opioid use disorder workforce. Health Serv Res 2021; 57:403-410. [PMID: 34648182 DOI: 10.1111/1475-6773.13894] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Revised: 07/21/2021] [Accepted: 07/25/2021] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVE To examine the responsiveness of primary care providers to pro-social and financial incentives to participate in a learning collaborative for the treatment of opioid use disorder (OUD). STUDY SETTING We conducted a statewide experiment in North Carolina from January 2019 to November 2019 to expand access to support for providers learning to treat opioid use disorder using different types of messaging and incentives. STUDY DESIGN We randomly assigned 15,835 primary care providers (physicians, nurse practitioners, and physician assistants) in North Carolina (NC) to receive one of four letters recruiting providers to participate in an online learning collaborative for providers learning to treat opioid use disorder. The four versions of the recruitment letters contained either pro-social messaging, mention of financial reimbursement for time spent in the learning collaborative, both, or neither. DATA COLLECTION We created a primary data source, tracking provider responses to the recruitment letters and emails. PRINCIPAL FINDINGS We found a 47.5% greater (p < 0.05) response rate using pro-social recruitment messaging that provided a greater description of the local conditions in each provider's region compared to the control group; this effect increased with higher overdose opioid death rates. Mention of financial reimbursement only modestly increased provider response rates. Some heterogeneity was observed by provider type, with NPs having the largest response to pro-social messaging. CONCLUSIONS Prosocial nudges had strong effects on efforts to enhance the behavioral health workforce in NC through participation in an ECHO for medication-assisted treatment (MAT) learning collaborative. The prosocial approach can and should be employed by states and professional societies in their efforts to create training programs for medication for OUD (MOUD), in order to expand access to lifesaving treatments for opioid use disorder.
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Affiliation(s)
- Marisa Elena Domino
- UNC Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA.,Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Sean Sylvia
- UNC Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA.,Carolina Population Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Sherri Green
- UNC Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA.,Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
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24
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You X, Gu J, Xu DR, Huang S, Xue H, Hao C, Ruan Y, Sylvia S, Liao J, Cai Y, Peng L, Wang X, Li R, Li J, Hao Y. Impact of the gate-keeping policies of China's primary healthcare model on the future burden of tuberculosis in China: a protocol for a mathematical modelling study. BMJ Open 2021; 11:e048449. [PMID: 34433597 PMCID: PMC8390147 DOI: 10.1136/bmjopen-2020-048449] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
INTRODUCTION In the past three decades, China has made great strides in the prevention and treatment of tuberculosis (TB). However, the TB burden remains high. In 2019, China accounted for 8.4% of global incident cases of TB, the third highest in the world, with a higher prevalence in rural areas. The Healthy China 2030 highlights the gate-keeping role of primary healthcare (PHC). However, the impact of PHC reforms on the future TB burden is unclear. We propose to use mathematical models to project and evaluate the impacts of different gate-keeping policies. METHODS AND ANALYSIS We will develop a deterministic, population-level, compartmental model to capture the dynamics of TB transmission within adult rural population. The model will incorporate seven main TB statuses, and each compartment will be subdivided by service providers. The parameters involving preference for healthcare seeking will be collected using discrete choice experiment (DCE) method. We will solve the deterministic model numerically over a 20-year (2021-2040) timeframe and predict the TB prevalence, incidence and cumulative new infections under the status quo or various policy scenarios. We will also conduct an analysis following standard protocols to calculate the average cost-effectiveness for each policy scenario relative to the status quo. A numerical calibration analysis against the available published TB prevalence data will be performed using a Bayesian approach. ETHICS AND DISSEMINATION Most of the data or parameters in the model will be obtained based on secondary data (eg, published literature and an open-access data set). The DCE survey has been reviewed and approved by the Ethics Committee of the School of Public Health, Sun Yat-sen University. The approval number is SYSU [2019]140. Results of the study will be disseminated through peer-reviewed journals, media and conference presentations.
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Affiliation(s)
- Xinyi You
- Department of Medical Statistics, School of Public Health, Sun Yat-Sen University, Guangzhou, Guangdong, China
| | - Jing Gu
- Department of Medical Statistics, School of Public Health, Sun Yat-Sen University, Guangzhou, Guangdong, China
- Sun Yat-Sen Global Health Institute, Sun Yat-Sen University, Guangzhou, Guangdong, China
| | - Dong Roman Xu
- ACACIA Labs, Institute for Global Health and School of Health Management, Southern Medical University, Guangzhou, Guangdong, China
| | - Shanshan Huang
- Centre for Tuberculosis Control of Guangdong Province, Guangzhou, Guangdong, China
| | - Hao Xue
- Stanford Center on China's Economy and Institutions, Stanford University, Stanford, California, USA
| | - Chun Hao
- Department of Medical Statistics, School of Public Health, Sun Yat-Sen University, Guangzhou, Guangdong, China
- Sun Yat-Sen Global Health Institute, Sun Yat-Sen University, Guangzhou, Guangdong, China
| | - Yunzhou Ruan
- Department of Tuberculosis Resistance Prevention and Control, Chinese Center for Disease Control and Prevention, Beijing, China
| | - Sean Sylvia
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, North Carolina, USA
| | - Jing Liao
- Department of Medical Statistics, School of Public Health, Sun Yat-Sen University, Guangzhou, Guangdong, China
| | - Yiyuan Cai
- Department of Medical Statistics, School of Public Health, Sun Yat-Sen University, Guangzhou, Guangdong, China
- Department of Epidemiology and Medical Statistics, School of Public Health, Guizhou Medical University, Guiyang, Guizhou, China
| | - Liping Peng
- Department of Medical Statistics, School of Public Health, Sun Yat-Sen University, Guangzhou, Guangdong, China
| | - Xiaohui Wang
- Department of Social Medicine and Health Management, School of Public Health, Lanzhou University, Lanzhou, Gansu, China
| | - Renzhong Li
- Department of Tuberculosis Resistance Prevention and Control, Chinese Center for Disease Control and Prevention, Beijing, China
| | - Jinghua Li
- Department of Medical Statistics, School of Public Health, Sun Yat-Sen University, Guangzhou, Guangdong, China
- Sun Yat-Sen Global Health Institute, Sun Yat-Sen University, Guangzhou, Guangdong, China
| | - Yuantao Hao
- Department of Medical Statistics, School of Public Health, Sun Yat-Sen University, Guangzhou, Guangdong, China
- Sun Yat-Sen Global Health Institute, Sun Yat-Sen University, Guangzhou, Guangdong, China
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25
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Emmers D, Jiang Q, Xue H, Zhang Y, Zhang Y, Zhao Y, Liu B, Dill SE, Qian Y, Warrinnier N, Johnstone H, Cai J, Wang X, Wang L, Luo R, Li G, Xu J, Liu M, Huang Y, Shan W, Li Z, Zhang Y, Sylvia S, Ma Y, Medina A, Rozelle S. Early childhood development and parental training interventions in rural China: a systematic review and meta-analysis. BMJ Glob Health 2021; 6:e005578. [PMID: 34417271 PMCID: PMC8381307 DOI: 10.1136/bmjgh-2021-005578] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Accepted: 06/19/2021] [Indexed: 11/26/2022] Open
Abstract
INTRODUCTION Inadequate care during early childhood can lead to long-term deficits in skills. Parenting programmes that encourage investment in young children are a promising tool for improving early development outcomes and long-term opportunities in low-income and middle-income regions, such as rural China. METHODS We conducted a systematic review and a meta-analysis to investigate the prevalence of early developmental delays and stimulating parenting practices as well as the effect of parental training programmes on child development outcomes in rural China. We obtained data in English from EconPapers, PubMed, PsycARTICLES, Cochrane Library, Web of Science and Scopus (Elsevier) and in Chinese from China National Knowledge Infrastructure, Wanfang Data and VIP Information. We conducted frequentist meta-analyses of aggregate data and estimated random-effects meta-regressions. Certainty of evidence was rated according to the Grading of Recommendations Assessment, Development and Evaluation approach. RESULTS We identified 19 observational studies on the prevalence of developmental delays and stimulating parenting practices for children under 5 years of age (n=19 762) and ten studies on the impact of parental training programmes on early child development (n=13 766). Children's risk of cognitive, language and social-emotional delays in the rural study sites (covering 14 provinces mostly in Central and Western China) was 45%, 46%, and 36%, respectively. Parental training programmes had a positive impact on child cognition, language and social-emotional development. CONCLUSION There is evidence to suggest that early developmental delay and the absence of stimulating parenting practices (ie, reading, storytelling and singing with children) may be prevalent across rural, low-income and middle-income regions in Central and Western China. Results support the effectiveness of parental training programmes to improve early development by encouraging parental engagement. TRIAL REGISTRATION NUMBER This study was registered with PROSPERO (CRD42020218852).
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Affiliation(s)
- Dorien Emmers
- LICOS Centre for Institutions and Economic Performance, KU Leuven, Leuven, Belgium
- Stanford Center on China's Economy and Institutions, Freeman Spogli Institute for International Studies & Stanford Institute for Economic Policy Research, Stanford University, Stanford, California, USA
| | - Qi Jiang
- Stanford Center on China's Economy and Institutions, Freeman Spogli Institute for International Studies & Stanford Institute for Economic Policy Research, Stanford University, Stanford, California, USA
| | - Hao Xue
- Stanford Center on China's Economy and Institutions, Freeman Spogli Institute for International Studies & Stanford Institute for Economic Policy Research, Stanford University, Stanford, California, USA
| | - Yue Zhang
- National Center for Women and Children Health, Chinese Center for Disease Control and Prevention, Beijing, China
| | - Yunting Zhang
- Child Health Advocacy Institute, Department of Developmental and Behavioral Pediatrics, National Children's Medical Center, Shanghai Children's Medical Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | | | - Bin Liu
- Xinhe Foundation, Beijing, China
| | - Sarah-Eve Dill
- Stanford Center on China's Economy and Institutions, Freeman Spogli Institute for International Studies & Stanford Institute for Economic Policy Research, Stanford University, Stanford, California, USA
| | - Yiwei Qian
- Department of Economics, University of Southern California, Los Angeles, California, USA
| | - Nele Warrinnier
- LICOS Centre for Institutions and Economic Performance, KU Leuven, Leuven, Belgium
- School of Economics and Finance, Queen Mary University of London, London, UK
| | - Hannah Johnstone
- Stanford Center on China's Economy and Institutions, Freeman Spogli Institute for International Studies & Stanford Institute for Economic Policy Research, Stanford University, Stanford, California, USA
| | - Jianhua Cai
- Administrators of Training Center of the National Health Commission of the PRC, Beijing, China
| | - Xiaoli Wang
- School of Public Health, Peking University Health Science Centre, Beijing, China
| | - Lei Wang
- International Business School, Shaanxi Normal University, Xi'an, Shaanxi, China
| | - Renfu Luo
- School of Advanced Agricultural Sciences, Peking University, Beijing, China
| | - Guirong Li
- International Center for Action Research on Education, Henan University School of Education, Kaifeng, Henan, China
| | - Jiajia Xu
- International Center for Action Research on Education, Henan University School of Education, Kaifeng, Henan, China
| | - Ming Liu
- Save the Children International China Program, Beijing, China
| | - Yaqing Huang
- Save the Children International China Program, Beijing, China
| | - Wenjie Shan
- Child Health Advocacy Institute, Department of Developmental and Behavioral Pediatrics, National Children's Medical Center, Shanghai Children's Medical Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Zhihui Li
- Child Health Advocacy Institute, Department of Developmental and Behavioral Pediatrics, National Children's Medical Center, Shanghai Children's Medical Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Vanke School of Public Health, Tsinghua University, Beijing, China
| | - Yu Zhang
- Hupan Modou Foundation, Hangzhou, China
| | - Sean Sylvia
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Yue Ma
- Stanford Center on China's Economy and Institutions, Freeman Spogli Institute for International Studies & Stanford Institute for Economic Policy Research, Stanford University, Stanford, California, USA
| | - Alexis Medina
- Stanford Center on China's Economy and Institutions, Freeman Spogli Institute for International Studies & Stanford Institute for Economic Policy Research, Stanford University, Stanford, California, USA
| | - Scott Rozelle
- Stanford Center on China's Economy and Institutions, Freeman Spogli Institute for International Studies & Stanford Institute for Economic Policy Research, Stanford University, Stanford, California, USA
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26
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Abstract
Nearly one-quarter of all children under age 2 in China are left behind in the countryside as parents migrate to urban areas for work. We use a four-wave longitudinal survey following young children from 6 to 30 months of age to provide first evidence on the effects of parental migration on development, health, and nutritional outcomes in the critical first stages of life. We find that maternal migration has a negative effect on cognitive development: migration before children reach 12 months of age reduces cognitive development by 0.3 standard deviations at age 2. Possible mechanisms include reduced dietary diversity and engagement in stimulating activities, both known to be causally associated with skill development in early life. We find no effects on other dimensions of physical and social-emotional health.
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Affiliation(s)
- Ai Yue
- Center for Experimental Economics in Education (CEEE), Shaanxi Normal University, No. 620 West Chang'an Avenue, Chang'an District, Xi'an, 710119, Shaanxi, China
| | - Yu Bai
- School of Economics, Minzu University of China, 27 Zhongguancun South Avenue, Beijing, China.
| | - Yaojiang Shi
- Center for Experimental Economics in Education (CEEE), Shaanxi Normal University, No. 620 West Chang'an Avenue, Chang'an District, Xi'an, 710119, Shaanxi, China
| | - Renfu Luo
- China Center for Agricultural Policy, School of Advanced Agricultural Sciences, Peking University, Beijing, China
| | - Scott Rozelle
- Freeman Spogli Institute for International Studies, Stanford University, Stanford, CA, USA
| | - Alexis Medina
- Freeman Spogli Institute for International Studies, Stanford University, Stanford, CA, USA
| | - Sean Sylvia
- Department of Health Policy and Management, Gillings School of Global Public Health and the Carolina Population Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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Wang H, Dill S, Zhou H, Ma Y, Xue H, Sylvia S, Smith K, Boswell M, Medina A, Loyalka P, Abby C, Friesen D, Rose N, Guo Y, Rozelle S. Health, economic, and social implications of COVID-19 for China's rural population. Agric Econ 2021; 52:495-504. [PMID: 34149132 PMCID: PMC8207079 DOI: 10.1111/agec.12630] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Accepted: 01/22/2021] [Indexed: 05/29/2023]
Abstract
This study examines the effects of local and nationwide COVID-19 disease control measures on the health and economy of China's rural population. We conducted phone surveys with 726 randomly selected village informants across seven rural Chinese provinces in February 2020. Four villages (0.55%) reported infections, and none reported deaths. Disease control measures had been universally implemented in all sample villages. About 74% of informants reported that villagers with wage-earning jobs outside the village had stopped working due to workplace closures. A higher percentage of rural individuals could not work due to transportation, housing, and other constraints. Local governments had taken measures to reduce the impact of COVID-19. Although schools in all surveyed villages were closed, 71% of village informants reported that students were attending classes online. Overall, measures to control COVID-19 appear to have been successful in limiting disease transmission in rural communities outside the main epidemic area. Rural Chinese citizens, however, have experienced significant economic consequences from the disease control measures.
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Affiliation(s)
- Huan Wang
- Stanford Center on China's Economy and InstitutionsStanford UniversityStanfordCaliforniaUSA
| | - Sarah‐Eve Dill
- Stanford Center on China's Economy and InstitutionsStanford UniversityStanfordCaliforniaUSA
| | - Huan Zhou
- West China School of Public HealthSichuan UniversitySichuanP.R. China
| | - Yue Ma
- Stanford Center on China's Economy and InstitutionsStanford UniversityStanfordCaliforniaUSA
| | - Hao Xue
- Stanford Center on China's Economy and InstitutionsStanford UniversityStanfordCaliforniaUSA
| | - Sean Sylvia
- Gillings School of Global Public HealthUniversity of North Carolina at Chapel HillNorth CarolinaUSA
| | - Kumi Smith
- University of MinnesotaMinneapolisMinnesotaUSA
| | - Matthew Boswell
- Stanford Center on China's Economy and InstitutionsStanford UniversityStanfordCaliforniaUSA
| | - Alexis Medina
- Stanford Center on China's Economy and InstitutionsStanford UniversityStanfordCaliforniaUSA
| | - Prashant Loyalka
- Stanford Center on China's Economy and InstitutionsStanford UniversityStanfordCaliforniaUSA
| | - Cody Abby
- Stanford Center on China's Economy and InstitutionsStanford UniversityStanfordCaliforniaUSA
| | - Dimitris Friesen
- Stanford Center on China's Economy and InstitutionsStanford UniversityStanfordCaliforniaUSA
| | - Nathan Rose
- Stanford Center on China's Economy and InstitutionsStanford UniversityStanfordCaliforniaUSA
| | - Yian Guo
- Stanford Center on China's Economy and InstitutionsStanford UniversityStanfordCaliforniaUSA
| | - Scott Rozelle
- Stanford Center on China's Economy and InstitutionsStanford UniversityStanfordCaliforniaUSA
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Li R, Rose N, Zheng YM, Chen Y, Sylvia S, Wilson-Smith H, Medina A, Dill SE, Rozelle S. Early Childhood Reading in Rural China and Obstacles to Caregiver Investment in Young Children: A Mixed-Methods Analysis. Int J Environ Res Public Health 2021; 18:1457. [PMID: 33557178 PMCID: PMC7913908 DOI: 10.3390/ijerph18041457] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Revised: 01/27/2021] [Accepted: 02/01/2021] [Indexed: 11/16/2022]
Abstract
Studies have shown that nearly half of rural toddlers in China have cognitive delays due to an absence of stimulating parenting practices, such as early childhood reading, during the critical first three years of life. However, few studies have examined the reasons behind these low levels of stimulating parenting, and no studies have sought to identify the factors that limit caregivers from providing effective early childhood reading practices (EECRP). This mixed-methods study investigates the perceptions, prevalence, and correlates of EECRP in rural China, as well as associations with child cognitive development. We use quantitative survey results from 1748 caregiver-child dyads across 100 rural villages/townships in northwestern China and field observation and interview data with 60 caregivers from these same sites. The quantitative results show significantly low rates of EECRP despite positive perceptions of early reading and positive associations between EECRP and cognitive development. The qualitative results suggest that low rates of EECRP in rural China are not due to the inability to access books, financial or time constraints, or the absence of aspirations. Rather, the low rate of book ownership and absence of reading to young children is driven by the insufficient and inaccurate knowledge of EECRP among caregivers, which leads to their delayed, misinformed reading decisions with their young children, ultimately contributing to developmental delays.
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Affiliation(s)
- Rui Li
- Rural Education Action Program (REAP), Freeman Spogli Institute for International Studies, Stanford University, Stanford, CA 94305, USA; (R.L.); (N.R.); (Y.M.Z.); (H.W.-S.); (A.M.); (S.R.)
| | - Nathan Rose
- Rural Education Action Program (REAP), Freeman Spogli Institute for International Studies, Stanford University, Stanford, CA 94305, USA; (R.L.); (N.R.); (Y.M.Z.); (H.W.-S.); (A.M.); (S.R.)
| | - Yi Ming Zheng
- Rural Education Action Program (REAP), Freeman Spogli Institute for International Studies, Stanford University, Stanford, CA 94305, USA; (R.L.); (N.R.); (Y.M.Z.); (H.W.-S.); (A.M.); (S.R.)
| | - Yunwei Chen
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA; (Y.C.); (S.S.)
| | - Sean Sylvia
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA; (Y.C.); (S.S.)
| | - Henry Wilson-Smith
- Rural Education Action Program (REAP), Freeman Spogli Institute for International Studies, Stanford University, Stanford, CA 94305, USA; (R.L.); (N.R.); (Y.M.Z.); (H.W.-S.); (A.M.); (S.R.)
| | - Alexis Medina
- Rural Education Action Program (REAP), Freeman Spogli Institute for International Studies, Stanford University, Stanford, CA 94305, USA; (R.L.); (N.R.); (Y.M.Z.); (H.W.-S.); (A.M.); (S.R.)
| | - Sarah-Eve Dill
- Rural Education Action Program (REAP), Freeman Spogli Institute for International Studies, Stanford University, Stanford, CA 94305, USA; (R.L.); (N.R.); (Y.M.Z.); (H.W.-S.); (A.M.); (S.R.)
| | - Scott Rozelle
- Rural Education Action Program (REAP), Freeman Spogli Institute for International Studies, Stanford University, Stanford, CA 94305, USA; (R.L.); (N.R.); (Y.M.Z.); (H.W.-S.); (A.M.); (S.R.)
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Zhang J, Xu J, Wang H, Huang X, Chen Y, Wang H, Chu Z, Hu Q, He X, Li Y, Zhang L, Hu Z, Bao R, Li S, Li H, Ding H, Jiang Y, Geng W, Sylvia S, Shang H. Preference for daily versus on-demand pre-exposure prophylaxis for HIV and correlates among men who have sex with men: the China Real-world Oral PrEP Demonstration study. J Int AIDS Soc 2021; 24:e25667. [PMID: 33586841 PMCID: PMC7883476 DOI: 10.1002/jia2.25667] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Revised: 01/09/2021] [Accepted: 01/13/2021] [Indexed: 12/15/2022] Open
Abstract
INTRODUCTION This study explores the preference for daily versus on-demand pre-exposure prophylaxis (PrEP) among men who have sex with men (MSM) in developing countries when both regimens are available. METHODS From 11 December 2018 to 19 October 2019, we recruited MSM for an open-label real-world PrEP demonstration study in four major cities in China. Subjects selected their preferred PrEP (oral tenofovir/emtricitabine) regimen (daily vs. on-demand) at recruitment and underwent on-site screening before initiation of PrEP. We used logistic regression to assess preference for daily PrEP and correlates. RESULTS Of 1933 recruited MSM, the median age was 29 years, 7.6% was currently married to or living with a female; the median number of male sexual partners was four and 6.1% had used post-exposure prophylaxis (PEP) in the previous six months. HIV infection risk was subjectively determined as very high (>75%) in 7.0% of subjects, high (50% to 75%) in 13.3%, moderate (25% to 49%) in 31.5% and low or none (0% to 24%) in 48.1%. On average, participants preferred on-demand PrEP over daily PrEP (1104 (57.1%) versus 829 (42.9%)) at recruitment. In multivariable analysis, currently being married to or living with a female was associated with 14.6 percentage points lower preference for daily PrEP (marginal effect = -0.146 [95% CI: -0.230, -0.062], p = 0.001); whereas the number of male sexual partners (marginal effect = 0.003 [95% CI: 0.000, 0.005], p = 0.034) and a subjective assessment of being very high risk of HIV infection (vs. low and no risk, marginal effect size = 0.105 [95% CI: 0.012, 0.198], p = 0.027) were associated with increased preference for daily versus on-demand PrEP. Among the 1933 potential participants, 721 (37.3%) did not attend the subsequent on-site screening. Lower-income, lower education level, lower subjective expected risk of HIV infection risk and younger age positively correlated with the absence of on-site screening. CONCLUSIONS MSM in China prefer both daily and on-demand PrEP when both regimens are provided free. Social structural factors and subjective risk of HIV infection have significant impacts on PrEP preference and use. The upcoming national PrEP guideline should consider incorporating both regimens and the correlates to help implement PrEP in China.
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Wang H, Zhang M, Li R, Zhong O, Johnstone H, Zhou H, Xue H, Sylvia S, Boswell M, Loyalka P, Rozelle S. Tracking the effects of COVID-19 in rural China over time. Int J Equity Health 2021; 20:35. [PMID: 33446205 PMCID: PMC7807215 DOI: 10.1186/s12939-020-01369-z] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Accepted: 12/22/2020] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND China issued strict nationwide guidelines to combat the COVID-19 outbreak in January 2020 and gradually loosened the restrictions on movement in early March. Little is known about how these disease control measures affected the 600 million people who live in rural China. The goal of this paper is to document the quarantine measures implemented in rural China outside the epicenter of Hubei Province and to assess the socioeconomic effect of the measures on rural communities over time. METHODS We conducted three rounds of interviews with informants from 726 villages in seven provinces, accounting for over 25% of China's overall rural population. The survey collected data on rural quarantine implementation; COVID-19 infections and deaths in the survey villages; and effects of the quarantine on employment, income, education, health care, and government policies to address any negative impacts. The empirical findings of the work established that strict quarantine measures were implemented in rural villages throughout China in February. RESULTS There was little spread of COVID-19 in rural communities: an infection rate of 0.001% and zero deaths reported in our sample. However, there were negative social and economic outcomes, including high rates of unemployment, falling household income, rising prices, and disrupted student learning. Health care was generally accessible, but many delayed their non-COVID-19 health care due to the quarantine measures. Only 20% of villagers received any form of local government aid, and only 11% of villages received financial subsidies. There were no reports of national government aid programs that targeted rural villagers in the sample areas. CONCLUSIONS By examining the economic and social effects of the COVID-19 restrictions in rural communities, this study will help to guide other middle- and low-income countries in their containment and restorative processes. Without consideration for economically vulnerable populations, economic hardships and poverty will likely continue to have a negative impact on the most susceptible communities.
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Affiliation(s)
- Huan Wang
- Freeman Spogli Institute for International Studies, Stanford University, 616 Jane Stanford Way, Stanford, California, 94305, USA
| | - Markus Zhang
- Freeman Spogli Institute for International Studies, Stanford University, 616 Jane Stanford Way, Stanford, California, 94305, USA
| | - Robin Li
- Freeman Spogli Institute for International Studies, Stanford University, 616 Jane Stanford Way, Stanford, California, 94305, USA
| | - Oliver Zhong
- Freeman Spogli Institute for International Studies, Stanford University, 616 Jane Stanford Way, Stanford, California, 94305, USA
| | - Hannah Johnstone
- Freeman Spogli Institute for International Studies, Stanford University, 616 Jane Stanford Way, Stanford, California, 94305, USA
| | - Huan Zhou
- West China School of Public Health, Sichuan University, No. 17, Section 3 Ren Min South Road, Chengdu, Sichuan Province, People's Republic of China.
| | - Hao Xue
- Freeman Spogli Institute for International Studies, Stanford University, 616 Jane Stanford Way, Stanford, California, 94305, USA
| | - Sean Sylvia
- Gillings School of Global Public Health, University of North Carolina at Chapel Hill, 1101D McGavran-Greenberg Hall, CB#7411, Chapel Hill, NC, 27599-7411, USA
| | - Matthew Boswell
- Freeman Spogli Institute for International Studies, Stanford University, 616 Jane Stanford Way, Stanford, California, 94305, USA
| | - Prashant Loyalka
- Freeman Spogli Institute for International Studies, Stanford University, 616 Jane Stanford Way, Stanford, California, 94305, USA
| | - Scott Rozelle
- Freeman Spogli Institute for International Studies, Stanford University, 616 Jane Stanford Way, Stanford, California, 94305, USA
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Yi H, Liu H, Wang Z, Xue H, Sylvia S, Shi H, Teuwen DE, Han Y, Qin J. The competence of village clinicians in the diagnosis and management of childhood epilepsy in Southwestern China and its determinants: A cross-sectional study. Lancet Reg Health West Pac 2020; 3:100031. [PMID: 34327383 PMCID: PMC8315368 DOI: 10.1016/j.lanwpc.2020.100031] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Revised: 09/09/2020] [Accepted: 09/10/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND Due to lack of neurologists in low- and middle-income countries, communities of patients living with epilepsy are calling for task-shifting of diagnosis and management from physicians to paramedical providers in the primary health care systems to narrow the huge treatment gap. Evidence to guide this work has been limited. This study assesses the competence of village clinicians (VC)- mostly paramedical providers- in the diagnosis and management of a presumptive case of childhood epilepsy and its determinants. METHODS A cross-sectional study was conducted in rural areas of a province in Southwestern China from July 2017 to January 2018. We randomly selected 370 VCs who practiced Western medicine and assumed the main responsibility of providing medical services in his/her clinic. A standardized clinical vignette based on national clinical practice guidelines was used to evaluate clinicians' competence in three domains: number and proportion of recommended (and essential) checklist (questions, examinations, and tests) completed, correctness of diagnosis, and correctness of case management. FINDINGS Though VCs completed 14•3% (IQR 9•5%-19•1%) of the recommended checklist, 63•2% (234/370, 95%CI 58•2%-68•0%) provided a correct diagnosis. Only 1•6% of VCs (6/370, 95%CI 0•7%-3•5%) gave correct management with both correct medication and referral, however 90•3% (334/370, 95%CI 86•8%-92•9%) provided partially correct management by referring patients to upper-level health facilities (89•5%, 331/370, 95%CI 85•9%-92•2%) or prescribing anti-epileptic drugs (AEDs) correctly (0•8%, 3/370, 95%CI 0•3%-2•4%). Around 1/4 VCs referred patients to Township Health Centers which usually were not staffed with pediatric neurologists. Fewer provided helpful medical advice to patients for daily management. The heuristic process was found to be negatively associated with the proportion of the recommended checklist that VCs completed, which is positively associated with correctness of diagnosis. INTERPRETATION Most VCs could diagnose and refer childhood epilepsy patients correctly; however, they lacked competence when it came to assuming the responsibility of primary care providers, referring efficiently, refilling AEDs, as well as supervising and instructing daily management of patients. FUNDING HY received the funding for this study from the "Health and Hope Fund" of the Business Development Center of the RCSC (Beijing) and UCB (Belgium). UCB provided support in the form of a salary for author DET.
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Affiliation(s)
- Hongmei Yi
- China Center for Agricultural Policy, School of Advanced Agricultural Sciences, Peking University, Room 408B, Wangkezhen Building, No. 5, Yiheyuan Road, Haidian, Beijing 100871, China
| | - Huidi Liu
- China Center for Agricultural Policy, School of Advanced Agricultural Sciences, Peking University, Room 408B, Wangkezhen Building, No. 5, Yiheyuan Road, Haidian, Beijing 100871, China
| | - Zhiping Wang
- Shanghai Children's Medical Center, Shanghai, China
| | - Hao Xue
- Stanford University, Stanford, CA, USA
| | - Sean Sylvia
- Department of Health Policy and Management and the Carolina Population Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Haonan Shi
- Business Development Center, Red Cross Society of China, Beijing, China
| | - Dirk E. Teuwen
- Corporate Societal Responsibility, UCB, Brussels, Belgium
| | - Ying Han
- Peking University First Hospital, Beijing, China
| | - Jiong Qin
- Peking University People's Hospital, Beijing, China
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Guo W, Sylvia S, Umble K, Chen Y, Zhang X, Yi H. The competence of village clinicians in the diagnosis and treatment of heart disease in rural China: A nationally representative assessment. Lancet Reg Health West Pac 2020; 2:100026. [PMID: 34327377 PMCID: PMC8315592 DOI: 10.1016/j.lanwpc.2020.100026] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Revised: 08/27/2020] [Accepted: 09/02/2020] [Indexed: 02/06/2023]
Abstract
Background While strengthening primary care quality is key to China's health system reforms, evidence to guide this work has been limited, particularly for rural areas. This study provides the first nationally-representative assessment of village doctors’ competence in diagnosing and managing presumptive heart disease. Methods A cross-sectional study of village clinics was conducted across five provinces. We presented standardized clinical vignettes to evaluate clinicians’ competence in diagnosing and managing unstable angina. Enumerators accompanying mock patients documented the interaction, including questions, physical examinations, diagnoses, and management options provided by the doctor. We measured diagnostic process competence as adherence to “recommended” questions and examinations based on national clinical practice guidelines, diagnostic competence according to whether clinicians provided a correct diagnosis, and management as correct medication and/or referral. Management was assessed twice: following clinicians’ own diagnoses determined through questioning and examinations, and after enumerators provided doctors with the correct diagnosis. Findings Clinicians completed 26% (95% CI 24% to 28%) of recommended diagnostic questions and examinations; 20% (14% to 27%) arrived at a correct diagnosis. Rates of correct management were 43% (35% to 51%) following clinicians’ own diagnosis and 51% (43% to 59%) after being given the correct diagnosis. When given the correct diagnosis and only asked to provide treatment, clinicians prescribed 82% fewer potentially harmful medications than in treatments based on their own (potentially incorrect) diagnosis. Interpretation The ability of village doctors to diagnose a textbook case of unstable angina is limited. Deficits in diagnostic competence led to low rates of correct management.
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Affiliation(s)
- Wilson Guo
- Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, United States
| | - Sean Sylvia
- Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, United States
| | - Karl Umble
- Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, United States
| | - Yunwei Chen
- Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, United States
| | - Xiaoyuan Zhang
- Charles H. Dyson School of Applied Economics and Management, Cornell University, Ithaca, NY, United States
| | - Hongmei Yi
- School of Advanced Agricultural Sciences, Peking University, Room 408B, Wangkezhen Building, No. 5, Yiheyuan Road, Haidian, Beijing 100871, China
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Fu P, Wang Y, Liu S, Li J, Gao Q, Zhou C, Meng Q, Sylvia S. Analysing the preferences for family doctor contract services in rural China: a study using a discrete choice experiment. BMC Fam Pract 2020; 21:148. [PMID: 32711467 PMCID: PMC7382837 DOI: 10.1186/s12875-020-01223-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/09/2019] [Accepted: 07/15/2020] [Indexed: 11/10/2022]
Abstract
BACKGROUND Preliminary evaluations have found that family doctor contract services (FDCSs) have significantly controlled medical expenses, better managed chronic diseases, and increased patient satisfaction and service compliance. In 2016, China proposed the establishment of a family doctor system to carry out contract services, but studies have found the uptake and utilization of these services to be limited. This study aimed to investigate rural residents' preferences for FDCSs from the perspective of the Chinese public. METHODS A discrete choice experiment (DCE) was performed to elicit the preferences for FDCSs among rural residents in China. Attributes and levels were established based on a literature review and qualitative methods. Five attributes, i.e., cost, medicine availability, the reimbursement rate, family doctor competence, and family doctor attitude, were evaluated using a mixed logit model. RESULTS A total of 609 residents were included in the main DCE analysis. The respondents valued the high competence (coefficient 2.44, [SE 0.13]) and the good attitude (coefficient 1.42, [SE 0.09]) of family doctors the most. Cost was negatively valued (coefficient - 0.01, [SE 0.01]), as expected. Preference heterogeneity analysis was conducted after adjusting the interaction terms, and we found that rural residents with higher educational attainment prefer a good attitude more than their counterparts with lower educational attainment. The estimated willingness to pay (WTP) for "high" relative to "low" competence was 441.13 RMB/year, and the WTP for a provider with a "good" attitude relative to a "poor" attitude was 255.77 RMB/year. CONCLUSION The present study suggests that strengthening and improving the quality of primary health care, including the competence and attitudes of family doctors, should be prioritized to increase the uptake of FDCSs. The contract service package, including the annual cost, the insurance reimbursement rate and individualized services, should be redesigned to be congruent with residents having different health statuses and their stated preferences.
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Affiliation(s)
- Peipei Fu
- NHC Key Laboratory of Health Economics and Policy Research, School of Health Care Management, Shandong University, Jinan, 250012 China
| | - Yi Wang
- School of Public Health, Shandong University, Jinan, 250012 China
| | - Shimeng Liu
- Key Lab of Health Technology Assessment, National Health Comission, School of Public Health, Fudan University, Shanghai, China
| | - Jiajia Li
- School of Public Health, Shandong University, Jinan, 250012 China
| | - Qiufeng Gao
- Center for Experimental Economics in Education, Shaanxi Normal University, Xi’an, China
| | - Chengchao Zhou
- Key Lab of Health Economics and Policy Research, School of Public Health, Shandong University, 44 Wen-hua-xi Road, Jinan, 250012 Shandong China
| | - Qingyue Meng
- China Center for Health Development Studies, Peking University, No. 38 Xueyuan Road, Haidian District, Beijing, 100191 China
| | - Sean Sylvia
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina USA
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Jackson KD, Higgins CR, Laing SK, Mwila C, Kobayashi T, Ippolito MM, Sylvia S, Ozawa S. Impact of substandard and falsified antimalarials in Zambia: application of the SAFARI model. BMC Public Health 2020; 20:1083. [PMID: 32646393 PMCID: PMC7350731 DOI: 10.1186/s12889-020-08852-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2020] [Accepted: 05/05/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Many countries are striving to become malaria-free, but global reduction in case estimates has stagnated in recent years. Substandard and falsified medicines may contribute to this lack of progress. Zambia aims to eliminate their annual burden of 1.2 million pediatric malaria cases and 2500 child deaths due to malaria. We examined the health and economic impact of poor-quality antimalarials in Zambia. METHODS An agent-based model, Substandard and Falsified Antimalarial Research Impact (SAFARI), was modified and applied to Zambia. The model was developed to simulate population characteristics, malaria incidence, patient care-seeking, disease progression, treatment outcomes, and associated costs of malaria for children under age five. Zambia-specific demographic, epidemiological, and cost inputs were extracted from the literature. Simulations were run to estimate the health and economic impact of poor-quality antimalarials, the effect of potential artemisinin resistance, and six additional malaria focused policy interventions. RESULTS We simulated annual malaria cases among Zambian children under five. At baseline, we found 2610 deaths resulting in $141.5 million in annual economic burden of malaria. We estimated that elimination of substandard and falsified antimalarials would result in an 8.1% (n = 213) reduction in under-five deaths, prevent 937 hospitalizations, and realize $8.5 million in economic savings, annually. Potential artemisinin resistance could further increase deaths by 6.3% (n = 166) and cost an additional $9.7 million every year. CONCLUSIONS Eliminating substandard and falsified antimalarials is an important step towards a malaria-free Zambia. Beyond the dissemination of insecticide-treated bed nets, indoor residual spraying, and other malaria control measures, attention must also be paid to assure the quality of antimalarial treatments.
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Affiliation(s)
- Kathryn D Jackson
- Department of Health Policy and Management, UNC Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC, USA
| | - Colleen R Higgins
- Division of Practice Advancement and Clinical Education, UNC Eshelman School of Pharmacy, University of North Carolina, CB#7574, Beard Hall, 115H, Chapel Hill, NC, 27599, USA
| | - Sarah K Laing
- Duke Global Health Institute, Duke University, Durham, NC, USA
| | - Chiluba Mwila
- Department of Pharmacy, School of Health Sciences, University of Zambia, Lusaka, Zambia
| | - Tamaki Kobayashi
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.,Malaria Research Institute, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Matthew M Ippolito
- Malaria Research Institute, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.,Division of Clinical Pharmacology and Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Sean Sylvia
- Department of Health Policy and Management, UNC Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC, USA.,Carolina Population Center, University of North Carolina, Chapel Hill, NC, USA
| | - Sachiko Ozawa
- Division of Practice Advancement and Clinical Education, UNC Eshelman School of Pharmacy, University of North Carolina, CB#7574, Beard Hall, 115H, Chapel Hill, NC, 27599, USA. .,Department of Maternal and Child Health, UNC Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC, USA.
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Yi H, Wu P, Zhang X, Teuwen DE, Sylvia S. Market competition and demand for skills in a credence goods market: Evidence from face-to-face and web-based non-physician clinician training in rural China. PLoS One 2020; 15:e0233955. [PMID: 32555610 PMCID: PMC7302647 DOI: 10.1371/journal.pone.0233955] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2020] [Accepted: 05/13/2020] [Indexed: 11/19/2022] Open
Abstract
Background Non-physician clinicians (NPCs) providing services in functionally private markets account for a large share of the workforce in the primary care system in many low-income and middle-income countries. Although regular in-service training is believed to be crucial to updating NPCs’ professional knowledge, skills, and practices, participation rates are often low. Low participation may result from the “credence good” nature of the market for primary care: if patients are unable to observe quality improvements from training, NPCs have weaker incentives to participate. Empirical evidence is limited on the relationship between market competition and NPC participation in-service training as well as how participation varies with the type of training available. Methods The study uses a dataset of 301 NPCs from three prefectures in Yunnan, a province in southwest China, collected in July 2017. Logistic regression is used to estimate the relationship between competition and NPC’s participation in in-service training. We assess the relationship between participation and both the quantity of competition (number of competitors in the same village and surrounding villages) and the quality of competition (proxied using characteristics of competing clinicians). Results In 2016, nearly two thirds of NPCs participated in face-to-face or web-based in-service trainings at least once. Specifically, 58 percent of NPCs participated in face-to-face in-service trainings, and 24 percent of NPCs participated in web-based in-service trainings. The quantity of competitors is unrelated to participation in in-service training. The quality of competition is not related to face-to-face training but has a significant positive relationship with participation in web-based training. Conclusions Web-based trainings may be a better approach to increase NPC skills in developing country primary care markets.
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Affiliation(s)
- Hongmei Yi
- China Center for Agricultural Policy, School of Advanced Agricultural Sciences, Peking University, Beijing, China
- * E-mail:
| | - Paiou Wu
- China Center for Agricultural Policy, School of Advanced Agricultural Sciences, Peking University, Beijing, China
| | - Xiaoyuan Zhang
- Charles H. Dyson School of Applied Economics and Management, Cornell University, Ithaca, New York, United States of America
| | - Dirk E. Teuwen
- Corporate Societal Responsibility, UCB, Brussels, Belgium
| | - Sean Sylvia
- Department of Health Policy and Management and the Carolina Population Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
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Nie J, Zhang L, Gao J, Li J, Zhou Q, Shi Y, Sylvia S, Congdon N. Using incognito standardised patients to evaluate quality of eye care in China. Br J Ophthalmol 2020; 105:311-316. [DOI: 10.1136/bjophthalmol-2019-315103] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2019] [Revised: 03/08/2020] [Accepted: 04/17/2020] [Indexed: 11/03/2022]
Abstract
Background/aimsFew studies have objectively examined the quality of eye care in China. We assessed refractive care using the incognito standardised patient (SP) approach, a gold standard for evaluating clinical practice.MethodsA total of 52 SPs were trained to provide standardised responses during eye examinations, and underwent automated and non-cycloplegic, subjective refraction by a senior ophthalmologist from Zhongshan Ophthalmologic Center, a national-level clinical and research centre. SPs subsequently received subjective refraction and eye exams at a randomly selected sample of 40 public hospitals and 93 private optical shops in Shaanxi, Northwestern China. Difference between expert and local refraction in the better-seeing eye was calculated by the vector diopteric method, and completeness of exams assessed against national standards. SP and provider demographic information and provider clinical experience were recorded.ResultsSPs (n=52, mean (range) age, 25.7 (22–31) years, 28.8% male) underwent 133 eye exams (mean total duration 15.0±11.7 min) by 133 local refractionists (24–60 years, 30.3% male). Only 93 (69.9%), 121 (91.0%) and 104 (78.2%) of local refractionists assessed vision, automated and subjective refraction, respectively. The median inaccuracy was −0.25 diopters (D), while 25.6% of results differed by an absolute value of ≥1.0 D and 6.0% by ≥2.0 D. Predictors of inaccurate refraction included spectacle power <−6.0 D (OR=2.66; 95% CI, 1.27 to 5.56), service at a public (vs private) hospital (OR=2.01; 95% CI, 1.11 to 3.63) and provider male sex (OR=2.03; 95% CI, 1.11 to 3.69).ConclusionInaccurate refractions are common in Northwestern China, particularly in public facilities. Important assessments, including subjective refraction, are frequently omitted.
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Adhikari SP, Meng S, Wu YJ, Mao YP, Ye RX, Wang QZ, Sun C, Sylvia S, Rozelle S, Raat H, Zhou H. Epidemiology, causes, clinical manifestation and diagnosis, prevention and control of coronavirus disease (COVID-19) during the early outbreak period: a scoping review. Infect Dis Poverty 2020; 9:29. [PMID: 32183901 PMCID: PMC7079521 DOI: 10.1186/s40249-020-00646-x] [Citation(s) in RCA: 1037] [Impact Index Per Article: 259.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Accepted: 03/05/2020] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND The coronavirus disease (COVID-19) has been identified as the cause of an outbreak of respiratory illness in Wuhan, Hubei Province, China beginning in December 2019. As of 31 January 2020, this epidemic had spread to 19 countries with 11 791 confirmed cases, including 213 deaths. The World Health Organization has declared it a Public Health Emergency of International Concern. METHODS A scoping review was conducted following the methodological framework suggested by Arksey and O'Malley. In this scoping review, 65 research articles published before 31 January 2020 were analyzed and discussed to better understand the epidemiology, causes, clinical diagnosis, prevention and control of this virus. The research domains, dates of publication, journal language, authors' affiliations, and methodological characteristics were included in the analysis. All the findings and statements in this review regarding the outbreak are based on published information as listed in the references. RESULTS Most of the publications were written using the English language (89.2%). The largest proportion of published articles were related to causes (38.5%) and a majority (67.7%) were published by Chinese scholars. Research articles initially focused on causes, but over time there was an increase of the articles related to prevention and control. Studies thus far have shown that the virus' origination is in connection to a seafood market in Wuhan, but specific animal associations have not been confirmed. Reported symptoms include fever, cough, fatigue, pneumonia, headache, diarrhea, hemoptysis, and dyspnea. Preventive measures such as masks, hand hygiene practices, avoidance of public contact, case detection, contact tracing, and quarantines have been discussed as ways to reduce transmission. To date, no specific antiviral treatment has proven effective; hence, infected people primarily rely on symptomatic treatment and supportive care. CONCLUSIONS There has been a rapid surge in research in response to the outbreak of COVID-19. During this early period, published research primarily explored the epidemiology, causes, clinical manifestation and diagnosis, as well as prevention and control of the novel coronavirus. Although these studies are relevant to control the current public emergency, more high-quality research is needed to provide valid and reliable ways to manage this kind of public health emergency in both the short- and long-term.
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Affiliation(s)
- Sasmita Poudel Adhikari
- West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, China
| | - Sha Meng
- West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, China
| | - Yu-Ju Wu
- West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, China
| | - Yu-Ping Mao
- Department of Communication Studies, California State University, Long Beach, CA, 90802, USA
| | - Rui-Xue Ye
- West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, China
| | - Qing-Zhi Wang
- West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, China
| | - Chang Sun
- West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, China
| | - Sean Sylvia
- Health Policy and Management, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Scott Rozelle
- Freeman Spogli Institute for International Studies, Stanford University, Stanford, CA, USA
| | - Hein Raat
- Department of Public Health, Erasmus MC-University Medical Center Rotterdam, 3000, CA, Rotterdam, The Netherlands
| | - Huan Zhou
- West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, China.
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Luo R, Miller G, Rozelle S, Sylvia S, Vera-Hernández M. Can Bureaucrats Really Be Paid Like Ceos? Substitution Between Incentives and Resources Among School Administrators in China. J Eur Econ Assoc 2020; 18:165-201. [PMID: 32161517 PMCID: PMC7053554 DOI: 10.1093/jeea/jvy047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Unlike performance incentives for private sector managers, little is known about performance incentives for managers in public sector bureaucracies. Through a randomized trial in rural China, we study performance incentives rewarding school administrators for reducing student anemia-as well as complementarity between incentives and orthogonally assigned discretionary resources. Large (but not small) incentives and unrestricted grants both reduced anemia, but incentives were more cost-effective. Although unrestricted grants and small incentives do not interact, grants fully crowd-out the effect of larger incentives. Our findings suggest that performance incentives can be effective in bureaucratic environments, but they are not complementary to discretionary resources.
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Cai R, Tang J, Deng C, Lv G, Xu X, Sylvia S, Pan J. Violence against health care workers in China, 2013-2016: evidence from the national judgment documents. Hum Resour Health 2019; 17:103. [PMID: 31878939 PMCID: PMC6933725 DOI: 10.1186/s12960-019-0440-y] [Citation(s) in RCA: 45] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/26/2019] [Accepted: 12/02/2019] [Indexed: 06/10/2023]
Abstract
BACKGROUND Incidents of patient-initiated workplace violence against health care workers have been a subject of substantial public attention in China. Patient-initiated violence not only represents a risk of harm to health care providers but is also indicative of general tensions between doctors and patients which pose a challenge to improving health system access and quality. This study aims to provide a systematic, national-level characterization of serious workplace violence against health care workers in China. METHODS This study extracted data from the China Judgment Online System, a comprehensive database of judgment documents. Three key phrases, "criminal case," "health care institution," and "health care worker" were used to search the China Judgment Online System for relevant cases between January 1, 2013, and December 31, 2016. Data extracted from identified cases was used to document the occurrence, the degree of risk, and the factors associated with serious workplace violence. RESULTS In total, 459 criminal cases involving patient-initiated workplace violence against health care workers in China were reported and processed. The analysis revealed geographic heterogeneity in the occurrence of serious workplace violence, with lower incidence in western provinces compared to central and eastern provinces. Primary hospitals experienced the highest rates of serious workplace violence and emergency departments and doctors were at higher risk compared with other departments and health workers. Perpetrators were primarily male farmers aged 18 to 44 with low levels of education. The most frequently reported reasons of serious patient-initiated workplace violence included perceived medical malpractice by the perpetrator after the death of a patient, death of a patient with no other reason given, failures of the compensation negotiations after the death of a patient, and dissatisfaction with the treatment outcomes. CONCLUSIONS Serious workplace violence against providers varies across regions and types of health care institutions in China. Perception of low-quality care is the most reported reason for violence. Efforts should be made to improve quality of care in the low-level health institutions and strengthen the doctor-patient communication during the whole course of service.
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Affiliation(s)
- Ruilie Cai
- West China School of Public Health and West China Fourth Hospital, Sichuan University, No. 17, Section 3, Ren Min Nan Road, Chengdu, 610041 Sichuan China
- West China Research Center for Rural Health Development, Sichuan University, No. 17, Section 3, Ren Min Nan Road, Chengdu, 610041 Sichuan China
| | - Ji Tang
- West China School of Public Health and West China Fourth Hospital, Sichuan University, No. 17, Section 3, Ren Min Nan Road, Chengdu, 610041 Sichuan China
- West China Research Center for Rural Health Development, Sichuan University, No. 17, Section 3, Ren Min Nan Road, Chengdu, 610041 Sichuan China
| | - Chenhui Deng
- West China School of Public Health and West China Fourth Hospital, Sichuan University, No. 17, Section 3, Ren Min Nan Road, Chengdu, 610041 Sichuan China
- West China Research Center for Rural Health Development, Sichuan University, No. 17, Section 3, Ren Min Nan Road, Chengdu, 610041 Sichuan China
| | - Guofan Lv
- School of Civil Aviation Security, Civil Aviation Flight University of China, NO. 46, Nanchang Road, Guanghan, 618307 Sichuan China
| | - Xiaohe Xu
- School of Public Administration, Sichuan University, Chengdu, China
- Department of Sociology, University of Texas at San Antonio, One UTSA Circle, San Antonio, TX 78249 United States of America
| | - Sean Sylvia
- Gillings School of Global Public Health, University of North Carolina at Chapel Hill, 1101D McGavran-Greenberg Hall, CB#7411, Chapel Hill, NC 27599-7411 United States of America
| | - Jay Pan
- West China School of Public Health and West China Fourth Hospital, Sichuan University, No. 17, Section 3, Ren Min Nan Road, Chengdu, 610041 Sichuan China
- West China Research Center for Rural Health Development, Sichuan University, No. 17, Section 3, Ren Min Nan Road, Chengdu, 610041 Sichuan China
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Wu Y, Zhou H, Ma X, Shi Y, Xue H, Zhou C, Yi H, Medina A, Li J, Sylvia S. Using standardised patients to assess the quality of medical records: an application and evidence from rural China. BMJ Qual Saf 2019; 29:491-498. [PMID: 31776199 PMCID: PMC7244376 DOI: 10.1136/bmjqs-2019-009890] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2019] [Revised: 09/25/2019] [Accepted: 11/10/2019] [Indexed: 12/28/2022]
Abstract
BACKGROUND Medical records play a fundamental role in healthcare delivery, quality assessment and improvement. However, there is little objective evidence on the quality of medical records in low and middle-income countries. OBJECTIVE To provide an unbiased assessment of the quality of medical records for outpatient visits to rural facilities in China. METHODS A sample of 207 township health facilities across three provinces of China were enrolled. Unannounced standardised patients (SPs) presented to providers following standardised scripts. Three weeks later, investigators returned to collect medical records from each facility. Audio recordings of clinical interactions were then used to evaluate completeness and accuracy of available medical records. RESULTS Medical records were located for 210 out of 620 SP visits (33.8%). Of those located, more than 80% contained basic patient information and drug treatment when mentioned in visits, but only 57.6% recorded diagnoses. The most incompletely recorded category of information was patient symptoms (74.3% unrecorded), followed by non-drug treatments (65.2% unrecorded). Most of the recorded information was accurate, but accuracy fell below 80% for some items. The keeping of any medical records was positively correlated with the provider's income (β 0.05, 95% CI 0.01 to 0.09). Providers at hospitals with prescription review were less likely to record completely (β -0.87, 95% CI -1.68 to 0.06). Significant variation by disease type was also found in keeping of any medical record and completeness. CONCLUSION Despite the importance of medical records for health system functioning, many rural facilities have yet to implement systems for maintaining patient records, and records are often incomplete when they exist. Prescription review tied to performance evaluation should be implemented with caution as it may create disincentives for record keeping. Interventions to improve record keeping and management are needed.
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Affiliation(s)
- Yuju Wu
- Department of Health and Social Behavior, West China School of Public Health and West China Forth Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Huan Zhou
- Department of Health and Social Behavior, West China School of Public Health and West China Forth Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Xiao Ma
- Department of Health and Social Behavior, West China School of Public Health and West China Forth Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Yaojiang Shi
- Center for Experimental Economics in Education, Shaanxi Normal University, Xi'an, Shaanxi, China
| | - Hao Xue
- Center for Experimental Economics in Education, Shaanxi Normal University, Xi'an, Shaanxi, China
| | - Chengchao Zhou
- Institute of Social Medicine and Health Administration, Shandong University, Jinan, Shandong, China
| | - Hongmei Yi
- School of Advanced Agricultural Sciences, Peking University, Beijing, Beijing, China
| | - Alexis Medina
- Freeman Spogli Institute for International Studies, Stanford, California, USA
| | - Jason Li
- Freeman Spogli Institute for International Studies, Stanford, California, USA
| | - Sean Sylvia
- Health Policy and Management, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA.,Carolina Population Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
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Luo R, Emmers D, Warrinnier N, Rozelle S, Sylvia S. Using community health workers to deliver a scalable integrated parenting program in rural China: A cluster-randomized controlled trial. Soc Sci Med 2019; 239:112545. [PMID: 31568997 DOI: 10.1016/j.socscimed.2019.112545] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2019] [Revised: 07/26/2019] [Accepted: 09/07/2019] [Indexed: 12/17/2022]
Abstract
Inadequate care during early childhood can lead to long-term deficits in skill development. Parenting programs are promising tools for improving parenting practices and opportunities for healthy development. We implemented a non-masked cluster-randomized controlled trial in rural China in order to assess the effectiveness of an integrated home-visitation program that includes both psychosocial stimulation and health promotion at fostering development and health outcomes of infants and toddlers in rural China. All 6-18 month-old children of two rural townships and their main caregiver were enrolled. Villages were stratified by township and randomly assigned to intervention or control. Specifically, in September 2015 we assigned 43 clusters to treatment (21 villages, 222 caregiver-child dyads) or control (22 villages, 227 caregiver-child dyads). In the intervention group, community health workers delivered education and training on how to provide young children with psychosocial stimulation and health care (henceforth psychosocial stimulation and health promotion) during bi-weekly home visits over the period of one year. The control group received no home visits. Primary outcomes include measures of child development (i.e. the Bayley Scales of Infant and Toddler Development, third edition-or Bayley-III) and health (i.e. measures of morbidity, nutrition, and growth). Secondary outcomes are measures of parenting practices. Intention-to-treat (ITT) effects show that the intervention led to an improvement of 0·24 standard deviations (SD) [95% CI 0·04 SD-0·44 SD] in cognitive development and to a reduction of 8·1 [95% CI 3·8-12·4] percentage points in the risk of diarrheal illness. In addition, we find positive effects on parenting practices mirroring these results. We conclude that an integrated psychosocial stimulation and health promotion program improves development and health outcomes of infants and toddlers (6-30 month-old children) in rural China. Because of low incremental costs of adding program components (that is, adding health promotion to psychosocial stimulation programs), integrated programs may be cost-effective.
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Affiliation(s)
- Renfu Luo
- China Centre for Agricultural Policy (CCAP), School of Advanced Agricultural Sciences (SAAS), Peking University (PKU), Beijing, China
| | | | | | - Scott Rozelle
- Freeman Spogli Institute for International Studies, Stanford University, Stanford, USA
| | - Sean Sylvia
- Department of Health Policy and Management, Gillings School of Global Public Health and the Carolina Population Center, University of North Carolina at Chapel Hill, Chapel Hill, USA.
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Xu DR, Hu M, He W, Liao J, Cai Y, Sylvia S, Hanson K, Chen Y, Pan J, Zhou Z, Zhang N, Tang C, Wang X, Rozelle S, He H, Wang H, Chan G, Melipillán ER, Zhou W, Gong W. Assessing the quality of primary healthcare in seven Chinese provinces with unannounced standardised patients: protocol of a cross-sectional survey. BMJ Open 2019; 9:e023997. [PMID: 30765399 PMCID: PMC6398795 DOI: 10.1136/bmjopen-2018-023997] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION Primary healthcare (PHC) serves as the cornerstone for the attainment of universal health coverage (UHC). Efforts to promote UHC should focus on the expansion of access and on healthcare quality. However, robust quality evidence has remained scarce in China. Common quality assessment methods such as chart abstraction, patient rating and clinical vignette use indirect information that may not represent real practice. This study will send standardised patients (SP or healthy person trained to consistently simulate the medical history, physical symptoms and emotional characteristics of a real patient) unannounced to PHC providers to collect quality information and represent real practice. METHODS AND ANALYSIS 1981 SP-clinician visits will be made to a random sample of PHC providers across seven provinces in China. SP cases will be developed for 10 tracer conditions in PHC. Each case will include a standard script for the SP to use and a quality checklist that the SP will complete after the clinical visit to indicate diagnostic and treatment activities performed by the clinician. Patient-centredness will be assessed according to the Patient Perception of Patient-Centeredness Rating Scale by the SP. SP cases and the checklist will be developed through a standard protocol and assessed for content, face and criterion validity, and test-retest and inter-rater reliability before its full use. Various descriptive analyses will be performed for the survey results, such as a tabulation of quality scores across geographies and provider types. ETHICS AND DISSEMINATION This study has been reviewed and approved by the Institutional Review Board of the School of Public Health of Sun Yat-sen University (#SYSU 2017-011). Results will be actively disseminated through print and social media, and SP tools will be made available for other researchers.
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Affiliation(s)
- Dong Roman Xu
- Sun Yat-sen Global Health Institute (SGHI), School of Public Health and Institute of State Governance, Sun Yat-sen University, Guangzhou, China
| | - Mengyao Hu
- Survey Research Center, Institute for Social Research, University of Michigan, Ann Arbor, Michigan, USA
| | - Wenjun He
- Department of Biostatistics and Epidemiology, School of Public Health, Sun Yat-sen University, Guangzhou, China
| | - Jing Liao
- Sun Yat-sen Global Health Institute (SGHI), School of Public Health and Institute of State Governance, Sun Yat-sen University, Guangzhou, China
- Department of Biostatistics and Epidemiology, School of Public Health, Sun Yat-sen University, Guangzhou, China
| | - Yiyuan Cai
- Sun Yat-sen Global Health Institute (SGHI), School of Public Health and Institute of State Governance, Sun Yat-sen University, Guangzhou, China
- Department of Biostatistics and Epidemiology, School of Public Health, Sun Yat-sen University, Guangzhou, China
| | - Sean Sylvia
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Kara Hanson
- Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Yaolong Chen
- Evidence Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou, China
| | - Jay Pan
- West China School of Public Health, Sichuan University, Chengdu, Sichuan, China
| | - Zhongliang Zhou
- School of Public Policy and Administration, Xi’an Jiaotong University, Xi’an, China
| | - Nan Zhang
- Department of Health Management, School of Health Management, Inner Mongolia Medical University, Hohhot, China
| | - Chengxiang Tang
- School of Public Administration, Guangzhou University, Guangzhou, China
| | - Xiaohui Wang
- Department of Social Medicine and Health Management, School of Public Health, Lanzhou University, Lanzhou, Gansu, China
| | - Scott Rozelle
- Freeman Spogli Institute for International Studies, Stanford University, Stanford, California, USA
| | - Hua He
- Department of Epidemiology, School of Public Health and Tropical Medicine, Tulane University, New Orleans, USA
| | - Hong Wang
- Health Economics, Financing and Systems, Bill & Melinda Gates Foundation, Seattle, USA
| | - Gary Chan
- Department of Biostatistics, University of Washington, Seattle, Washington, USA
| | | | - Wei Zhou
- Hospital Administration Institute, Xiangya Hospital, Central South University, Changsha, China
| | - Wenjie Gong
- Xiangya School of Public Health, Central South University, Changsha, China
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Liu C, Lu L, Zhang L, Luo R, Sylvia S, Medina A, Rozelle S, Smith DS, Chen Y, Zhu T. Effect of Deworming on Indices of Health, Cognition, and Education Among Schoolchildren in Rural China: A Cluster-Randomized Controlled Trial. Am J Trop Med Hyg 2018; 96:1478-1489. [PMID: 28093533 DOI: 10.4269/ajtmh.16-0354] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
AbstractSoil-transmitted helminths (STHs) infect over one billion people worldwide. There is concern that chronic infection with STHs among school-aged children may detrimentally affect their development, including their health, cognition, and education. However, two recent Cochrane reviews examining the impact of deworming drugs for STH on nutrition, hemoglobin, and school performance found that randomized controlled trials (RCTs) in the literature provide an insufficient evidence base to draw reliable conclusions. This study uses a cluster-RCT to add to existing evidence by assessing the impact of a deworming intervention on nutrition, cognition, and school performance among schoolchildren in rural China. The intervention, implemented by local health practitioners in a setting with a baseline infection prevalence of 41.9% (95% confidence interval [CI] = 39.8%, 43.9%) and infection intensity of 599.5 eggs per gram of feces among positive-tested schoolchildren (95% CI = 473.2, 725.8), consisted of distributing a 400-mg dose of albendazole accompanied with educational training about STH infection, treatment, and prevention. The intervention was conducted twice over the course of the study-at baseline in May 2013 and later in November 2013. We found that the deworming intervention reduced both infection prevalence and infection intensity, but these declines in infection were not accompanied by an impact on outcomes of nutrition, cognition, or school performance. Our interpretation is that the impact of deworming was attenuated by the light infection intensity in our sample population. Evidence from future RCTs is needed to assess the effect of deworming on key outcomes in areas with moderate and severe worm infections.
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Affiliation(s)
- Chengfang Liu
- China Center for Agricultural Policy, School of Advanced Agricultural Sciences, Peking University, Beijing, China
| | - Louise Lu
- Freeman Spogli Institute, Stanford University, Stanford, California.,Yale University School of Medicine, New Haven, Connecticut
| | - Linxiu Zhang
- Center for Chinese Agricultural Policy, Institute of Geographic Sciences and Natural Resources Research, Chinese Academy of Sciences, Beijing, China
| | - Renfu Luo
- China Center for Agricultural Policy, School of Advanced Agricultural Sciences, Peking University, Beijing, China
| | - Sean Sylvia
- School of Economics, Renmin University of China, Beijing, China
| | - Alexis Medina
- Freeman Spogli Institute, Stanford University, Stanford, California
| | - Scott Rozelle
- Freeman Spogli Institute, Stanford University, Stanford, California
| | | | - Yingdan Chen
- National Institute of Parasitic Diseases, Chinese Center for Disease Control and Prevention, Shanghai, China
| | - Tingjun Zhu
- National Institute of Parasitic Diseases, Chinese Center for Disease Control and Prevention, Shanghai, China
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Xue H, Hager J, An Q, Liu K, Zhang J, Auden E, Yang B, Yang J, Liu H, Nie J, Wang A, Zhou C, Shi Y, Sylvia S. The Quality of Tuberculosis Care in Urban Migrant Clinics in China. Int J Environ Res Public Health 2018; 15:E2037. [PMID: 30231511 PMCID: PMC6163912 DOI: 10.3390/ijerph15092037] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/09/2018] [Revised: 09/11/2018] [Accepted: 09/13/2018] [Indexed: 02/07/2023]
Abstract
Large and increasing numbers of rural-to-urban migrants provided new challenges for tuberculosis control in large cities in China and increased the need for high quality tuberculosis care delivered by clinics in urban migrant communities. Based on a household survey in migrant communities, we selected and separated clinics into those that mainly serve migrants and those that mainly serve local residents. Using standardized patients, this study provided an objective comparison of the quality of tuberculosis care delivered by both types of clinics and examined factors related to quality care. Only 27% (95% confidence interval (CI) 14⁻46) of cases were correctly managed in migrant clinics, which is significantly worse than it in local clinics (50%, 95% CI 28⁻72). Clinicians with a base salary were 41 percentage points more likely to demonstrate better case management. Furthermore, clinicians with upper secondary or higher education level charged 20 RMB lower out of pocket fees than less-educated clinicians. In conclusion, the quality of tuberculosis care accessed by migrants was very poor and policies to improve the quality should be prioritized in current health reforms. Providing a base salary was a possible way to improve quality of care and increasing the education attainment of urban community clinicians might reduce the heavy barrier of medical expenses for migrants.
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Affiliation(s)
- Hao Xue
- School of Economics and Management, Northwest University, Xi'an 710069, China.
| | - Jennifer Hager
- Department of Health, Sport, and Exercise Sciences, School of Education, University of Kansas, Lawrence, KS 66045, USA.
| | - Qi An
- Center for Experimental Economics in Education, Shaanxi Normal University, Xi'an 710127, China.
| | - Kai Liu
- Center for Experimental Economics in Education, Shaanxi Normal University, Xi'an 710127, China.
| | - Jing Zhang
- Faculty of Liberal Arts, Northwest University, Xi'an 710069, China.
| | - Emma Auden
- Center for Experimental Economics in Education, Shaanxi Normal University, Xi'an 710127, China.
- Rural Education Action Program, Freeman Spogli Institute for International Studies, Stanford University, Stanford, CA 94305, USA.
| | - Bingyan Yang
- School of Economics and Management, Wuhan University, Wuhan 430072, China.
| | - Jie Yang
- Center for Experimental Economics in Education, Shaanxi Normal University, Xi'an 710127, China.
| | - Hongyan Liu
- School of Economics, Northwest University of Political Science and Law, Xi'an 710122, China.
| | - Jingchun Nie
- Center for Experimental Economics in Education, Shaanxi Normal University, Xi'an 710127, China.
| | - Aiqin Wang
- School of Economics and Finance, Xi'an Jiaotong University, Xi'an 710061, China.
| | - Chengchao Zhou
- Institute of Social Medicine and Health Administration, School of Public Health, Shandong University, Jinan 250012, China.
| | - Yaojiang Shi
- Center for Experimental Economics in Education, Shaanxi Normal University, Xi'an 710127, China.
| | - Sean Sylvia
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA.
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Liao J, Chen Y, Cai Y, Zhan N, Sylvia S, Hanson K, Wang H, Wasserheit JN, Gong W, Zhou Z, Pan J, Wang X, Tang C, Zhou W, Xu D. Using smartphone-based virtual patients to assess the quality of primary healthcare in rural China: protocol for a prospective multicentre study. BMJ Open 2018; 8:e020943. [PMID: 29997138 PMCID: PMC6089284 DOI: 10.1136/bmjopen-2017-020943] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
INTRODUCTION Valid and low-cost quality assessment tools examining care quality are not readily available. The unannounced standardised patient (USP), the gold standard for assessing quality, is costly to implement while the validity of clinical vignettes, as a low-cost alternative, has been challenged. Computerised virtual patients (VPs) create high-fidelity and interactive simulations of doctor-patient encounters which can be easily implemented via smartphone at low marginal cost. Our study aims to develop and validate smartphone-based VP as a quality assessment tool for primary care, compared with USP. METHODS AND ANALYSIS The study will be implemented in primary health centres (PHCs) in rural areas of seven Chinese provinces, and physicians practicing at township health centres and village clinics will be our study population. The development of VPs involves three steps: (1) identifying 10 VP cases that can best represent rural PHCs' work, (2) designing each case by a case-specific development team and (3) developing corresponding quality scoring criteria. After being externally reviewed for content validity, these VP cases will be implemented on a smartphone-based platform and will be tested for feasibility and face validity. This smartphone-based VP tool will then be validated for its criterion validity against USP and its reliability (ie, internal consistency and stability), with 1260 VP/USP-clinician encounters across the seven study provinces for all 10 VP cases. ETHICS AND DISSEMINATION Sun Yat-sen University: No. 2017-007. Study findings will be published and tools developed will be freely available to low-income and middle-income countries for research purposes.
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Affiliation(s)
- Jing Liao
- Sun Yat-sen Global Health Institute, School of Public Health and Institute of State Governance, Sun Yat-sen University
| | - Yaolong Chen
- Evidence-Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou, China
| | - Yiyuan Cai
- School of Public Health, Guizhou Medical University, Guiyang, China
| | - Nan Zhan
- Department of Health Management, School of Health Management, Inner Mongolia Medical University, Hohhot, China
| | - Sean Sylvia
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Kara Hanson
- Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene & Tropical Medicine, London, UK
| | - Hong Wang
- Health Economics, Financing & Systems, Bill & Melinda Gates Foundation, Seattle, Washington, USA
| | - Judith N Wasserheit
- Departments of Global Health, Medicine, and Epidemiology, Schools of Medicine and Public Health, University of Washington, Seattle, Washington, USA
| | - Wenjie Gong
- Xiangya School of Public Health, Central South University, Changsha, China
| | - Zhongliang Zhou
- School of Public Policy and Administration, Xi’an Jiaotong University, Xi’an, China
| | - Jay Pan
- West China School of Public Health, Sichuan University, Chengdu, China
| | - Xiaohui Wang
- School of Public Health, Lanzhou University, Lanzhou, China
| | - Chengxiang Tang
- School of Public Administration, Guangzhou University, Guangzhou, China
| | - Wei Zhou
- Hospital Administration Institute, Xiangya Hospital, Central South University, Changsha, China
| | - Dong Xu
- Sun Yat-sen Global Health Institute, School of Public Health and Institute of State Governance, Sun Yat-sen University
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Sylvia S, Xue H, Zhou C, Shi Y, Yi H, Zhou H, Rozelle S, Pai M, Das J. Tuberculosis detection and the challenges of integrated care in rural China: A cross-sectional standardized patient study. PLoS Med 2017; 14:e1002405. [PMID: 29040263 PMCID: PMC5644979 DOI: 10.1371/journal.pmed.1002405] [Citation(s) in RCA: 75] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2017] [Accepted: 09/08/2017] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Despite recent reductions in prevalence, China still faces a substantial tuberculosis (TB) burden, with future progress dependent on the ability of rural providers to appropriately detect and refer TB patients for further care. This study (a) provides a baseline assessment of the ability of rural providers to correctly manage presumptive TB cases; (b) measures the gap between provider knowledge and practice and; (c) evaluates how ongoing reforms of China's health system-characterized by a movement toward "integrated care" and promotion of initial contact with grassroots providers-will affect the care of TB patients. METHODS/FINDINGS Unannounced standardized patients (SPs) presenting with classic pulmonary TB symptoms were deployed in 3 provinces of China in July 2015. The SPs successfully completed 274 interactions across all 3 tiers of China's rural health system, interacting with providers in 46 village clinics, 207 township health centers, and 21 county hospitals. Interactions between providers and standardized patients were assessed against international and national standards of TB care. Using a lenient definition of correct management as at least a referral, chest X-ray or sputum test, 41% (111 of 274) SPs were correctly managed. Although there were no cases of empirical anti-TB treatment, antibiotics unrelated to the treatment of TB were prescribed in 168 of 274 interactions or 61.3% (95% CI: 55%-67%). Correct management proportions significantly higher at county hospitals compared to township health centers (OR 0.06, 95% CI: 0.01-0.25, p < 0.001) and village clinics (OR 0.02, 95% CI: 0.0-0.17, p < 0.001). Correct management in tests of knowledge administered to the same 274 physicians for the same case was 45 percentage points (95% CI: 37%-53%) higher with 24 percentage points (95% CI: -33% to -15%) fewer antibiotic prescriptions. Relative to the current system, where patients can choose to bypass any level of care, simulations suggest that a system of managed referral with gatekeeping at the level of village clinics would reduce proportions of correct management from 41% to 16%, while gatekeeping at the level of the township hospital would retain correct management close to current levels at 37%. The main limitations of the study are 2-fold. First, we evaluate the management of a one-time new patient presenting with presumptive TB, which may not reflect how providers manage repeat patients or more complicated TB presentations. Second, simulations under alternate policies require behavioral and statistical assumptions that should be addressed in future applications of this method. CONCLUSIONS There were significant quality deficits among village clinics and township health centers in the management of a classic case of presumptive TB, with higher proportions of correct case management in county hospitals. Poor clinical performance does not arise only from a lack of knowledge, a phenomenon known as the "know-do" gap. Given significant deficits in quality of care, reforms encouraging first contact with lower tiers of the health system can improve efficiency only with concomitant improvements in appropriate management of presumptive TB patients in village clinics and township health centers.
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Affiliation(s)
- Sean Sylvia
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
| | - Hao Xue
- Center for Experimental Economics in Education, Shaanxi Normal University, Xi’an, China
| | - Chengchao Zhou
- Institute of Social Medicine and Health Administration, School of Public Health, Shandong University, Jinan, China
| | - Yaojiang Shi
- Center for Experimental Economics in Education, Shaanxi Normal University, Xi’an, China
| | - Hongmei Yi
- School of Advanced Agricultural Sciences, Peking University, Beijing, China
| | - Huan Zhou
- Department of Health and Social Behavior, West China School of Public Health, Sichuan University, Chengdu, China
| | - Scott Rozelle
- Freeman Spogli Institute for International Studies, Stanford University, Stanford, California, United States of America
| | - Madhukar Pai
- McGill International TB Centre & Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Canada
| | - Jishnu Das
- Development Research Group, The World Bank, Washington, D.C., United States of America
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Luo R, Yue A, Zhou H, Shi Y, Zhang L, Martorell R, Medina A, Rozelle S, Sylvia S. The effect of a micronutrient powder home fortification program on anemia and cognitive outcomes among young children in rural China: a cluster randomized trial. BMC Public Health 2017; 17:738. [PMID: 28946866 PMCID: PMC5613507 DOI: 10.1186/s12889-017-4755-0] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2017] [Accepted: 09/12/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Anemia early in life has been associated with delayed cognitive and motor development. The WHO recommends home fortification using multiple micronutrient powders (MNPs) containing iron as a strategy to address anemia in children under two. We evaluated the effects of a program freely distributing MNP sachets to caregivers of infants in rural China. METHODS We conducted a cluster-randomized controlled trial in Shaanxi province, enrolling all children aged 6-11 months in target villages. Following a baseline survey, investigators randomly assigned each village/cluster to a control or treatment group. In the treatment group, caregivers were instructed to give MNPs daily. Follow-up was after 6, 12, and 18 months of intervention. Primary outcomes were hemoglobin concentrations and scores on the Bayley Scales of Infant Development. RESULTS One thousand, eight hundred and-two eligible children and their caregivers were enrolled. At baseline 48% (870) of children were anemic and 29% (529) were developmentally delayed. Six hundred and-ten children (117 villages) were assigned to the control group and 1192 children (234 villages) were assigned to the treatment group. Assignment to the treatment group was associated with an improvement in hemoglobin levels (marginal effect 1.77 g/L, 95% CI 0.017-3.520, p-value = 0.048) and cognitive development (marginal effect 2.23 points, 95% CI 0.061-4.399, p-value = 0.044) after 6 months but not thereafter. There were no significant effects on motor development. Zero effects after the first 6 months were not due to low compliance, low statistical power, or changes in feeding behavior. Hemoglobin concentrations improved in both the treatment and control groups over the course of the study; however, 22% (325) of children remained anemic at endline, and 48% (721) were cognitively delayed. CONCLUSIONS Providing caregivers with MNP sachets modestly hastened improvement in hemoglobin levels that was occurring absent intervention; however, this improvement did not translate into improved developmental outcomes at endline. TRIAL REGISTRATION ISRCTN44149146 ; prospectively registered on 15th April 2013.
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Affiliation(s)
- Renfu Luo
- China Center for Agricultural Policy, School of Advanced Agricultural Sciences, Peking University, Beijing, China
| | - Ai Yue
- Center for Experimental Economics in Education, Shaanxi Normal University, 620 Chang'an Road West, Xi'an, 710119, China.
| | - Huan Zhou
- West China School of Public Health, Sichuan University, Chengdu, China
| | - Yaojiang Shi
- Center for Experimental Economics in Education, Shaanxi Normal University, 620 Chang'an Road West, Xi'an, 710119, China
| | - Linxiu Zhang
- Center for Chinese Agricultural Policy, Chinese Academy of Sciences, Beijing, China
| | | | - Alexis Medina
- Freeman Spogli Institute for International Studies, Stanford University, Stanford, USA
| | - Scott Rozelle
- Freeman Spogli Institute for International Studies, Stanford University, Stanford, USA
| | - Sean Sylvia
- Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, USA
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Zhou H, Sun S, Luo R, Sylvia S, Yue A, Shi Y, Zhang L, Medina A, Rozelle S. Impact of Text Message Reminders on Caregivers' Adherence to a Home Fortification Program Against Child Anemia in Rural Western China: A Cluster-Randomized Controlled Trial. Am J Public Health 2016; 106:1256-62. [PMID: 27077354 DOI: 10.2105/ajph.2016.303140] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
OBJECTIVES To test whether text message reminders sent to caregivers improve the effectiveness of a home micronutrient fortification program in western China. METHODS We carried out a cluster-randomized controlled trial in 351 villages (clusters) in Shaanxi Province in 2013 and 2014, enrolling children aged 6 to 12 months. We randomly assigned each village to 1 of 3 groups: free delivery group, text messaging group, or control group. We collected information on compliance with treatments and hemoglobin concentrations from all children at baseline and 6-month follow-up. We estimated the intent-to-treat effects on compliance and child anemia using a logistic regression model. RESULTS There were 1393 eligible children. We found that assignment to the text messaging group led to an increase in full compliance (marginal effect = 0.10; 95% confidence interval [CI] = 0.03, 0.16) compared with the free delivery group and decrease in the rate of anemia at end line relative to the control group (marginal effect = -0.07; 95% CI = -0.12, -0.01), but not relative to the free delivery group (marginal effect = -0.03; 95% CI = -0.09, 0.03). CONCLUSIONS Text messages improved compliance of caregivers to a home fortification program and children's nutrition.
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Affiliation(s)
- Huan Zhou
- Huan Zhou and Shuai Sun are with the Department of Health and Social Behavior, West China School of Public Health, Sichuan University, Chengdu, Sichuan, China. Renfu Luo is with the Center for Chinese Agricultural Policy, School of Advanced Agricultural Sciences, Peking University, Beijing, China. Sean Sylvia is with the School of Economics, Renmin University of China, Beijing. Ai Yue and Yaojiang Shi are with the Center for Experimental Economics in Education (CEEE), Shaanxi Normal University, Shaanxi, China. Linxiu Zhang is with the Center for Chinese Agricultural Policy, Institute of Geographical Sciences and Natural Resources Research, Chinese Academy of Sciences, Beijing. Alexis Medina and Scott Rozelle are with the Freeman Spogli Institute for International Studies, Stanford University, Stanford, CA
| | - Shuai Sun
- Huan Zhou and Shuai Sun are with the Department of Health and Social Behavior, West China School of Public Health, Sichuan University, Chengdu, Sichuan, China. Renfu Luo is with the Center for Chinese Agricultural Policy, School of Advanced Agricultural Sciences, Peking University, Beijing, China. Sean Sylvia is with the School of Economics, Renmin University of China, Beijing. Ai Yue and Yaojiang Shi are with the Center for Experimental Economics in Education (CEEE), Shaanxi Normal University, Shaanxi, China. Linxiu Zhang is with the Center for Chinese Agricultural Policy, Institute of Geographical Sciences and Natural Resources Research, Chinese Academy of Sciences, Beijing. Alexis Medina and Scott Rozelle are with the Freeman Spogli Institute for International Studies, Stanford University, Stanford, CA
| | - Renfu Luo
- Huan Zhou and Shuai Sun are with the Department of Health and Social Behavior, West China School of Public Health, Sichuan University, Chengdu, Sichuan, China. Renfu Luo is with the Center for Chinese Agricultural Policy, School of Advanced Agricultural Sciences, Peking University, Beijing, China. Sean Sylvia is with the School of Economics, Renmin University of China, Beijing. Ai Yue and Yaojiang Shi are with the Center for Experimental Economics in Education (CEEE), Shaanxi Normal University, Shaanxi, China. Linxiu Zhang is with the Center for Chinese Agricultural Policy, Institute of Geographical Sciences and Natural Resources Research, Chinese Academy of Sciences, Beijing. Alexis Medina and Scott Rozelle are with the Freeman Spogli Institute for International Studies, Stanford University, Stanford, CA
| | - Sean Sylvia
- Huan Zhou and Shuai Sun are with the Department of Health and Social Behavior, West China School of Public Health, Sichuan University, Chengdu, Sichuan, China. Renfu Luo is with the Center for Chinese Agricultural Policy, School of Advanced Agricultural Sciences, Peking University, Beijing, China. Sean Sylvia is with the School of Economics, Renmin University of China, Beijing. Ai Yue and Yaojiang Shi are with the Center for Experimental Economics in Education (CEEE), Shaanxi Normal University, Shaanxi, China. Linxiu Zhang is with the Center for Chinese Agricultural Policy, Institute of Geographical Sciences and Natural Resources Research, Chinese Academy of Sciences, Beijing. Alexis Medina and Scott Rozelle are with the Freeman Spogli Institute for International Studies, Stanford University, Stanford, CA
| | - Ai Yue
- Huan Zhou and Shuai Sun are with the Department of Health and Social Behavior, West China School of Public Health, Sichuan University, Chengdu, Sichuan, China. Renfu Luo is with the Center for Chinese Agricultural Policy, School of Advanced Agricultural Sciences, Peking University, Beijing, China. Sean Sylvia is with the School of Economics, Renmin University of China, Beijing. Ai Yue and Yaojiang Shi are with the Center for Experimental Economics in Education (CEEE), Shaanxi Normal University, Shaanxi, China. Linxiu Zhang is with the Center for Chinese Agricultural Policy, Institute of Geographical Sciences and Natural Resources Research, Chinese Academy of Sciences, Beijing. Alexis Medina and Scott Rozelle are with the Freeman Spogli Institute for International Studies, Stanford University, Stanford, CA
| | - Yaojiang Shi
- Huan Zhou and Shuai Sun are with the Department of Health and Social Behavior, West China School of Public Health, Sichuan University, Chengdu, Sichuan, China. Renfu Luo is with the Center for Chinese Agricultural Policy, School of Advanced Agricultural Sciences, Peking University, Beijing, China. Sean Sylvia is with the School of Economics, Renmin University of China, Beijing. Ai Yue and Yaojiang Shi are with the Center for Experimental Economics in Education (CEEE), Shaanxi Normal University, Shaanxi, China. Linxiu Zhang is with the Center for Chinese Agricultural Policy, Institute of Geographical Sciences and Natural Resources Research, Chinese Academy of Sciences, Beijing. Alexis Medina and Scott Rozelle are with the Freeman Spogli Institute for International Studies, Stanford University, Stanford, CA
| | - Linxiu Zhang
- Huan Zhou and Shuai Sun are with the Department of Health and Social Behavior, West China School of Public Health, Sichuan University, Chengdu, Sichuan, China. Renfu Luo is with the Center for Chinese Agricultural Policy, School of Advanced Agricultural Sciences, Peking University, Beijing, China. Sean Sylvia is with the School of Economics, Renmin University of China, Beijing. Ai Yue and Yaojiang Shi are with the Center for Experimental Economics in Education (CEEE), Shaanxi Normal University, Shaanxi, China. Linxiu Zhang is with the Center for Chinese Agricultural Policy, Institute of Geographical Sciences and Natural Resources Research, Chinese Academy of Sciences, Beijing. Alexis Medina and Scott Rozelle are with the Freeman Spogli Institute for International Studies, Stanford University, Stanford, CA
| | - Alexis Medina
- Huan Zhou and Shuai Sun are with the Department of Health and Social Behavior, West China School of Public Health, Sichuan University, Chengdu, Sichuan, China. Renfu Luo is with the Center for Chinese Agricultural Policy, School of Advanced Agricultural Sciences, Peking University, Beijing, China. Sean Sylvia is with the School of Economics, Renmin University of China, Beijing. Ai Yue and Yaojiang Shi are with the Center for Experimental Economics in Education (CEEE), Shaanxi Normal University, Shaanxi, China. Linxiu Zhang is with the Center for Chinese Agricultural Policy, Institute of Geographical Sciences and Natural Resources Research, Chinese Academy of Sciences, Beijing. Alexis Medina and Scott Rozelle are with the Freeman Spogli Institute for International Studies, Stanford University, Stanford, CA
| | - Scott Rozelle
- Huan Zhou and Shuai Sun are with the Department of Health and Social Behavior, West China School of Public Health, Sichuan University, Chengdu, Sichuan, China. Renfu Luo is with the Center for Chinese Agricultural Policy, School of Advanced Agricultural Sciences, Peking University, Beijing, China. Sean Sylvia is with the School of Economics, Renmin University of China, Beijing. Ai Yue and Yaojiang Shi are with the Center for Experimental Economics in Education (CEEE), Shaanxi Normal University, Shaanxi, China. Linxiu Zhang is with the Center for Chinese Agricultural Policy, Institute of Geographical Sciences and Natural Resources Research, Chinese Academy of Sciences, Beijing. Alexis Medina and Scott Rozelle are with the Freeman Spogli Institute for International Studies, Stanford University, Stanford, CA
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Zhou C, Sylvia S, Zhang L, Luo R, Yi H, Liu C, Shi Y, Loyalka P, Chu J, Medina A, Rozelle S. China’s Left-Behind Children: Impact Of Parental Migration On Health, Nutrition, And Educational Outcomes. Health Aff (Millwood) 2015; 34:1964-71. [DOI: 10.1377/hlthaff.2015.0150] [Citation(s) in RCA: 140] [Impact Index Per Article: 15.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Chengchao Zhou
- Chengchao Zhou is an associate professor of public health at the School of Public Health, Shandong University, in China
| | - Sean Sylvia
- Sean Sylvia is an assistant professor of economics at the School of Economics, Renmin University of China, in Beijing
| | - Linxiu Zhang
- Linxiu Zhang (
) is a professor of economics at the Center for Chinese Agricultural Policy, Chinese Academy of Sciences, in Beijing
| | - Renfu Luo
- Renfu Luo is an associate professor of economics at the Center for Chinese Agricultural Policy, Chinese Academy of Sciences
| | - Hongmei Yi
- Hongmei Yi is an associate professor of economics at the Center for Chinese Agricultural Policy, Chinese Academy of Sciences
| | - Chengfang Liu
- Chengfang Liu is an associate professor of economics at the Center for Chinese Agricultural Policy, Chinese Academy of Sciences
| | - Yaojiang Shi
- Yaojiang Shi is a professor of economics at the Center for Experimental Economics in Education, Shaanxi Normal University, in China
| | - Prashant Loyalka
- Prashant Loyalka is an assistant (research) professor of education at the Graduate School of Education and a center research fellow at the Freeman Spogli Institute for International Studies, Stanford University, in California
| | - James Chu
- James Chu is a doctoral student in the Department of Sociology, Stanford University
| | - Alexis Medina
- Alexis Medina is a project manager at the Freeman Spogli Institute for International Studies, Stanford University
| | - Scott Rozelle
- Scott Rozelle is a professor of economics at the Freeman Spogli Institute for International Studies, Stanford University
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Luo R, Shi Y, Zhou H, Yue A, Zhang L, Sylvia S, Medina A, Rozelle S. Micronutrient deficiencies and developmental delays among infants: evidence from a cross-sectional survey in rural China. BMJ Open 2015; 5:e008400. [PMID: 26438137 PMCID: PMC4611485 DOI: 10.1136/bmjopen-2015-008400] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2015] [Revised: 07/30/2015] [Accepted: 09/14/2015] [Indexed: 11/10/2022] Open
Abstract
OBJECTIVES Research increasingly indicates the importance of the nutritional programming that occurs in the first 2-3 years of life. Quality nutrition during this brief window has been shown to have large and significant effects on health and development throughout childhood and even into adulthood. Despite the widespread understanding of this critical window, and the long-term consequences of leaving nutritional deficiencies unaddressed, little is known about the status of infant nutrition in rural China, or about the relationship between infant nutrition and cognitive development in rural China. DESIGN, SETTING AND PARTICIPANTS In April 2013 and October 2013, we conducted a survey of 1808 infants aged 6-12 months living in 351 villages across 174 townships in nationally designated poverty counties in rural areas of southern Shaanxi Province, China. MAIN OUTCOME MEASURES Infants were administered a finger prick blood test for haemoglobin and assessed according to the Bayley Scales of Infant Development. They were also measured for length and weight. Caregivers were administered a survey of demographic characteristics and feeding practices. RESULTS We found that 48.8% of sample infants were anaemic, 3.7% were stunted, 1.2% were underweight and 1.6% were wasted. Approximately 20.0% of the sample infants were significantly delayed in their cognitive development, while just over 32.3% of the sample infants were significantly delayed in their psychomotor development. After controlling for potential confounders, infants with lower haemoglobin counts were significantly more likely to be delayed in both their cognitive (p<0.01) and psychomotor development (p<0.01). CONCLUSIONS The anaemia rates that we identify in this study classify anaemia as a 'severe' public health problem according to the WHO. In contrast, there is virtually no linear growth failure among this population. We find that low haemoglobin levels among our sample population are associated with significant cognitive and psychomotor delays that could eventually affect children's schooling performance and labour force outcomes. TRIAL REGISTRATION NUMBER ISRCTN44149146.
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Affiliation(s)
- Renfu Luo
- Chinese Academy of Sciences, Center for Chinese Agricultural Policy, Institute of Geographical Sciences and Natural Resources Research, Beijing, China
| | - Yaojiang Shi
- Center for Experimental Economics in Education (CEEE), Shaanxi Normal University, Xi'an, Shaanxi, China
| | - Huan Zhou
- West China School of Public Health, Sichuan University, Chengdu, Sichuan, China
| | - Ai Yue
- Center for Experimental Economics in Education (CEEE), Shaanxi Normal University, Xi'an, Shaanxi, China
| | - Linxiu Zhang
- Chinese Academy of Sciences, Center for Chinese Agricultural Policy, Institute of Geographical Sciences and Natural Resources Research, Beijing, China
| | - Sean Sylvia
- School of Economics, Renmin University of China, Beijing, China
| | - Alexis Medina
- Rural Education Action Program, Freeman Spogli Institute for International Studies, Stanford University, Stanford, California, USA
| | - Scott Rozelle
- Rural Education Action Program, Freeman Spogli Institute for International Studies, Stanford University, Stanford, California, USA
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