Chaojie Liu

Social support and Quality of Life: a cross-sectional study on survivors eight months after the 2008 Wenchuan earthquake

BackgroundThe 2008 Wenchuan earthquake resulted in extensive loss of life and physical and psychological injuries for survivors. This research examines the relationship between social support and health-related quality of life for the earthquake survivors.MethodsA multistage cluster sampling strategy was employed to select participants from 11 shelters in nine counties exposed to different degrees of earthquake damage, for a questionnaire survey. The participants were asked to complete the Short Form 36 and the Social Support Rating Scale eight months after the earthquake struck. A total of 1617 participants returned the questionnaires. The quality of life of the survivors (in the four weeks preceding the survey) was compared with that of the general population in the region. Multivariate logistic regression analysis and canonical correlation analysis were performed to determine the association between social support and quality of life.ResultsThe earthquake survivors reported poorer quality of life than the general population, with an average of 4.8% to 19.62% reduction in scores of the SF-36 (p < 0.001). The multivariate logistic regression analysis showed that those with stronger social support were more likely to have better quality of life. The canonical correlation analysis found that there was a discrepancy between actual social support received and perceived social support available, and the magnitude of this discrepancy was inversely related to perceived general health (rs = 0.467), and positively related to mental health (rs = 0.395).ConclusionSocial support is associated with quality of life in the survivors of the earthquake. More attention needs to be paid to increasing social support for those with poorer mental health.

The impact of the National Essential Medicines Policy on prescribing behaviours in primary care facilities in Hubei province of China

AIM To assess the impact of the National Essential Medicines Policy (NEMP) on the use of medicines in government-owned primary care institutions in Hubei province of China. STUDY DESIGN Quasi-experimental design and time-trend analysis. METHODS A systematic random sampling strategy was employed to select 55,800 prescriptions from 18 primary care organizations who progressively implemented the NEMP from January 2009 to July 2011. We examined the change of patterns of prescriptions. The facilities that implemented the NEMP at a later stage served as control. RESULTS An immediate increased uptake of essential medicines of all drugs prescribed which ultimately neared 95%. In total, 38,151 prescriptions (68%) involved antibiotics, and we found no evidence of reduction after the NEMP interventions. A high percentage (59-66%) of prescription drugs were administered through parenteral routes and no reduction was found after the NEMP interventions. Although the average number of medicines per prescription remained unchanged (nearly four), the average cost per prescription declined significantly after the NEMP interventions (¥ 44.67 vs ¥ 26.67 CNY, P < 0.03). CONCLUSIONS The NEMP interventions reduced the average cost per prescription; however, the irrational use of antibiotics and unnecessary parenteral administration remains prevalent. The goals of the NEMP are partially achieved; we therefore recommend a strategic approach involving all stakeholders to comprehensively achieve all aspirations.

Quality of life of Chinese urban community residents: a psychometric study of the mainland Chinese version of the WHOQOL-BREF

BackgroundThe short version of the World Health Organizations Quality of Life Instrument (WHOQOL-BREF) is widely validated and popularly used in assessing the subjective quality of life (QOL) of patients and the general public. We examined its psychometric properties in a large sample of community residents in mainland China.MethodsThe WHOQOL-BREF was administered to 1052 adult community residents in a major metropolitan city in southern China. The structural integrity of the 4-factor model in confirmatory factor analyses (CFA) and the relationship of QOL with demographic variables were examined. Validity was assessed using the known-group comparison (229 with vs. 823 without chronic illness), item-domain correlations, and CFA using the ML estimation in LISREL.ResultsInternal consistency reliability of the whole instrument (26 items) was 0.89, and the psychological, social, and environment domains had acceptable reliability (alpha = 0.76, 0.72, 0.78 respectively), while that of the physical domain was slightly lower (α = 0.67). The respective mean scores of these domains were 13.69, 14.11, 12.33 and 14.56. Item-domain correlations were much higher for corresponding domains than for non-corresponding domains, indicating good convergent validity. CFA provided a marginally acceptable fit to the a priori four-factor model when two matching content item pairs were allowed to be correlated; χ2 (244) = 1836, RMSEA = 0.088, NNFI = 0.898, CFI = 0.909. This factorial structure was shown to be equivalent between the participants with and without chronic illness. The differences in means between these two groups were significant but small in some domains; effect size = 0.55, 0.15, 0.18 in the physical, psychological, and social relationship domains respectively. Furthermore, males had significantly higher QOL scores than females in the psychological domain, while individuals with a younger age, higher income, and higher education levels also had significantly higher QOL. Compared with the international data, the Chinese in this study had relatively low QOL scores with about 5% of males and 16% of females being at risk for poor QOL.ConclusionsThis study has provided psychometric properties of the WHOQOL-BREF as used in China and should definitely be useful for researchers who would like to use or further refine the instrument.

Factors contributing to the high prevalence of multidrug-resistant tuberculosis: a study from China

Background The rapid spread of multidrug-resistant tuberculosis (MDR-TB) has attracted global concerns. This study aimed to identify factors contributing to the high prevalence of MDR-TB in Chinas Heilongjiang province. Methods A cross-sectional survey following the WHO/International Union Against Tuberculosis and Lung Disease guidelines was conducted with consecutive recruitment of patients with TB in 30 counties selected at random in Heilongjiang in 2004. A total of 1995 patients were tested for MDR-TB. Factors associated with MDR-TB were identified through multilevel models and traditional logistic regression analysis, along with in-depth interviews with nine patients, five healthcare managers and four doctors. Results 241 patients (12%) were identified with MDR-TB. The retreatment patients were 5.48 times (95% CI 4.04 to 7.44) more likely to have MDR-TB than newly diagnosed patients. The patients who were treated with isoniazid and rifampin for >180 days were 4.82 times (95% CI 2.97 to 7.81) more likely to develop MDR-TB than those treated <180 days. Age and delay in initiating TB treatment were associated with MDR-TB. Financial burden, poor knowledge and side effects of TB treatment were perceived by the interviewees as influencing factors. Lack of coordination of services, unsatisfactory supervision of treatment and infection control jeopardised the control of MDR-TB. Conclusions Inappropriate treatment is the most important influencing factor of MDR-TB. Increasing peoples awareness of TB, early detection and appropriate treatment of patients with TB should become a priority, which requires strong commitment and collaboration among health organisations and greater compliance with TB treatment guidelines by service providers and patients.

Catastrophic Health Expenditure and Rural Household Impoverishment in China: What Role Does the New Cooperative Health Insurance Scheme Play?

Objective To determine whether the New Cooperative Medical Insurance Scheme (NCMS) is associated with decreased levels of catastrophic health expenditure and reduced impoverishment due to medical expenses in rural households of China. Methods An analysis of a national representative sample of 38,945 rural households (129,635 people) from the 2008 National Health Service Survey was performed. Logistic regression models used binary indicator of catastrophic health expenditure as dependent variable, with household consumption, demographic characteristics, health insurance schemes, and chronic illness as independent variables. Results Higher percentage of households experiencing catastrophic health expenditure and medical impoverishment correlates to increased health care need. While the higher socio-economic status households had similar levels of catastrophic health expenditure as compared with the lowest. Households covered by the NCMS had similar levels of catastrophic health expenditure and medical impoverishment as those without health insurance. Conclusion Despite over 95% of coverage, the NCMS has failed to prevent catastrophic health expenditure and medical impoverishment. An upgrade of benefit packages is needed, and effective cost control mechanisms on the provider side needs to be considered.

Public reporting improves antibiotic prescribing for upper respiratory tract infections in primary care: a matched-pair cluster-randomized trial in China

BackgroundInappropriate use and overuse of antibiotics is a serious concern in the treatment of upper respiratory tract infections (URTIs), especially in developing countries. In recent decades, information disclosure and public reporting (PR) has become an instrument for encouraging good practice in healthcare. This study evaluated the impact of PR on antibiotic prescribing for URTIs in a sample of primary care institutions in China.MethodsA matched-pair cluster-randomized trial was undertaken in QJ city, with 20 primary care institutions participating in the trial. Participating institutions were matched into pairs before being randomly assigned into a control and an intervention group. Prescription statistics were disclosed to patients, health authorities, and health workers monthly within the intervention group, starting from October 2013. Outpatient prescriptions for URTIs were collected from both groups before (1st March to 31st May, 2013) and after the intervention (1st March to 31st May, 2014). A total of 34,815 URTI prescriptions were included in a difference-in-difference analysis using multivariate linear or logistic regression models, controlling for patient attributes as well as institutional characteristics.ResultsOverall, 90% URTI prescriptions required antibiotics and 21% required combined use of antibiotics. More than 77% of URTI prescriptions required intravenous (IV) injection or infusion of drugs. PR resulted in a 9 percentage point (95% CI -17 to -1) reduction in the use of oral antibiotics (adjusted RR =39%, P =0.027), while the use of injectable antibiotics remained unchanged. PR led to a 7 percentage point reduction (95% CI -14 to 0; adjusted RR =36%) in combined use of antibiotics (P =0.049), which was largely driven by a significant reduction in male patients (-7.5%, 95% CI -14 to -1, P =0.03). The intervention had little impact on the use of IV injections or infusions, or the total prescription expenditure.ConclusionsThe results suggest that PR could improve prescribing practices in terms of reducing oral antibiotics and combined use of antibiotics; however, the impacts were limited. We suggest that PR would probably be enhanced by provider payment reform, management and training for providers, and health education for patients.

Patient safety culture in China: a case study in an outpatient setting in Beijing

Objectives To investigate the patient safety culture in an outpatient setting in Beijing and explore the meaning and implications of the safety culture from the perspective of health workers and patients. Methods A mixed methods approach involving a questionnaire survey and in-depth interviews was adopted. Among the 410 invited staff members, 318 completed the Hospital Survey of Patient Safety Culture (HSOPC). Patient safety culture was described using 12 subscale scores. Inter-subscale correlation analysis, ANOVA and stepwise multivariate regression analyses were performed to identify the determinants of the patient safety culture scores. Interviewees included 22 patients selected through opportunity sampling and 27 staff members selected through purposive sampling. The interview data were analysed thematically. Results The survey respondents perceived high levels of unsafe care but had personally reported few events. Lack of ‘communication openness’ was identified as a major safety culture problem, and a perception of ‘penalty’ was the greatest barrier to the encouragement of error reporting. Cohesive ‘teamwork within units’, while found to be an area of strength, conversely served as a protective and defensive mechanism for medical practice. Low levels of trust between providers and consumers and lack of management support constituted an obstacle to building a positive patient safety culture. Conclusions This study in China demonstrates that a punitive approach to error is still widespread despite increasing awareness of unsafe care, and managers have been slow in acknowledging the importance of building a positive patient safety culture. Strong ‘teamwork within units’, a common area of strength, could fuel the concealment of errors.

Identifying determinants of socioeconomic inequality in health service utilization among patients with chronic non-communicable diseases in China.

Background People with chronic non-communicable diseases (NCD) are particularly vulnerable to socioeconomic inequality due to their long-term expensive health needs. This study aimed to assess socioeconomic-related inequality in health service utilization among NCD patients in China and to analyze factors associated with this disparity. Methods Data were taken from the 2008 Chinese National Health Survey, in which a multiple stage stratified random sampling method was employed to survey 56,456 households. We analyzed the distribution of actual use, need-expected use, and need-standardized usage of outpatient services (over a two-week period) and inpatient services (over one-year) across different income groups in 27,233 adult respondents who reported as having a NCD. We used a concentration index to measure inequality in the distribution of health services, which was expressed as HI (Horizontal Inequity Index) for need-standardized use of services. A non-linear probit regression model was employed to detect inequality across socio-economic groups. Results Pro-rich inequity in health services among NCD patients was more substantial than the average population. A higher degree of pro-rich inequity (HI = 0.253) was found in inpatient services compared to outpatient services (HI = 0.089). Despite a greater need for health services amongst those of lower socio-economic status, their actual use is much less than their more affluent counterparts. Health service underuse by the poor and overuse by the affluent are evident. Household income disparity was the greatest inequality factor in NCD service use for both outpatients (71.3%) and inpatients (108%), more so than health insurance policies. Some medical insurance schemes, such as the MIUE, actually made a pro-rich contribution to health service inequality (16.1% for outpatient and 12.1% for inpatient). Conclusions Inequality in health services amongst NCD patients in China remains largely determined by patient financial capability. The current insurance schemes are insufficient to address this inequity. A comprehensive social policy that encompasses a more progressive taxation package and redistribution of social capital as well as pro-poor welfare is needed.

Inequality in the distribution of health resources and health services in China: hospitals versus primary care institutions

BackgroundEquity is one of the major goals of China’s recent health system reform. This study aimed to evaluate the equality of the distribution of health resources and health services between hospitals and primary care institutions.MethodsData of this study were drawn from the China Health Statistical Year Books. We calculated Gini coefficients based on population size and geographic size, respectively, for the indicators: number of institutions, number of health workers and number of beds; and the concentration index (CI) for the indicators: per capita outpatient visits and annual hospitalization rates.ResultsThe Gini coefficients against population size ranged between 0.17 and 0.44 in the hospital sector, indicating a relatively good equality. The primary care sector showed a slightly higher level of Gini coefficients (around 0.45) in the number of health workers. However, inequality was evident in the geographic distribution of health resources. The Gini coefficients exceeded 0.7 in the geographic distribution of institutions, health workers and beds in both the hospital and the primary care sectors, indicating high levels of inequality. The CI values of hospital inpatient care and outpatient visits to primary care institutions were small (ranging from -0.02 to 0.02), indicating good wealth-related equality. The CI values of outpatient visits to hospitals ranged from 0.16 to 0.21, indicating a concentration of services towards the richer populations. By contrast, the CI values of inpatient care in primary care institutions ranged from -0.24 to -0.22, indicating a concentration of services towards the poorer populations. The eastern developed region also had a high internal inequality compared with the other less developed regions.ConclusionSignificant inequality in the geographic distribution of health resources is evident, despite a more equitable per capita distribution of resources. Richer people are more likely to use well-resourced hospitals for outpatient care. By contrast, poorer people are more likely to use poorly-resourced primary care institutions for inpatient care. There is a risk of the emergence of a two-tiered health care delivery system.

Is traditional rural lifestyle a barrier for quality of life assessment? A case study using the Short Form 36 in a rural Chinese population.

PurposeThe majority of existing quality of life measures are based on urban-living environments. This study aimed at exploring the validity of using an urban-lifestyle-based health questionnaire with individuals living a traditional rural lifestyle.MethodsThe Short Form-36 (SF-36) interview was administered to 1603 rural Chinese residents. Semantic ambiguity of the items was investigated using tests of internal consistency, test–retest reliability, exploratory factor analysis, and clustering and ordering of item mean scores. The self-explanations from the respondents were adopted to interpret the implications of the changes in meanings of the items.ResultsCronbach’s α reliability coefficients were high, whereas test–retest reliabilities were low. Consistent with the original factor structure, eight factors were extracted using exploratory factor analysis. However, the composition of these eight factors was not in full accordance with the priori assignment of items to scales. Seven items violated the clustering and ordering of item mean scores. The association between the identified problems in validity and the change in semantic meanings in the context of the rural lifestyle was established.ConclusionsQuality of life assessment instruments based on urban-living arrangements may not be reliably used with individuals living in rural environments.