Xiaolin Wei

Tuberculosis (TB) is an infectious disease of major public health concern. The disease has demonstrated large space-time variations. This study aims to explore the space-time dynamics of TB cases in an economically and geographically dynamic province in China with specific references of TB control for policy makers. Data on all reported TB cases from 2009 to 2012 were collected from the TB program at the Zhejiang Provincial Center for Disease Control and Prevention. We employed time series and exploratory spatial data analyses, including Moran’s I, Local Getis’s G i * , and Kulldorff’s space-time scan statistics, to identify the temporal trends and spatial patterns of TB at a county level. A total of 147,941 TB cases were reported during 2009–2012 in Zhejiang. A higher proportion of TB cases were younger, male, and registered permanent residents among all TB cases notified in the province. TB cases were reported most frequently in April with small peaks in June, July, and October. This disease was spatially clustering with Moran’s I values ranged from 0.29 to 0.32 (p < 0.001). A most likely cluster and ten secondary clusters were identified, mainly concentrated in the southeast and west counties of the province. This study identified seasonal patterns and significant space-time clusters of TB cases in Zhejiang, China. Poverty, migration, and seasonal effects may play important roles in potential clusters.

Barriers to hospital and tuberculosis programme collaboration in China: context matters

Hypertension should be best managed under primary care settings. This study aimed to compare, between Shanghai and Shenzhen, the perceived quality of primary care in terms of accessibility, continuity, co-ordination, and comprehensiveness among hypertensive patients. A cross-sectional study was conducted in Shanghai and Shenzhen, China. Multistage random sampling method was used to select 8 community health centers. Data from primary care users were collected through on-site face-to-face interviews using the primary care assessment tool. Good quality standard was set as a value of 3 for each attribute and a value of 18 for total score. We included 568 patients in Shanghai and 128 patients in Shenzhen. Compared with those in Shenzhen, hypertensive patients in Shanghai reported a higher score in co-ordination of information (3.37 vs 3.66; P < 0.001), but lower scores in continuity of care (3.36 vs 3.27; P < 0.001), and comprehensiveness-service provision (3.26 vs 2.79; P < 0.001). There was no statistically significant difference in total scores between the 2 cities (18.19 vs 18.15). Over 3-quarters of hypertensive patients in both cities reported accessibility (97.2% vs 91.4%) and co-ordination of services (76.1% vs 80.5%) under good quality standard, while <1-quarter of them rated continuity of care (23.6% vs 22.7%), co-ordination of information (4.8% vs 21.1%), and comprehensiveness-service availability (15.1% vs 25.0%) under that standard. Compared with Shenzhen, the perceived quality of primary care for hypertensive patients in Shanghai was better in terms of co-ordination of information, but poorer on continuity of care and comprehensiveness-service provision. Our study suggests that there is room for quality improvement in both cities.

Objective: Shandong Province has implemented the standardised treatment of multidrug‐resistant tuberculosis (MDR‐TB) supported by the Global Fund. The study aimed to understand the managements and delays of patients with MDR‐TB before initiating their treatments.Methods: All patients with MDR‐TB who had completed intensive phase treatment from January 2010 to May 2012 were interviewed using a structured questionnaire. Delays and treatments were analysed. Diagnosis delay is defined as the period between having sputum smear results and drug susceptibility test (DST) results. Treatment delay was defined as starting MDR‐TB treatment more than 2 days after receiving the diagnosis of MDR‐TB. Total delay is the sum of diagnosis delay and treatment delay.Results: In total, 110 patients with MDR‐TB participated in the study. Median delay for diagnosis was 102 days. Over 80% of patients had a diagnosis delay longer than 90 days. MDR‐TB treatments commenced after a median of 9 days after DST results, and over 37% of the patients with MDR‐TB experienced treatment delays. Chronic cases or patients with indifferent attitude had significantly longer treatment delay than other groups (P = 0.03 and 0.03, respectively). During their delays, of 44 patients with retreatment failures, 12 (27.3%) were treated through adding single second line drugs (SLDs) to first‐line regimens, and 25 (56.8%) were treated with first‐line drugs. A high proportion of initial treatment failure/relapsed/returned cases (37%) and new cases (43%) were administered with SLDs.Conclusions: Most of the patients with MDR‐TB experienced prolonged diagnosis delay, which was the most important factor contributing to the total delay. Misuse of SLDs during the days was common, so necessary training should be given to prevent irrational prescription of medications.

There are three major models of primary care providers (Community Health Centers, CHCs) in China, i.e., government managed, hospital managed and privately owned CHCs. We performed a systematic review of structures and health care delivery patterns of the three models of CHCs. Studies from relevant English and Chinese databases for the period of 1997–2011 were searched. Two independent researchers extracted data from the eligible studies using a standardized abstraction form. Methodological quality of included articles was assessed with the Mixed Methods Appraisal Tool (MMAT). A total of 13 studies was included in the final analysis. Compared with the other two models, private CHCs had a smaller health workforce and lower share of government funding in their total revenues. Private CHCs also had fewer training opportunities, were less recognized by health insurance schemes and tended to provide primary care services of poor quality. Hospital managed CHCs attracted patients through their higher quality of clinical care, while private CHCs attracted users through convenience and medical equipment. Our study suggested that government and hospital managed CHCs were more competent and provided better primary care than privately owned CHCs. Further studies are warranted to comprehensively compare performances among different models of CHCs.

Hypertension, with a global prevalence of 40%, is a risk factor for cardiovascular diseases (CVD). We conducted an exploratory study in Zhejiang China to understand the prevention of CVD among hypertensive patients with a 10 year CVD risk of 20% or higher. We assessed current practices in a rural ‘township hospital’ (a primary care facility), and compared them with international evidence-based practice. A questionnaire survey was conducted to examine the use of modern drugs (antihypertensive drugs, statins and aspirin) and traditional drugs, compliance to medications and lifestyle among 274 hypertensive patients aged 40-74, with a CVD risk of 20% or higher (using the Asian Equation). The majority (72%) were diagnosed with hypertension at township hospitals. Only 15% of study participants used two anti-hypertensive drugs, 0.7% took statin and 2.9% aspirin. Only 2.9% combined two types of modern drugs, while 0.4% combined three types (antihypertensives, statins and aspirin). Herbal compounds, sometimes with internationally rarely recommended drugs such as Reserpine were taken by 44%. Analysis of drug adherence showed that 9.8% had discontinued their drug therapy by themselves. 16% had missed doses and these were on less anti-hypertensive drugs than those who did not (t=-5.217, P=0.003). Of all participants, 28% currently smoked, 39% drank regularly and only 21% exercised frequently. The average salt intake per day was 7.1 (±3.8) g, while the national recommended level is 6g. The study revealed outdated and inadequate treatment and health education for hypertensive patients, especially for those who have high risk scores for CVD. There is a need to review the community-based guidelines for hypertension management. Health providers and patients should make a transition from solely treating hypertension, towards prevention of CVD. Health system issues need addressing including improving rural health insurance cover and primary care doctors’ capacity to manage chronic disease patients.

Objectives Community health centres are the main form of provision of primary care in China. There are three models: government managed, hospital managed and private. Our aim was to describe and compare primary care under the three ownership models. Methods Four aspects of primary care were studied: services, organization, financing and human resources. Interviews were undertaken with 60 managerial and professional staff in 13 community health centres in the Pearl River Delta region in 2010. Three community health centres were selected in the capital city and two were selected from each of the other five cities. Thematic framework analysis was conducted. Results Government-managed community health centres received the largest public funding, followed by hospital-managed community health centres, while private community health centres received the least. Private community health centres were the smallest in scale and provided lower quality public health services compared with the other two models. Patient out-of-pocket costs accounted for the majority of the revenue in all models of community health centres despite improved government funding for preventive services. General challenges such as the shortage of public funding, the exclusion of migrants in the funding for preventive services, low capacity in human resources and the separation of clinical and preventive care in community health centres were identified in all three models of community health centres. Conclusions The ownership and management of a community health centre greatly influence the service it provides. Private community health centres are in a disadvantaged position to deliver high quality clinical and preventive care.

To assess changes in the quality of primary care in two megacities following the introduction of health system reforms in China. We conducted multistage stratified random face-to-face surveys of patients visiting community health centres in Shanghai in 2011 and 2013, and Shenzhen in 2012 and 2013. Quality of primary care was measured using an assessment tool. Difference-in-difference analyses based on multiple linear regressions were used to compare the changes over time, after controlling for potential confounders. Most (2721) of the 3214 participants used a community health centre as their regular source of care and were included in our analyses. The mean total scores for quality of primary care were similar for Shanghai and Shenzhen at baseline. In Shenzhen, the mean total scores for all participants and those on low incomes had worsened by 0.922 (95% CI: 0.629 to 1.215) and 1.203 (95% CI: 0.397 to 2.009), respectively. In Shanghai, however, there were improvements in the mean total scores which included increases in the scores for first-contact utilization, continuity, coordination of information and comprehensiveness. The quality of primary care improved in Shanghai but not in Shenzhen. This may be because, in Shanghai, beneficial long-term relationships between patients and general practitioners were supported by capitation payments and the provision of services tailored to the local health priorities.

Strong primary care is in urgent need for the management and control of hypertension. This study aimed to compare the quality of hypertensive care delivered by community health centers (CHCs) in Shanghai and Shenzhen. Multistage random sampling method was used to select 4 CHCs in each city as study settings. A cohort of hypertensive patients under the hypertensive management program in the CHCs was selected from the electronic information system by using a systematic random sampling method. Binary logistic regression models were constructed for comparison between the 2 cities. A total of 3196 patients’ records were assessed. The proportions of hypertensive patients who received advice on smoking cessation (33.8 vs 7.7%, P < 0.001), increasing physical activity (52.4 vs 16.8%, P < 0.001), low-sodium diet (72.0 vs 64.1%, P < 0.001), and regular follow-up (37.8 vs 8.6%, P < 0.001) were higher in Shenzhen than in Shanghai. However, the drug treatment rate in Shenzhen was lower than that in Shanghai (74.2 vs 95.2%, P < 0.001). The hypertension control rate in Shenzhen was lower than that in Shanghai (76.3 vs 83.2%, P < 0.001). Better performance in the process of hypertensive care in terms of increasing physical activity advice, low-sodium diet advice, regular follow-up, and drug prescription was associated with a higher rate of hypertension control. The study indicates that primary care is effective in managing hypertension irrespective of management and operation models of CHCs in urban China. Our study suggests that improvements in the process of hypertensive care may lead to better hypertension control.

Metabolic syndrome (MetSyn) increases the incidence of cardiovascular disease. Information on changes in prevalence of MetSyn in developing countries is limited. This study aims to compare MetSyn prevalence and its associated vascular risk over the period between 2002 and 2010 in a population which has had the world’s fastest economic development over the past three decades. Two health surveys were conducted by using the multistage cluster random sampling method in a Chinese population of 85 million in southern China. The participants received a full medical check-up, including measurement of blood pressure (BP), obesity indices, fasting lipids and glucose levels. Data describing socio-economic status and lifestyle factors were also collected through interview. Metabolic syndrome was defined in accordance with the International Diabetes Federation criteria. A total of 3,561 participants from Survey 2010 were included in the data analysis. Women had a significantly higher prevalence of MetSyn than men. Comparison between the two surveys shows that age-standardized prevalence of MetSyn increased fourfold (from 5.4% in 2002 to 21.3% in 2010) in those ≧ 20 years. Among the MetSyn components, prevalence of hyperglycaemia has increased most (from 9.1% to 53.1%). The age-standardized prevalence of central obesity, hypertension, hypertriglyceridaemia and low HDL-cholesterol increased from 13.5% to 25.4%, from 23.6% to 40.8%, from 12.1% to 17.4% and from 32.1% to 71.1%, respectively. Differences between rural and urban residents in the prevalence in MetSyn and its components narrowed in 2010. Cardiovascular risk escalated dramatically in this population between 2002 and 2010. The escalation may relate to the rapid economic development, which led to accelerating changes in nutrition, lifestyle, and socio-economic status. Our findings suggest that health transition in rapidly developing second- and third-world countries may be much faster than what has been observed in Western countries.