Does unequal economic development contribute to the inequitable distribution of healthcare resources? Evidence from China spanning 2001-2020.

BACKGROUND: There is a dearth of research combining geographical big data on medical resource allocation and growth with various statistical data. Given the recent achievements of China in economic development and healthcare, this study takes China as an example to investigate the dynamic geographical distribution patterns of medical resources, utilizing data on healthcare resources from 290 cities in China, as well as economic and population-related data. The study aims to examine the correlation between economic growth and spatial distribution of medical resources, with the ultimate goal of providing evidence for promoting global health equity. METHODS: The data used in this study was sourced from the China City Statistical Yearbook from 2001 to 2020. Two indicators were employed to measure medical resources: the number of doctors per million population and the number of hospital and clinic beds per million population. We employed dynamic convergence model and fixed-effects model to examine the correlation between economic growth and the spatial distribution of medical resources. Ordinary least squares (OLS) were used to estimate the ß values of the samples. RESULTS: The average GDP for all city samples across all years was 36,019.31 ± 32,029.36, with an average of 2016.31 ± 1104.16 doctors per million people, and an average of 5986.2 ± 6801.67 hospital beds per million people. In the eastern cities, the average GDP for all city samples was 47,672.71 ± 37,850.77, with an average of 2264.58 ± 1288.89 doctors per million people, and an average of 3998.92 ± 1896.49 hospital beds per million people. Cities with initially low medical resources experienced faster growth (all ß < 0, P < 0.001). The long-term convergence rate of the geographic distribution of medical resources in China was higher than the short-term convergence rate (|ßi + 1| > |ßi|, i = 1, 2, 3, …, 9, all ß < 0, P < 0.001), and the convergence speed of doctor density exceeded that of bed density (bed: |ßi| >doc: |ßi|, i = 3, 4, 5, …, 10, P < 0.001). Economic growth significantly affected the convergence speed of medical resources, and this effect was nonlinear (doc: ßi < 0, i = 1, 2, 3, …, 9, P < 0.05; bed: ßi < 0, i = 1, 2, 3, …, 10, P < 0.01). The heterogeneity between provinces had a notable impact on the convergence of medical resources. CONCLUSIONS: The experiences of China have provided significant insights for nations worldwide. Governments and institutions in all countries worldwide, should actively undertake measures to actively reduce health inequalities. This includes enhancing healthcare standards in impoverished regions, addressing issues of unequal distribution, and emphasizing the examination of social determinants of health within the domain of public health research.

Lifestyle factors and subjective well­being among older adults in China: A national community-based cohort study.

There has been limited research on the relationship between health habits and subjective well-being (SWB) among Chinese oldest older adults. This study aims to explore lifestyle factors associated with SWB in this population. We analyzed data from three waves (2008-2014) of the CLHLS, including 28,683 older adults. Lifestyle factors analyzed included fruit and vegetable intake, smoking, alcohol consumption, physical exercise, and social participation. Results suggested that high frequency of fruit and vegetable intake, current and past physical exercise, and high levels of social participation were associated with increased SWB. SWB was lower in older adults who never smoked compared to persistent smokers and in those who never drank alcohol or ceased drinking compared to persistent drinkers. We encourage older adults to enhance SWB through increased fruit and vegetable intake, physical exercise, and social participation. However, quitting smoking and drinking may not necessarily improve SWB, particularly in the context of China.

The mechanisms underlying the negative effect of socioeconomic status on depressive symptoms among older adults: The roles of social support and living arrangement.

OBJECTIVES: Previous studies have found an association between socioeconomic status (SES) and depressive symptoms among older adults, however the mechanisms underlying this association remained unclear. This study aimed to examine the mediating role of social support and the moderating role of living arrangement in the association between SES and depressive symptoms. METHODS: Data was collected from the 2020 Household Health Interview Survey in Taian city, Shandong Province, China. A total of 3896 older adults aged 60 and above were included in this study. Depressive symptoms was measured by the Patient health Questionnaire-9 (PHQ-9), Social support by the Multidimensional Scale of Perceived Social Support (MSPSS), and other variables by related demographic scales. The moderated mediation model was examined using HAYES PROCESS 3.5. RESULTS: SES negatively predicted depressive symptoms among older adults, and social support could mediate this association. Living arrangement played a moderating role in the relationship between social support and depressive symptoms (the second half of the mediating effect), and the effect was stronger among older adults who lived alone. CONCLUSIONS: Social support partially mediated the relationship between SES and depressive symptoms among older adults, and living alone strengthened the effect of social support on depressive symptoms. Interventions that address older adults' social support and living arrangement may ameliorate depressive symptoms among older adults.

Association and mediators between the impact of oral health-related quality of life and depression.

OBJECTIVES: Our research intended to explore the association and mediators (perceived social support and sleep quality) between the impact of oral health-related quality of life (OHRQoL) and depression among Chinese older adults. METHODS: A stratified, multi-stage random sampling approach was used in our study. A total of 3896 older individuals aged 60 years and older were included. Process macro 3.5 for SPSS was utilized for testing mediation hypotheses. RESULTS: The mean score of the OHRQoL of the elderly was 3.26 ± 7.15. The correlation coefficient between OHRQoL and depression was 0.25 (p < 0.001). Perceived social support (ß = 0.009, 95% CI = 0.006, 0.012) and sleep quality (ß = 0.073, 95% CI = 0.074, 0.093) mediated the relationship between OHRQoL and depression, respectively. The association between OHRQoL and depression was mediated sequentially by perceived social support and sleep quality (ß = 0.004, 95% CI = 0.002, 0.006). CONCLUSIONS: The participants reported relatively good OHRQoL. OHRQoL and depression showed a significant positive correlation. The relationship between OHRQoL and depression among Chinese seniors was mediated by perceived social support and sleep quality. Both directly and indirectly, OHRQoL can affect depression.

Pathways linking relative deprivation to blood pressure control: the mediating role of depression and medication adherence among Chinese middle-aged and older hypertensive patients.

BACKGROUND: Studies have demonstrated that individuals of low socioeconomic status have higher blood pressure. Yet, whether socioeconomic inequality would influence blood pressure control and the underlying mechanisms associated with socioeconomic inequality in blood pressure control are unknown. Central to socioeconomic inequality is relative deprivation. We aim to examine the association between relative deprivation and blood pressure control and to investigate the pathways of the association among middle-aged and older adults with hypertension. METHODS: Data were collected from the 2020 Household Health Interview Survey in Taian City, Shandong province. This study included 2382 eligible respondents aged 45 years and older with a diagnosis of hypertension. Our primary outcome was dichotomous blood pressure control. Relative deprivation was calculated with the Deaton Index. Depressive symptoms and medication adherence were considered as mediators. Multivariable binary logistic regression models were used to estimate the effect of relative deprivation on blood pressure control. The "KHB-method" was used to perform mediation analysis. RESULTS: Among 2382 middle-aged and older adults with hypertension, the mean age was 64.9 years (SD 9.1), with 61.3% females. The overall proportion of participants with uncontrolled blood pressure was 65.1%. Increased relative deprivation was likely to have higher odds of uncontrolled blood pressure (OR: 2.35, 95%CI: 1.78-7.14). Furthermore, depressive symptoms and medication adherence partially mediated the overall association between relative deprivation and blood pressure control, with depressive symptoms and medication adherence explaining 5.91% and 37.76%, respectively, of the total effect of relative deprivation on blood pressure control. CONCLUSIONS: Individual relative deprivation could threaten blood pressure control among middle-aged and older hypertension patients through the mechanisms of depression and medication adherence. Hence, improving blood pressure control may require more than just health management and education but fundamental reform of the income distribution and social security system to narrow the income gap, reducing relative economic deprivation. Additionally, interventions tailoring psychological services and medication adherence could be designed to reduce the harmful effect of relative deprivation on blood pressure control among disadvantaged individuals.

Relationship between hearing loss and depression symptoms among older adults in China: The mediating role of social isolation and loneliness.

OBJECTIVES: To evaluate whether social isolation and loneliness mediates the relationship between hearing loss and depression symptoms in older adults in China. METHODS: A cross-sectional analysis was conducted of 3769 participants (aged≥60 years) in Shandong province of China. Hearing loss was assessed using Pure-Tone Audiometry test, depression symptoms using 15-item Geriatric Depression Scale, loneliness through UCLA Loneliness Scale and social isolation using Lubben Social Network Scale. Regression and bootstrap analyses were performed to test both direct associations of hearing loss and depression symptoms, and whether the mediating role of social isolation and loneliness. RESULTS: Overall, 44% of older adults had hearing loss, which was generally mild (30%) rather than moderate (10%), severe (3%) or profound (0.6%). Increasing levels of hearing loss was associated with increasing levels of social isolation and depressions. Hearing loss was also associated with loneliness, but here a threshold effect was apparent and no trend for increasing loneliness with increasing hearing loss. Models that included social isolation and loneliness showed an amelioration in the association of hearing loss and depression, although it remained significant at all levels of hearing loss. Overall, 8% of the total effect of hearing loss on depression symptoms was explained by the mediated effect through social isolation and 42% by loneliness. CONCLUSIONS: Psychosocial factors such as social isolation and loneliness might explain the association between hearing loss and depression. Interventions that address older adults' social isolation and loneliness may ameliorate depression in older adults with hearing loss.

Hearing impairment and loneliness in older adults in Shandong, China: the modifying effect of living arrangement.

BACKGROUND: Hearing impairment is a highly prevalent condition and potential risk factor of loneliness in older adults. There is little evidence on whether living arrangement modifies the effects of hearing impairment on loneliness in older adults. AIMS: (1) Explore the relationship between hearing impairment and loneliness in old adults; (2) investigate the modifying effect of living arrangement on the association between hearing impairment and loneliness. METHODS: A cross-sectional analysis was conducted of 7070 participants (aged 60-101) in Shandong province of China. Hearing impairment was measured by a single self-reported question. Variables about social demography and physical functioning were assessed using self-administered questionnaires, and loneliness using short-form UCLA Loneliness Scale. Linear regression models were performed to evaluate the association between hearing impairment and loneliness and possible effect modified by living arrangement. RESULTS: After controlling variables, older adults with hearing impairment reported significantly higher levels of loneliness than those with normal hearing (ß = 0.024; P < 0.001). Living arrangement has a significant modifying effect on association between hearing impairment and loneliness. CONCLUSIONS: Our results underscored the potential impact of hearing impairment on loneliness in older adults, and also suggested that having adult children in the same village/community may play a protective role in reducing the loneliness of older adults with hearing impairment.

Rural-urban differences in home-based care willingness among older adults: A cross-sectional study in Shandong, China.

OBJECTIVE: To examine the rural-urban disparities of home-based care willingness among older adults and identify the influencing factors. DESIGN: A cross-sectional study. SETTING: The data used in this cross-sectional study were conducted in Shandong province. STUDY PARTICIPANTS: 7070 older adults (60 years and older) with complete data were included in this analysis from the 2017 Survey of the Shandong Elderly Family Health Service. INTERVENTION: N/A. MAIN OUTCOME MEASURE: The data were analyzed using logistic regression models to examine whether socio-demographic characteristic, physical health, loneliness score and other factors were associated with home-based care willingness in rural and urban older adults. After exploring the factors, we compared the difference. RESULTS: Of 7070 participants, 66.9% were rural older adults and 33.1% were urban. The urban older adults less likely chose home-based care than the rural (OR = 0.667; P < 0.05). Binary logistic regression analysis showed that age (P < 0.05), income (P < 0.05), current employment (P < 0.05) and loneliness (P < 0.05) were significantly associated with the home-based care willingness both in rural and urban residence. Besides, the number of family members (P = 0.010), education years (P = 0.026) and financial support from children (P = 0.017) were associated factors of rural respondents' home-based care willingness. The bad self-reported-health-status-urban-older adults (P = 0.026) were more willing for home-based care. CONCLUSIONS: The research we have done suggests that there is a residence difference toward home-based care willingness among older adults. Targeted policies and an age-friendly environment should be made for different subgroups of older adults.

Gender difference in the association of frailty and health care utilization among Chinese older adults: results from a population-based study.

BACKGROUND: Frailty is a public health concern in the ageing population. Little is known about the role of gender in the relationship between frailty and health care utilization in older adults. AIMS: The study aims to examine gender differences in the association between different frailty status and health care utilization among Chinese older people. METHODS: A total of 7070 older adults (60+) from Shandong Province, China, were enrolled in this study. Frailty was assessed by frailty index constructed using 45 health deficits. Multivariate logistic regression models were employed separately for men and women to examine the impact of frailty on self-care, outpatient, and inpatient utilization. RESULTS: Overall, the prevalence of frailty was 7.9% in older adults, with 7.1% and 8.3% in men and women, respectively. 49.4% respondents reported they had self-care in the previous 2 weeks, and women were more likely to have self-care than men. Being pre-frail and frail was significantly associated with utilization of all types of health care among older men and women, and the relationship was stronger in the frail groups than that in the pre-frail groups except for self-care. Respective odds ratios for outpatient utilization were higher in men than that in women. CONCLUSIONS: Frailty is a frequent condition in Chinese older adults. The association between frailty and health care utilization (except outpatient) tended to be stronger in women than men. The gender differences should be considered when designing the preventing or delaying the installation of frailty and geriatric care plans.

Gender difference in suicidal ideation and related factors among rural elderly: a cross-sectional study in Shandong, China.

BACKGROUND: Suicide is a global public health problem which has significant negative influence on individuals, families and the society. The aim of this study is to investigate the prevalence of suicidal ideation and related factors among elderly people in rural China, and further examine the gender differences of suicidal ideation. METHODS: Data were collected from the 2017 Survey of the Shandong Elderly Family Health Service, which was conducted by Shandong University. A total of 5514 elderly aged 60 and above from rural Shandong were included in this study. Binary logistic regression model was performed to examine the gender difference towards suicidal ideation, and to identify the influencing factors of suicidal ideation by gender among elderly. RESULTS: 7.7% rural elderly reported suicidal ideation in the past 12 months in Shandong, China. The prevalence of suicidal ideation among females was significantly higher than that among males (P < 0.001). Education level, debts, stress of daily life, loneliness and psychological distress were significantly related to suicidal ideation in both males and females. Besides, negative life events and life satisfaction were found to be significantly associated with suicidal ideation in females but not in males. CONCLUSIONS: There was a significant gender difference towards suicidal ideation among rural elderly in Shandong, China. So, gender difference should be considered when medical practitioners and public health workers seek to prevent and manage suicidal ideation among rural elderly, which will be important to develop strategies for coping with risk factors for suicidal ideation among males and females. In other words, more attention should be paid to females who had encountered negative life event or with lower life satisfaction.

Association between frailty and life satisfaction among older people in Shandong, China: the differences in age and general self-efficacy.

BACKGROUND: Frailty and other functional declines may be related to life satisfaction (LS) in the general elderly population. This study aims to investigate the association between frailty and LS among older individuals (age ≥60) and the impacts of age and general self-efficacy on the relationships. METHODS: Using data from the 2017 Survey of the Shandong elderly Family Health Service, a cross-sectional study was conducted and 7070 older people aged 60+ were analysed. LS was measured using the Satisfaction with Life Scale. A Frailty Index (ranged 0~1) was determined as a proportion of accumulated deficits over 51 categories. General self-efficacy was measured using the Chinese version of the General Self-Efficacy Scale. Multiple weighted linear regression was used to examine possible relationships between the research variables. RESULTS: There was a negative association between frailty and LS. A dose-response-type relationship between net income and LS was observed. The interaction between frailty and age was found to be significantly associated with LS. Frailty has a stronger negative impact on LS among the young-old (60-69 years) than among the middle-old (70-79 years) and old-old (80+ years), which suggests a protective effect of ageing on LS reduction due to frailty. However, this protective effect was observed among individuals with low and medium level self-efficacy. CONCLUSIONS: The relationship between frailty and LS generally weaken with age. The higher level of general self-efficacy may provide a partial buffer against the negative impact of frailty on LS. Interventions that target to prevent and manage frailty should consider being prioritised among the young-old population. Development of self-efficacy could serve as an important strategy to buffer the negative effect of frailty on LS among older people.

Isolation measures and protection awareness are significant for latent tuberculosis infection: a cross-sectional study based on T-SPOT.TB among health care workers in China.

This study aimed to reveal the associated risk factors for latent tuberculosis infection (LTBI) detected by T-SPOT.TB assay among health care workers (HCWs) at different working locations or job categories in China. This cross-sectional study included 934 HCWs who underwent the T-SPOT.TB assay. Demographic and social characteristics of the participants, including age, sex, job categories, department/ward and duration of healthcare service, were recorded. Among 934 HCWs, 267 (28.5867%) were diagnosed as having LTBI with positive T-SPOT.TB assay. HCWs working in inpatient tuberculosis (TB) (odds ratio (OR) 2.917; 95% confidence interval (CI) 1.852-4.596; P < 0.001) and respiratory wards (OR 1.840; 95% CI 1.124-3.011; P = 0.015), and with longer duration of healthcare service (OR 1.048; 95% CI 1.016-1.080; P = 0.003) were risk factors for positive T-SPOT.TB result. Furthermore, longer working duration increased the positive rate of T-SPOT.TB results for physicians and nurses, and physicians had higher risks than nurses for the same working duration. Inpatient TB and respiratory wards were high-risk working locations for HCWs with LTBI, and longer duration of healthcare service also increased the risk of LTBI among HCWs. A complete strategy for TB infection control and protection awareness among HCWs should be enhanced.

Health care utilization and affordability among older people following China's 2009 health reform -- evidence from CHARLS pilot study.

BACKGROUND: In 2009, China unveiled an ambitious national health care reform program, with the goal of providing equitable and affordable basic health care for everyone. This study was intended to partially fill the knowledge gap in understanding of the demand-side impact on health care utilization and affordability among older people in Zhejiang and Gansu provinces of China. METHODS: We used two waves of data from the pilot survey of CHARLS implemented in 2008 and 2012. Chi-square tests and t tests were performed to examine whether out-of-pocket (OOP) and pharmaceutical spending (PS), as a share of total health expenditures (THEs), have significantly changed following the health reform. Two-part model was employed to confirm these changes after controlling for confounding variables. All analyses were weighted and clustered the standard errors. RESULTS: After controlling for confounding variables, older people in 2012 were 2.1 and 6.8% more likely to use outpatient and inpatient care than they did in 2008, respectively. Among those who have at least one outpatient visit, declines of OOP-to- THEs and PS-to-THEs percentage significantly reduced 0.998 (p < 0.1) and 2.324 (p < 0.01) from 2008 to 2012, respectively. However, conditional on having at least one inpatient stay, no significant reduction in terms of the OOP-to-THEs and even increase in terms of the PS-to-THEs percentage observed between 2008 and 2012. Compared to elderly people in Gansu, Zhejiang aged people had obviously better utilization, lighter inpatient OOP burden and lower inpatient PS proportion, but higher outpatient OOP burden and PS proportion. CONCLUSIONS: Although the OOP burden and PS portion had been reduced following the health reform, these impacts were still limited. Better results can be observed in outpatient care than in inpatient care, which provide a strong foundation for the next stage of reform.

Association between interpersonal trust and suicidal ideation in older adults: a cross-sectional analysis of 7070 subjects in Shandong, China.

BACKGROUNDS: Suicidal ideation is an important public health issue due to devastating mortality. In the meantime, interpersonal trust was found to be negatively associated with mental disorder and physical health. Although there is increasing evidence that interpersonal trust is a significant predictor of suicidal ideation, evidence of this association is still lacking in the developing world. The aim of this study was to test the association between interpersonal trust and suicidal ideation among older adults in China. METHODS: Using a multi-stage stratified sampling strategy, 7070 older adults aged 60 and above from Shandong Province, China were recruited in this study. Socio-demographic characteristics, health status, family relationship, psychological distress, interpersonal trust and suicidal ideation in the last 12 months were obtained through face to face interviews. The association between interpersonal trust and suicidal ideation was assessed using multiple logistic regression models adjusting for socio-demographic characteristics, health status, family relationship and psychological distress. RESULTS: 7.1% of participants reported suicidal ideation in the past 12 months, which was related to gender, resident area, marital status, educational level, self-rated economic, chronic disease, self-rated health status and family relationship within 1 month, psychological distress and interpersonal trust. After adjusting for sociodemographic factors, health status, family relationship and psychological distress, interpersonal mistrust was associated with two times odds of suicidal ideation when compared to interpersonal trust CONCLUSIONS: The interpersonal trust was associated with suicidal ideation among elderly in Shandong, China. Intervention approaches regarding inducing and promoting interpersonal trust should be developed to prevent suicide.

Gender differences in the association between body mass index and health-related quality of life among adults:a cross-sectional study in Shandong, China.

BACKGROUND: This study aims to assess the association between body mass index (BMI) and health-related quality of life (HRQOL), and to further explore gender differences in BMI-HRQOL association among adults. METHODS: We used data from the fifth Health Service Survey of Shandong Province, which was part of China's National Health Service Survey (NHSS), a total of 27,257 adults aged 18 and over were interviewed. The HRQOL was measured using the EuroQOL-5 Dimensions (EQ-5D) instrument. One-way ANOVA and Post hoc tests were used to compare EQ-5D utility values and visual analogue scale (VAS) scores between BMI categories. Tobit regression models were used to identify the association between BMI and HRQOL for male and female separately after controlling for influential confounders, and to assess gender differences on the relationship between BMI and HRQOL. RESULTS: The prevalence of underweight in men and women were 3.2 and 5.3%, respectively, while the prevalence of overweight/obesity in men and women were 35.7 and 34.6%, respectively. Men had higher EQ-5D utility values and VAS scores than women. The mean EQ-5D utility value and VAS score was highest in obese men and normal-weight women, respectively. After controlling potential confounders, being underweight was significantly and negatively associated with lower HRQOL among adults. The relationship between obesity and gender was that in women obesity was negatively and significantly associated with HRQOL, whereas in men this association was positive but not statistically significant. Results of gender by BMI interaction in regression model showed that this difference between men and women in this respect was significant. CONCLUSIONS: The association between BMI and HRQOL differed by gender and the so-called "obesity-HRQOL paradox" phenomenon was verified in male adults. Gender difference should be considered when implementing targeted weight control programs and appropriate interventions to improve HRQOL.

Job satisfaction of certified primary care physicians in rural Shandong Province, China: a cross-sectional study.

BACKGROUND: The purpose of this study was to measure the level of job satisfaction of certified physicians in rural primary health care facilities (PHCFs) in Shandong Province in order to ascertain the key factors affecting their satisfaction and to provide effective information for policy decisions. METHODS: This cross-sectional study was conducted among certified physicians in PHCFs in rural Shandong from June to August 2016. An anonymous questionnaire was completed by 495 participants (valid response rate: 91.6%). Data were analyzed using an exploratory factor analysis (EFA), one-way analysis of variance (ANOVA), and multiple linear regression. RESULTS: The participants consisted of 310 (62.6%) males and 185 (37.4%) females. The overall mean score for job satisfaction among respondents was 3.41 (standard deviation (SD) 0.68), which indicated that certified physicians were partially satisfied with their jobs. Results also indicated that factors for the highest level of satisfaction among certified physicians were the internal environment and job description. Moreover, physicians were more satisfied with competency behaviours and organizational management than with working conditions and job rewards. In contrast, physicians were dissatisfied with the external environment to an extent. Overall job satisfaction decreased with more years of service. Older physicians were less satisfied with their jobs than younger ones. Physicians with a higher level of education or senior professional title were less satisfied with their jobs than those with a lower level of education or junior professional tilte. Organizational management and the external environment were the most important factors influencing job satisfaction. CONCLUSION: Certified physicians working in PHCFs in rural Shandong had a slightly higher level of overall job satisfaciton than usual. After recent healthcare reforms, the job satisfaction of primary health care physicians in Shandong has changed little in comparison to that of physicians in other provinces in China. More attention should be paid to the impacts of these variables (age, educational background, technical title, monthly salary, form of employment, and years of service) on job satisfaction. Numerous recommendations may be considered to enhance organizational management and the external environment. The Government should enhace the formulation, implementation, and evaluation of policies to ensure that physicians continue to enjoy working in PHCFs. In short, the Government should pay more attention to protecting the legitimate rights and interests of primary care physicians when devising medical reforms.

Correction to: Cost-effectiveness analysis of rotavirus vaccination in China: Projected possibility of scale-up from the current domestic option.

After the publication of our article [1] we have been made aware of a number of mislabelling and reporting errors, which were introduced in the preparation of the manuscript. The conclusions are not affected by these errors and thus remain unchanged.

Estimating benefit equity of government health subsidy in healthcare Services in Shandong Province, China: a cross-sectional study.

BACKGROUND: Government health subsidy (GHS) is an effective tool to improve population health in China. Ensuring an equitable allocation of GHS, particularly among the poorer socio-economic groups, is a major goal of China's healthcare reform. The paper aims to explore how GHS was allocated across different socioeconomic groups, and how well the overall health system was performing in terms of the allocation of subsidy for different types of health services. METHODS: Data from China's National Health Services Survey (NHSS) in 2013 were used. Benefit incidence analysis (BIA) was applied to examine if GHS was equally distributed across income quintile. Benefit incidence was presented as each quintile's percentage share of total benefits, and the concentration index (CI) and Kakwani index (KI) were calculated. Health benefits from three types of healthcare services (primary health care, outpatient and inpatient services) were analyzed, separated into urban and rural populations. In addition, the distribution of benefits was compared to the distribution of healthcare need (measured by self-reported illness and chronic disease) across income quintiles. RESULTS: In urban populations, the CI value of GHS for primary care was negative. (- 0.14), implying an allocation tendency toward poor region; the CI values of outpatient and inpatient services were both positive (0.174 and 0.194), indicating allocation tendencies toward rich region. Similar allocation pattern was observed in rural population, with pro-poor tendency of primary care service (CI = - 0.082), and pro-rich tendencies of outpatient (CI = 0.153) and inpatient services (CI = 0.203). All the KI values of three health services in urban and rural populations were negative (- 0.4991,-0.1851 and - 0.1651; - 0.482, - 0.247and - 0.197), indicating that government health subsidy was progressive and contributed to the narrowing of economic gap between the poor and rich. CONCLUSIONS: The inequitable distribution of GHS in China exited in different healthcare services; however, the GHS benefit is generally progressive. Future healthcare reforms in China should not only focus on expanding the coverage, but also on improving the equity of distribution of healthcare benefits.

Rural-urban disparity in category II vaccination among children under five years of age: evidence from a survey in Shandong, China.

BACKGROUND: Compared with the Expanded Program on Immunization (EPI) vaccines, the coverage rate of the non-EPI vaccines is still low. The aim of this study is to explore the rural-urban disparity in category II vaccine and its determinants among children under 5 years old in China. METHODS: A cross-sectional study was conducted in 17 cities in Shandong province from August to October, 2013. A total of 1638 children were included in the analysis. Unadjusted and adjusted regression model were used to identify the rural-urban difference in vaccination of category II vaccine. Multivariate logistic regression models were employed to analyze the determinants associated with vaccination of category II vaccine in rural and urban areas respectively. RESULTS: The coverage rates of category II vaccine in rural and urban children were 81.5 and 69.4% respectively. Factors including age and satisfaction with vaccination services were associated with category II vaccination both in rural and urban children (Ρ < 0.05). It was also found that the households with four or less members are more likely to vaccinate category II vaccine in rural children. CONCLUSIONS: There was a big difference between rural and urban children in the use of category II vaccine. The government should strengthen financial support and regulation for the category II vaccine. The identified at-risk factors, including age, satisfaction with the vaccination services, and family size should be taken into account when designing targeted vaccination policies for rural and urban children.

Urban-rural disparities in health care utilization among Chinese adults from 1993 to 2011.

BACKGROUND: Despite economic growth and improved health outcomes over the past few decades, China still experiences striking urban-rural health inequalities. Urban and rural residents distinguished by the hukou system may experience profound disparities because of institutional effect. The aim of this study is to estimate trends in urban-rural disparities in self-care, outpatient care, and inpatient care utilization from a perspective of the hukou system. METHODS: Data were extracted from the seven latest waves of the China Health and Nutrition Survey (CHNS). We used the hukou system to distinguish between urban and rural residents. Chi-square tests were performed to examine urban-rural gaps in self-care, outpatient care, and inpatient care utilization. Multinomial logistic regression was employed to confirm these disparities and to explore whether the urban-rural gaps have narrowed or widened from 1993 to 2011 once known determinants of utilization are taken into account according to Andersen/Aday's Health Behaviour Model. RESULTS: The urban-rural disparities were evident after controlling for confounding variables: urban adults were 3.24 (p < 0.05), 2.23 (p < 0.1), and 4.77 (p < 0.01) times more likely to choose self-care vs. no care, outpatient care vs. no care, and inpatient care vs. no care than their rural counterparts, respectively. The results showed upward trends in self-care, outpatient care, and inpatient care utilization from 2004 to 2011. The urban-rural gaps in health care utilization gradually narrowed during the period of 1993-2011. The hukou distinctions of self-care, outpatient care, and inpatient care in 2011 were only 33.3%, 35.5%, and 9.6% of that in 1993, respectively. CONCLUSIONS: Although rural residents were underutilizing health care when compared to their urban counterparts, the significant decrements in urban-rural disparities reflect the positive effect of the on-going health system reform in China. To maintain an equitable distribution of health care utilization, policy makers need to be aware of challenges due to aging problems and health expenditure increment.