Quality in screening and measuring blood pressure in China's primary health care: a national cross-sectional study using unannounced standardized patients.

Background: This study aims to evaluate primary care providers' adherence to the standard of measuring blood pressure for people aged 35 or above during their initial visit, as per Chinese guidelines, and to identify factors affecting their practices. Methods: We developed 11 standardized patients (SP) cases as tracer conditions to evaluate primary care, and deployed trained SPs for unannounced visits to randomly selected providers in seven provinces of China. The SPs used a checklist based on guidelines to record whether and how blood pressure was measured. Data were analyzed descriptively and regression analysis was performed to examine the association between outcomes and factors such as provider, patient, facility, and clinical case characteristics. Findings: The SPs conducted 1201 visits and found that less than one-third of USPs ≥35 had their blood pressure measured. Only 26.9% of migraine and 15.4% of diabetes cases received blood pressure measurements. Additionally, these measurements did not follow the proper guidelines and recommended steps. On average, 55.6% of the steps were followed with few providers considering influencing factors before measurement and only 6.0% of patients received both-arm measurements. The use of wrist sphygmomanometers was associated with poor blood pressure measurement. Interpretation: In China, primary care hypertension screening practices fall short of guidelines, with infrequent initiation of blood pressure measurements and inadequate adherence to proper measurement steps. To address this, priority should be placed on adopting, implementing, and upholding guidelines for hypertension screening and measurement. Funding: National Natural Science Foundation of China, Swiss Agency for Development and Cooperation, Doctoral Fund Project of Inner Mongolia Medical University, China Postdoctoral Science Foundation.

Exploring causal mechanisms and essential factors in the prevention and control of chlamydia in Guangdong, Southern China: a study protocol.

BACKGROUND: Chlamydia Trachomatis (CT) is among the most prevalent sexually transmitted diseases (STDs) globally. According to the World Health Organization, more than 131 million people get infected with CT annually. CT is usually transmitted via sexual contact or perinatal exposure and can result in severe long-term complications. In developing nations, particularly, the prevention and control of CT is challenging. Hence, this study will explore the feedback mechanisms of chlamydia prevention and control, as well as identify the essential factors affecting the control and prevention of this infection in China. METHODS: Our study will employ a mixed-methods research design that encompasses both qualitative and quantitative methods. Firstly, we will develop a causal loop diagram (CLD) based on the literature review and optimize it via in-depth interviews with stakeholders. Additionally, we will utilize a quantitative method called MICMAC(Impact Matrix Cross-Reference Multiplication Applied to a Classification tool) to obtain consensus among different stakeholders and pinpoint the key information. Next, the CLD will be transformed into a system dynamics model (SDM) to evaluate the feedback mechanisms within the CLD. The causality in the CLD will be modeled using mathematical equations, which facilitate the transformation into an SDM. As such, we will be able to analyze the dynamic behavior of the system and its response to different decisions. DISCUSSION: Our study offers a systematic perspective on the control and prevention of chlamydia infection through system dynamics modeling, examining the dynamic properties and background factors of the system. The creation of the CLD affords stakeholders the chance to comprehend the functionality of their relationships and improve cooperation. Consequently, by evaluating the outcomes of these simulations, it will be possible to analyze and determine potential interventions and their effects on chlamydia infections. This modeling approach can help us gain insight into the dynamic characteristics of the system, evaluate the potential outcomes of different decisions, and design control strategies to either stabilize the system or adjust its behavior.

Improving eye care quality through brief verbal intervention on optometry service provider by using unannounced standardized patient with refractive error: study protocol for a randomized controlled trial.

BACKGROUND: Improper refractive correction can be harmful to eye health, aggravating the burden of vision impairment. During most optometry clinical consultations, practitioner-patient interactions play a key role. Maybe it is feasible for patients themselves to do something to get high-quality optometry. But the present empirical research on the quality improvement of eye care needs to be strengthened. The study aims to test the effect of the brief verbal intervention (BVI) through patients on the quality of optometry service. METHODS: This study will take unannounced standardized patient (USP) with refractive error as the core research tool, both in measurement and intervention. The USP case and the checklist will be developed through a standard protocol and assessed for validity and reliability before its full use. USP will be trained to provide standardized responses during optical visits and receive baseline refraction by the skilled study optometrist who will be recruited within each site. A multi-arm parallel-group randomized trial will be used, with one common control and three intervention groups. The study will be performed in four cities, Guangzhou and three cities in Inner Mongolia, China. A total of 480 optometry service providers (OSPs) will be stratified and randomly selected and divided into four groups. The common control group will receive USP usual visits (without intervention), and three intervention groups will separately receive USP visits with three kinds of BVI on the patient side. A detailed outcome evaluation will include the optometry accuracy, optometry process, patient satisfaction, cost information and service time. Descriptive analysis will be performed for the survey results, and the difference in outcomes between interventions and control providers will be compared and statistically tested using generalized linear models (GLMs). DISCUSSION: This research will help policymakers understand the current situation and influencing factors of refractive error care quality, and then implement precise policies; at the same time, explore short and easy interventions for patients to improve the quality of optometry service. TRIAL REGISTRATION: Chinese Clinical Trial Registry ChiCTR2200062819. Registered on August 19, 2022.

Validity of patients' online reviews at direct-to-consumer teleconsultation platforms: a protocol for a cross-sectional study using unannounced standardised patients.

INTRODUCTION: As direct-to-consumer teleconsultation (hereafter referred to as 'teleconsultation') has gained popularity, an increasing number of patients have been leaving online reviews of their teleconsultation experiences. These reviews can help guide patients in identifying doctors for teleconsultation. However, few studies have examined the validity of online reviews in assessing the quality of teleconsultation against a gold standard. Therefore, we aim to use unannounced standardised patients (USPs) to validate online reviews in assessing both the technical and patient-centred quality of teleconsultations. We hypothesise that online review results will be more consistent with the patient-centred quality, rather than the technical quality, as assessed by the USPs. METHODS AND ANALYSIS: In this cross-sectional study, USPs representing 11 common primary care conditions will randomly visit 253 physicians via the three largest teleconsultation platforms in China. Each physician will receive a text-based and a voice/video-based USP visit, resulting in a total of 506 USP visits. The USP will complete a quality checklist to assess the proportion of clinical practice guideline-recommended items during teleconsultation. After each visit, the USP will also complete the Patient Perception of Patient-Centeredness Rating. The USP-assessed results will be compared with online review results using the intraclass correlation coefficient (ICC). If ICC >0.4 (p<0.05), we will assume reasonable concordance between the USP-assessed quality and online reviews. Furthermore, we will use correlation analysis, Lin's Coordinated Correlation Coefficient and Kappa as supplementary analyses. ETHICS AND DISSEMINATION: This study has received approval from the Institutional Review Board of Southern Medical University (#Southern Medical Audit (2022) No. 013). Results will be actively disseminated through print and social media, and USP tools will be made available for other researchers. TRIAL REGISTRATION: The study has been registered at the China Clinical Trials Registry (ChiCTR2200062975).

Retention in care for type 2 diabetes management in Sub-Saharan Africa: A systematic review.

OBJECTIVE: Diabetes prevalence has risen rapidly in Sub-Saharan Africa, but rates of retention in diabetes care are poorly understood. We conducted a systematic review and meta-analysis to determine rates of retention in care of persons with type 2 diabetes. METHODS: We searched MEDLINE, Global Health and CINAHL online databases for cohort studies and randomised control trials (RCTs) published up to 12 October 2021, that reported retention in or attrition from care for patients with type 2 diabetes in Sub-Saharan Africa. Retention was defined as persons diagnosed with diabetes who were alive and in care or with a known outcome, while attrition was defined as loss from care. RESULTS: From 6559 articles identified, after title and abstract screening, 209 articles underwent full text review. Forty six papers met the inclusion criteria, comprising 22,610 participants. Twenty one articles were of RCTs of which 8 trials had 1 year or more of follow-up and 25 articles were of non-randomised studies of which 19 had 12 months or more of follow-up. A total of 11 studies (5 RCTs and 6 non-randomised) were assessed to be of good quality. Sixteen RCTs were done in secondary or tertiary care settings. Their pooled retention rate (95% CI) was 80% (77%, 84%) in the control arm. Four RCTs had been done in primary care settings and their pooled retention rate (95% CI) was 53% (45%, 62%) in the control arm. The setting of one trial was unclear. For non-randomised studies, retention rates (95% CI) were 68% (62%, 75%) among 19 studies done in secondary and tertiary care settings, and 40% (33%, 49%) among the 6 studies done in primary care settings. CONCLUSION: Rates of retention in care of people living with diabetes are poor in primary care research settings.

Standardising Training of Nurses in an Evidence-Based Psychosocial Intervention for Perinatal Depression: Randomized Trial of Electronic vs. Face-to-Face Training in China.

BACKGROUND: Rates of perinatal depression in China are high. The Thinking Healthy Programme is a WHO-endorsed, evidence-based psychosocial intervention for perinatal depression, requiring five days of face-to-face training by a specialist trainer. Given the paucity of specialist trainers and logistical challenges, standardized training of large numbers of nurses is a major challenge for scaling up. We developed an electronic training programme (e-training) which eliminates the need for specialist-led, face-to-face training. The aim of this study was to evaluate the effectiveness of the e-training compared to conventional face-to-face training in nursing students. METHODS: A single blind, non-inferiority, randomized controlled trial was conducted. One hundred nursing students from two nursing schools were randomly assigned to either e-training or conventional face-to-face training. RESULTS: E-training was not inferior to specialist-led face-to-face training immediately post-training [mean ENhancing Assessment of Common Therapeutic factors (ENACT) score (M) 45.73, standard deviation (SD) 4.03 vs. M 47.08, SD 4.53; mean difference (MD) -1.35, 95% CI; (-3.17, 0.46), p = 0.14]. There was no difference in ENACT scores at three months [M = 42.16, SD 4.85 vs. M = 42.65, SD 4.65; MD = -0.481, 95% CI; (-2.35, 1.39), p = 0.61]. CONCLUSIONS: E-training is a promising tool with comparative effectiveness to specialist-led face-to-face training. E-training can be used for training of non-specialists for evidence-based psychosocial interventions at scale and utilized where there is a shortage of specialist trainers, but practice under supervision is necessary to maintain competence. However, continued practice under supervision may be necessary to maintain competence.

Associations between CT pulmonary opacity score on admission and clinical characteristics and outcomes in patients with COVID-19.

This study investigated associations between chest computed tomography (CT) pulmonary opacity score on admission and clinical features and outcomes in COVID-19 patients. The retrospective multi-center cohort study included 496 COVID-19 patients in Jiangsu province, China diagnosed as of March 15, 2020. Patients were divided into four groups based on the quartile of pulmonary opacity score: ≤ 5%, 6-20%, 21-40% and 41% +. CT pulmonary opacity score was independently associated with age, single onset, fever, cough, peripheral capillary oxygen saturation, lymphocyte count, platelet count, albumin level, C-reactive protein (CRP) level and fibrinogen level on admission. Patients with score ≥ 41% had a dramatic increased risk of severe or critical illness [odds ratio (OR), 15.58, 95% confidence interval (CI) 3.82-63.53), intensive care unit (ICU)] admission (OR, 6.26, 95% CI 2.15-18.23), respiratory failure (OR, 19.49, 95% CI 4.55-83.40), and a prolonged hospital stay (coefficient, 2.59, 95% CI 0.46-4.72) compared to those with score ≤ 5%. CT pulmonary opacity score on admission, especially when ≥ 41%, was closely related to some clinical characteristics and was an independent predictor of disease severity, ICU admission, respiratory failure and long hospital stay in patients with COVID-19.

Kinetics of anti-SARS-CoV-2 IgG antibody levels and potential influential factors in subjects with COVID-19: A 11-month follow-up study.

We aim to study kinetics of anti-SARS-CoV-2 IgG antibody levels in subjects with COVID-19 for up to 11 months and the potential influential factors. The study was a prospective longitudinal study. The analyses were based on 77 serum/plasma samples with a mean of 4 samples per participant (range 1 - 18) in 20 participants with at least one positive Polymerase Chain Reaction testing result from 19 March 2020 up to 10 February 2021. Among the subjects (median age 34.5 years, 65% male), IgG level declined with the follow-up time (per month; geometric mean ratio [GMR] 0.73; 95% CI, 0.72 - 0.74). In a small sample of subjects from the general population with COVID-19, IgG levels declined non-linearly from month 2 to 11 with individual heterogeneity in quantity and changing speed and may be associated with gender, race and the loss of smell and taste.

A nomogram predicting severe COVID-19 based on a large study cohort from China.

BACKGROUND: The use of accurate prediction tools and early intervention are important for addressing severe coronavirus disease 2019 (COVID-19). However, the prediction models for severe COVID-19 available to date are subject to various biases. This study aimed to construct a nomogram to provide accurate, personalized predictions of the risk of severe COVID-19. METHODS: This study was based on a large, multicenter retrospective derivation cohort and a validation cohort. The derivation cohort consisted of 496 patients from Jiangsu Province, China, between January 10, 2020, and March 15, 2020, and the validation cohort contained 105 patients from Huangshi, Hunan Province, China, between January 21, 2020, and February 29, 2020. A nomogram was developed with the selected predictors of severe COVID-19, which were identified by univariate and multivariate logistic regression analyses. We evaluated the discrimination of the nomogram with the area under the receiver operating characteristic curve (AUC) and the calibration of the nomogram with calibration plots and Hosmer-Lemeshow tests. RESULTS: Three predictors, namely, age, lymphocyte count, and pulmonary opacity score, were selected to develop the nomogram. The nomogram exhibited good discrimination (AUC 0.93, 95% confidence interval [CI] 0.90-0.96 in the derivation cohort; AUC 0.85, 95% CI 0.76-0.93 in the validation cohort) and satisfactory agreement. CONCLUSIONS: The nomogram was a reliable tool for assessing the probability of severe COVID-19 and may facilitate clinicians stratifying patients and providing early and optimal therapies.

A mixed method study to examine the mental health problems of college students who had left-behind experiences.

BACKGROUND: China's rapid urbanization has created a large number of labour transferring from rural to urban areas and large numbers of college students with left-behind experience (LBE). LBE was an important influencing factor on college students' mental health. METHODS: A mixed method involving quantitative survey and qualitative interview was emplyed to explore the influence of LBE on mental health of college students. In the quantitative survey, 1605 college students from three different universities of Shandong province in China were recruited. Their mental health status was measured using Symptom Check-list 90(SCL-90 scale) compiled by American psychologist Derogatis. In the qualitative interview, 40 college students with left-behind experience from the same three universities were interviewed. RESULTS: The prevalence estimate of total mental health problems among left-behind students was 2.14 times higher than that among those without left-behindexperience. LBE increased the problems of somatization, obsessive-compulsion (Ocd), international sensitivity, depression, anxiety, hostility, terror, paranoia, psychoticism and other symptoms. The result of qualitative interview showed the mental health problems of the college students with left-behind experience were mainly on anxiety, depression, Ocd, interpersonal sensitive and hostility, which was consistent with the results of quantitative survey. LIMITATION: Representativeness of the sample is the major limitation of our study. Due to rare similar studies performed in other countries, we could not compare the results in China to that in other countries. CONCLUSION: Left-behind experience was an important factor associated with the mental health of college students. The mental health of college students with LBE needs more attention.

Comparison of Depressive Symptoms and Its Influencing Factors among the Elderly in Urban and Rural Areas: Evidence from the China Health and Retirement Longitudinal Study (CHARLS).

Depression amongst the elderly population is a worldwide public health problem, especially in China. Affected by the urban-rural dual structure, depressive symptoms of the elderly in urban and rural areas are significantly different. In order to compare depressive symptoms and its influencing factors among the elderly in urban and rural areas, we used the data from the fourth wave of the China Health and Retirement Longitudinal Study (CHARLS). A total of 7690 participants at age 60 or older were included in this study. The results showed that there was a significant difference in the prevalence estimate of depression between urban and rural elderly (χ2 = 10.9.76, p < 0.001). The prevalence of depression among rural elderly was significantly higher than that of urban elderly (OR-unadjusted = 1.88, 95% CI: 1.67 to 2.12). After adjusting for gender, age, marital status, education level, minorities, religious belief, self-reported health, duration of sleep, life satisfaction, chronic disease, social activities and having income or not, the prevalence of depression in rural elderly is 1.52 times (OR = 1.52, 95% CI: 1.32 to 1.76) than that of urban elderly. Gender, education level, self-reported health, duration of sleep, chronic diseases were associated with depression in both urban and rural areas. In addition, social activities were connected with depression in urban areas, while minorities, marital status and having income or not were influencing factors of depression among the rural elderly. The interaction analysis showed that the interaction between marital status, social activities and urban and rural sources was statistically significant (divorced: coefficient was 1.567, p < 0.05; social activities: coefficient was 0.340, p < 0.05), while gender, education level, minorities, self-reported health, duration of sleep, life satisfaction, chronic disease, social activities having income or not and urban and rural sources have no interaction (p > 0.05). Thus, it is necessary to propose targeted and precise intervention strategies to prevent depression after accurately identifying the factors' effects.

Age differences in clinical features and outcomes in patients with COVID-19, Jiangsu, China: a retrospective, multicentre cohort study.

OBJECTIVES: To determine the age-specific clinical presentations and incidence of adverse outcomes among patients with COVID-19 in Jiangsu, China. DESIGN AND SETTING: Retrospective, multicentre cohort study performed at 24 hospitals in Jiangsu, China. PARTICIPANTS: 625 patients with COVID-19 enrolled between 10 January and 15 March 2020. RESULTS: Of the 625 patients (median age, 46 years; 329 (52.6%) men), 37 (5.9%) were children (18 years or younger), 261 (41.8%) young adults (19-44 years), 248 (39.7%) middle-aged adults (45-64 years) and 79 (12.6%) elderly adults (65 years or older). The incidence of hypertension, coronary heart disease, chronic obstructive pulmonary disease and diabetes comorbidities increased with age (trend test, p<0.0001, p=0.0003, p<0.0001 and p<0.0001, respectively). Fever, cough and shortness of breath occurred more commonly among older patients, especially the elderly, compared with children (χ2 test, p=0.0008, 0.0146 and 0.0282, respectively). The quadrant score and pulmonary opacity score increased with age (trend test, both p<0.0001). Older patients had many significantly different laboratory parameters from younger patients. Elderly patients had the highest proportion of severe or critically-ill cases (33.0%, χ2 test p<0.0001), intensive care unit use (35.4%, χ2 test p<0.0001), respiratory failure (31.6%, χ2 test p<0.0001) and the longest hospital stay (median 21 days, Kruskal-Wallis test p<0.0001). CONCLUSIONS: Elderly (≥65 years) patients with COVID-19 had the highest risk of severe or critical illness, intensive care use, respiratory failure and the longest hospital stay, which may be due partly to their having a higher incidence of comorbidities and poor immune responses to COVID-19.

Clinical characteristics and risk factors of patients with severe COVID-19 in Jiangsu province, China: a retrospective multicentre cohort study.

BACKGROUND: Coronavirus Disease-2019 (COVID-19) pandemic has become a major health event that endangers people health throughout China and the world. Understanding the factors associated with COVID-19 disease severity could support the early identification of patients with high risk for disease progression, inform prevention and control activities, and potentially reduce mortality. This study aims to describe the characteristics of patients with COVID-19 and factors associated with severe or critically ill presentation in Jiangsu province, China. METHODS: Multicentre retrospective cohort study of all individuals with confirmed Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2) infections diagnosed at 24 COVID-19-designated hospitals in Jiangsu province between the 10th January and 15th March 2020. Demographic, clinical, laboratory, and radiological data were collected at hospital admission and data on disease severity were collected during follow-up. Patients were categorised as asymptomatic/mild/moderate, and severe/critically ill according to the worst level of COVID-19 recorded during hospitalisation. RESULTS: A total of 625 patients, 64 (10.2%) were severe/critically ill and 561 (89.8%) were asymptomatic/mild/moderate. All patients were discharged and no patients died. Patients with severe/critically ill COVID-19 were more likely to be older, to be single onset (i.e. not belong to a cluster of cases in a family/community, etc.), to have a medical history of hypertension and diabetes; had higher temperature, faster respiratory rates, lower peripheral capillary oxygen saturation (SpO2), and higher computer tomography (CT) image quadrant scores and pulmonary opacity percentage; had increased C-reactive protein, fibrinogen, and D-dimer on admission; and had lower white blood cells, lymphocyte, and platelet counts and albumin on admission than asymptomatic/mild/moderate cases. Multivariable regression showed that odds of being a severe/critically ill case were associated with age (year) (OR 1.06, 95%CI 1.03-1.09), lymphocyte count (109/L) (OR 0.25, 95%CI 0.08-0.74), and pulmonary opacity in CT (per 5%) on admission (OR 1.31, 95%CI 1.15-1.51). CONCLUSIONS: Severe or critically ill patients with COVID-19 is about one-tenths of patients in Jiangsu. Age, lymphocyte count, and pulmonary opacity in CT on admission were associated with risk of severe or critically ill COVID-19.

Dynamic evolution of COVID-19 on chest computed tomography: experience from Jiangsu Province of China.

OBJECTIVES: To determine the patterns of chest computed tomography (CT) evolution according to disease severity in a large coronavirus disease 2019 (COVID-19) cohort in Jiangsu Province, China. METHODS: This retrospective cohort study was conducted from January 10, 2020, to February 18, 2020. All patients diagnosed with COVID-19 in Jiangsu Province were included, retrospectively. Quantitative CT measurements of pulmonary opacities including volume, density, and location were extracted by deep learning algorithm. Dynamic evolution of these measurements was investigated from symptom onset (day 1) to beyond day 15. Comparison was made between severity groups. RESULTS: A total of 484 patients (median age of 47 years, interquartile range 33-57) with 954 CT examinations were included, and each was assigned to one of the three groups: asymptomatic/mild (n = 63), moderate (n = 378), severe/critically ill (n = 43). Time series showed different evolution patterns of CT measurements in the groups. Following disease onset, posteroinferior subpleural area of the lung was the most common location for pulmonary opacities. Opacity volume continued to increase beyond 15 days in the severe/critically ill group, compared with peaking on days 13-15 in the moderate group. Asymptomatic/mild group had the lowest opacity volume which almost resolved after 15 days. The opacity density began to drop from day 10 to day 12 for moderately ill patients. CONCLUSIONS: Volume, density, and location of the pulmonary opacity and their evolution on CT varied with disease severity in COVID-19. These findings are valuable in understanding the nature of the disease and monitoring the patient's condition during the course of illness. KEY POINTS: • Volume, density, and location of the pulmonary opacity on CT change over time in COVID-19. • The evolution of CT appearance follows specific pattern, varying with disease severity.

Growth in syphilis-exposed and -unexposed uninfected children from birth to 18 months of age in China: a longitudinal study.

Early infant growth and development has attracted worldwide attention. Although numerous studies have demonstrated that maternal syphilis increases the risk of adverse pregnancy outcomes and congenital syphilis, the subsequent growth pattern and morbidity of syphilis-exposed uninfected infants are less understood. We conducted a longitudinal study to compare the growth pattern and disease distribution of syphilis-exposed and syphilis-unexposed uninfected children, and World Health Organization (WHO) reference standards from birth to 18 months of age. We obtained data from a prospective cohort study in three representative regions of Zhejiang Province in China. A total of 333 syphilis-uninfected children born to women with syphilis were recruited at birth and matched with 333 syphilis-uninfected children born to women without syphilis during pregnancy. Children were followed-up by medical staff every 3 months until 18 months of age. The mixed-effects model was used to compare changes in growth patterns and influencing factors between the two groups. Mean weight, length, and head circumference of children, as well as disease prevalence, were similar between the groups. Multilevel analysis indicated that, after controlling confounders, growth velocities were comparable in both weight and length measures from birth to 18 months old between the two groups; however, low birth weight had a negative impact on weight gain in both groups. There was no significant negative association between syphilis exposure and early growth and health in children, under 18 months in a setting with universal coverage of therapeutic interventions for maternal syphilis. These findings may contribute to improving prevention efforts for mother-to-child transmission of syphilis, such as early screening for syphilis in pregnant women, universal coverage of treatment, and interventions for exposed children. Children with low birth weight should be given priority as this is a risk factor for weight gain.