Comparing transmission potential networks based on social network surveys, close contacts and environmental overlap in rural Madagascar.

Social and spatial network analysis is an important approach for investigating infectious disease transmission, especially for pathogens transmitted directly between individuals or via environmental reservoirs. Given the diversity of ways to construct networks, however, it remains unclear how well networks constructed from different data types effectively capture transmission potential. We used empirical networks from a population in rural Madagascar to compare social network survey and spatial data-based networks of the same individuals. Close contact and environmental pathogen transmission pathways were modelled with the spatial data. We found that naming social partners during the surveys predicted higher close-contact rates and the proportion of environmental overlap on the spatial data-based networks. The spatial networks captured many strong and weak connections that were missed using social network surveys alone. Across networks, we found weak correlations among centrality measures (a proxy for superspreading potential). We conclude that social network surveys provide important scaffolding for understanding disease transmission pathways but miss contact-specific heterogeneities revealed by spatial data. Our analyses also highlight that the superspreading potential of individuals may vary across transmission modes. We provide detailed methods to construct networks for close-contact transmission pathogens when not all individuals simultaneously wear GPS trackers.

Food insecurity related to agricultural practices and household characteristics in rural communities of northeast Madagascar.

Ending hunger and alleviating poverty are key goals for a sustainable future. Food security is a constant challenge for agrarian communities in low-income countries, especially in Madagascar. We investigated agricultural practices, household characteristics, and food security in northeast Madagascar. We tested whether agricultural practices, demographics, and socioeconomics in rural populations were related to food security. Over 70% of respondents reported times during the last three years during which food for the household was insufficient, and the most frequently reported cause was small land size (57%). The probability of food insecurity decreased with increasing vanilla yield, rice yield, and land size. There was an interaction effect between land size and household size; larger families with smaller land holdings had higher food insecurity, while larger families with larger land had lower food insecurity. Other socioeconomic and agricultural variables were not significantly related to food insecurity, including material wealth, education, crop diversity, and livestock ownership. Our results highlight the high levels of food insecurity in these communities and point to interventions that would alleviate food stress. In particular, because current crop and livestock diversity were low, agricultural diversification could improve outputs and mitigate food insecurity. Development of sustainable agricultural intensification, including improving rice and vanilla cultivation to raise yields on small land areas, would likely have positive impacts on food security and alleviating poverty. Increasing market access and off-farm income, as well as improving policies related to land tenure could also play valuable roles in mitigating challenges in food security. SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1007/s12571-021-01179-3.

Adherence to Multidrug Resistant Tuberculosis Treatment and Case Management in Chongqing, China - A Mixed Method Research Study.

AIM: This paper evaluated the treatment adherence for multidrug-resistant tuberculosis (MDR-TB) and MDR-TB case management (MTCM) in Chongqing, China in order to identify factors associated with poor treatment adherence and case management. METHODS: Surveys with 132 MDR-TB patients and six in-depth interviews with health care workers (HCWs) from primary health centers (PHC), doctors from MDR-TB designated hospitals and MDR-TB patients were conducted. Surveys collected demographic and socio-economic characteristics, as well as factors associated with treatment and case management. In-depth interviews gathered information on treatment and case management experience and adherence behaviors. RESULTS: Patient surveys found the two main reasons for poor adherence were negative side-effects from the treatment and busy work schedules. In-depth interviews with key stakeholders found that self-perceived symptom improvement, negative side-effects from treatment and financial difficulties were the main reasons for poor adherence. MDR-TB patients from urban areas, who were unmarried, were female, had migrant status, and whose treatments were supervised by health care workers from primary health clinics, had poorer treatment adherence (P<0.05). Among the MDR-TB patients surveyed, 86.7% received any type of MTCM in general (received any kind of MTCM from HCWs in PHC, MDR-TB designated hospital and centers of disease control/TB dispensaries and 62.50% received MTCM from HCWs in PHC sectors). Patients from suburban areas were more likely to receive both MTCM in general (OR=6.70) and MTCM from HCWs in MDR-TB designated hospitals (OR=2.77), but female patients (OR=0.26) were less likely to receive MTCM from HCWs in PHC sectors, and patients who were not educated about MTCM by TB doctors in designated hospitals were less likely to receive MTCM in general (OR=0.14). Patients who had not been hospitalized were less likely to receive MTCM from HCWs in MDR-TB designated hospitals (OR=0.21). CONCLUSION: Stronger MTCM by HCWs in PHC sectors would improve treatment adherence among MDR-TB patients. Community-based patient-centered models of MTCM in PHC sectors and the use of digital health technology could help to improve case management and thereby improve adherence.

Reduction in healthcare services during the COVID-19 pandemic in China.

INTRODUCTION: The COVID-19 pandemic caused a healthcare crisis in China and continues to wreak havoc across the world. This paper evaluated COVID-19's impact on national and regional healthcare service utilisation and expenditure in China. METHODS: Using a big data approach, we collected data from 300 million bank card transactions to measure individual healthcare expenditure and utilisation in mainland China. Since the outbreak coincided with the 2020 Chinese Spring Festival holiday, a difference-in-difference (DID) method was employed to compare changes in healthcare utilisation before, during and after the Spring Festival in 2020 and 2019. We also tracked healthcare utilisation before, during and after the outbreak. RESULTS: Healthcare utilisation declined overall, especially during the post-festival period in 2020. Total healthcare expenditure and utilisation declined by 37.8% and 40.8%, respectively, while per capita expenditure increased by 3.3%. In a subgroup analysis, we found that the outbreak had a greater impact on healthcare utilisation in cities at higher risk of COVID-19, with stricter lockdown measures and those located in the western region. The DID results suggest that, compared with low-risk cities, the pandemic induced a 14.8%, 26.4% and 27.5% reduction in total healthcare expenditure in medium-risk and high-risk cities, and in cities located in Hubei province during the post-festival period in 2020 relative to 2019, an 8.6%, 15.9% and 24.4% reduction in utilisation services; and a 7.3% and 18.4% reduction in per capita expenditure in medium-risk and high-risk cities, respectively. By the last week of April 2020, as the outbreak came under control, healthcare utilisation gradually recovered, but only to 79.9%-89.3% of its pre-outbreak levels. CONCLUSION: The COVID-19 pandemic had a significantly negative effect on healthcare utilisation in China, evident by a dramatic decline in healthcare expenditure. While the utilisation level has gradually increased post-outbreak, it has yet to return to normal levels.

Advancing universal health coverage in China and Vietnam: lessons for other countries.

BACKGROUND: China and Vietnam have made impressive progress towards universal health coverage (UHC) through government-led health insurance reforms. We compared the different pathways used to achieve UHC, to identify the lessons other countries can learn from China and Vietnam. METHODS: This was a mixed method study which included a literature review, in-depth interviews and secondary data analysis. We conducted a literature search in English and Chinese databases, and reviewed policy documents from internal contacts. We conducted semi-structured interviews with 16 policy makers, government bureaucrats, health insurance scholars in China and Vietnam. Secondary data was collected from National Health Statistics Reports, Health Insurance Statistical Reports and National Health Household Surveys carried out in both countries. We used population insurance coverage, insurance policies, reimbursement rates, number of households experiencing catastrophic heath expenditure (CHE) and incidence of impoverishment due to health expenditure (IHE) to measure the World Health Organization's three dimensions of UHC: population coverage, service coverage, and financial coverage. RESULTS: China has increased population coverage through strong political commitment and extensive government financial subsidies to expand coverage. Vietnam expanded population coverage gradually, by prioritizing the poor and the near-poor in an incremental way. In China, insurance service packages varied across regions and schemes and were greatly determined by financial contributions, resulting in limited service coverage in less developed areas. Vietnam focused on providing a comprehensive and universal service packages for all enrollees thereby approaching UHC in a more equitable manner. CHE rate decreased in Vietnam but increased in China between 2003 and 2008. While Vietnam has decreased the CHE gap between urban and rural populations, China suffers from persistent disparities among population income levels and geographic location. CHE and CHE rates were still high in lower income groups. CONCLUSION: Political commitment, sustainable financial sources and administrative capacity are strong driving factors in achieving UHC through health insurance reform. Health insurance schemes need to consider covering essential health services for all beneficiaries and providing government subsidies for vulnerable populations' in order to help achieve health for all.

Under-reporting of TB cases and associated factors: a case study in China.

BACKGROUND: Tuberculosis is a leading cause of death worldwide and has become a high global health priority. Accurate country level surveillance is critical to ending the pandemic. Effective routine reporting systems which track the course of the epidemic are vital in addressing TB. China, which has the third largest TB epidemic in the world and has developed a reporting system to help with the control and prevention of TB, this study examined its effectiveness in Eastern China. METHODS: The number of TB cases reported internally in two hospitals in Eastern China were compared to the number TB cases reported by these same hospitals in the national reporting systems in order to assess the accuracy of reporting. Qualitative data from interviews with key health officials and researcher experience using the TB reporting systems were used to identify factors affecting the accuracy of TB cases being reported in the national systems. RESULTS: This study found that over a quarter of TB cases recorded in the internal hospital records were not entered into the national TB reporting systems, leading to an under representation of national TB cases. Factors associated with underreporting included unqualified and overworked health personnel, poor supervision and accountability at local and national levels, and a complicated incohesive health information management system. CONCLUSIONS: This study demonstrates that TB in Eastern China is being underreported. Given that Eastern China is a developed province, one could assume similar problems may be found in other parts of China with fewer resources as well as many low- and middle-income countries. Having an accurate account of the number of national TB cases is essential to understanding the national and global burden of the disease and in managing TB prevention and control efforts. As such, factors associated with underreporting need to be addressed in order to reduce underreporting.

The association between quality of life(QOL) and health literacy among junior middle school students: a cross-sectional study.

BACKGROUND: Lower health literacy is associated with poor quality of life (QOL) among patients with chronic disease; little is known about this relationship among the general population, especially for child and adolescent. To fill this gap, this paper aimed to investigate the association between health literacy and QOL in junior middle school students, and explore how QOL varies by health literacy. METHODS: An anonymous cross-sectional survey was conducted among junior middle school students (aged 12-15) from Shapingba district, Chongqing in China, and participants were recruited using stratified cluster sampling. Health literacy and QOL were measured using two validated scales, and quantified using a five-point Likert scale with health literacy classified as low, medium, or high. We used multivariable logistic regression to test adjusted association between health literacy and QOL. RESULTS: A total of 1774 junior middle school students were evaluated, with the mean age was 13.8 ± 1.0 and of whom 905 (51.0%) were male. About 25.5% of the research subjects had a low health literacy. When controlling for age, grade, family structure and other covariates, highest discrimination was found among participants with low to high health literacy. Overall, Students who equipped with higher health literacy was associated with greater QOL (P < 0.01), and this discrimination remained significant in subscales: physiological well-being (P < 0.01), mental well-being (P < 0.01), social well-being (P < 0.01) and pubertal well-being (P < 0.01). CONCLUSIONS: The prevalence of low health literacy among junior middle school students in Chongqing area was relatively high, and inadequate health literacy may contribute to poorer QOL among junior middle school students. It merits further longitudinal studies to confirm the impact of health literacy on QOL. Overall, to improve students' QOL, public health efforts for further improving awareness and enhancing effective promotion and education are urgently needed in junior middle school students, especially for low health literacy populations.

Experiences and challenges in the health protection of medical teams in the Chinese Ebola treatment center, Liberia: a qualitative study.

BACKGROUND: Health care workers are at the frontline in the fight against infectious disease, and as a result are at a high risk of infection. During the 2014-2015 Ebola outbreak in West Africa, many health care workers contracted Ebola, some fatally. However, no members of the Chinese Anti-Ebola medical team, deployed to provide vital medical care in Liberia were infected. This study aims to understand how this zero infection rate was achieved. METHODS: Data was collected through 15 in-depth interviews with participants from the People's Liberation Army of China medical team which operated the Chinese Ebola Treatment Center from October 2014 to January 2015 in Liberia. Data were analysed using systematic framework analysis. RESULTS: This study found numerous bio-psycho-socio-behavioural risk factors that directly or indirectly threatened the health of the medical team working in the Chinese Ebola Treatment Center. These factors included social and emotional stress caused by: (1) the disruption of family and social networks; (2) adapting to a different culture; (3) and anxiety over social and political unrest in Liberia. Exposure to Ebola from patients and local co-workers, and the incorrect use of personal protective equipment due to fatigue was another major risk factor. Other risk factors identified were: (1) shortage of supplies; (2) lack of trained health personnel; (3) exposure to contaminated food and water; (4) and long working hours. Comprehensive efforts were taken throughout the mission to mitigate these factors. Every measure was taken to prevent the medical team's exposure to the Ebola virus, and to provide the medical team with safe, comfortable working and living environments. There were many challenges in maintaining the health safety of the team, such as the limited capability of the emergency command system (the standardized approach to the command, control, and coordination of an emergency response), and the lack of comprehensive international protocols for dealing with emerging infectious disease pandemics. CONCLUSIONS: The comprehensive and multidisciplinary measures employed to protect the health of the medical team proved successful even in Liberia's resource-limited setting. The global health community can learn valuable lessons from this experience which could improve the safety of health care workers in future emergencies. These lessons include: establishing capable command systems; implementing effective coordination mechanisms; providing adequate equipment; providing training for medical teams; investing in the development of global health professionals; and improving research on ways to protect health care workers.