COVID-19 in the Community: Changes to Women's Mental Health, Financial Security, and Physical Activity.

Introduction: This study describes changes in the mental health, financial security, and physical activity levels of women in North Carolina during the COVID-19 pandemic. Methods: Data were collected from women aged 20-40 years receiving primary care at 2 health centers in North Carolina during 2020-2022. Surveys (N=127) evaluated changes in mental health, financial security, and physical activity during the COVID-19 pandemic. These outcomes were analyzed both descriptively and for association with sociodemographic factors using logistic regression. A subset of participants (n=46) participated in semistructured interviews. Interview transcripts were reviewed and evaluated for recurring themes by primary and secondary coders using a rapid-coding technique. Analysis was conducted in 2022. Results: Women surveyed were 28.4% non-Hispanic White, 38.6% non-Hispanic Black, and 33.1% Hispanic/Latina. Compared with reports before the pandemic, participants reported increased frustration or boredom (69.1%), loneliness (51.6%), anxiety (64.3%), depression (52.4%), and changed sleep patterns (68.3%). Increased alcohol and other recreational substance use were associated with race and ethnicity (p<0.05) after adjustment for other sociodemographic factors. Participants reported difficulty in paying for basic expenses (44.0%). Financial difficulties during COVID-19 were associated with non-Hispanic Black race and ethnicity, less education, and lower prepandemic household income. Data showed pandemic-associated reductions in mild (32.8%), moderate (39.5%), and strenuous (43.3%) exercise, with a correlation between increased depression and reduced mild exercise. Interviews identified themes including reduced activity while working remotely, lack of gym access, and reduced motivation for exercise. Conclusions: This mixed-methods study is one of the first to evaluate the mental health, financial security, and physical activity challenges women aged between 20 and 40 years in the southern U.S. faced during the COVID-19 pandemic.

Economic hardships from COVID-19 and its association with socioeconomic factors and diabetes management indicators: A cross-sectional study.

Aims: The three objectives of this study were to determine the economic hardships of COVID-19 pandemic, their socio-economic predictors, and their association with diabetes management indicators in three cities in a middle-income country. Methods: A community-based cross-sectional survey of 309 people with diabetes aged 34-85 was carried out in 10 communities during July and August 2020. Face-to-face surveys were conducted by trained community physicians. Economic hardship was assessed by income loss and "financial toxicity" during the COVID-19 pandemic, where financial toxicity was defined as experiencing economic difficulties in accessing diabetes management resources. Indicators of diabetes management was assessed by blood glucose and Hemoglobin A1c (HbA1c) monitoring frequency. Results: Among all respondents, 38.5% reported having income loss, and 15.5% experiencing financial toxicity during the pandemic. Younger and self-employed people living suburban areas were more likely to experience income loss. Similarly, suburban area residency and lower household income were associated with financial toxicity. Patients with financial toxicity were less likely to monitor HbA1c in the past three months (OR = 0.20; 95% CI, 0.07-0.48). Conclusion: Diabetes management as indicated by less frequent HbA1c monitoring was associated with experiencing COVID-19 related financial toxicity. Our findings identified vulnerable groups in need of additional support for diabetes management.

Interventions to promote dementia knowledge among racial/ethnic minority groups: A systematic review.

BACKGROUND: Certain racial/ethnic minority groups have a higher risk of developing dementia, yet studies have demonstrated that they often have limited knowledge and understanding of this disease. An increasing number of educational and advocacy programs have been developed to promote dementia knowledge. We aimed at assessing current evidence and quality regarding educational interventions for promoting dementia knowledge. METHODS: We searched for intervention studies published in English that focused on educational interventions for promoting dementia knowledge among racial/ethnic minority groups. We identified 25 relevant studies through PubMed, PsycINFO, CINAHL, and Scopus, using tailored search terms. We screened titles and abstracts, reviewed full texts, synthesized relevant evidence, and evaluated the studies' quality based on the Mixed Methods Appraisal Tool. Relevant intervention studies took place in communities, hospitals or clinics, and schools, and online. RESULTS: Most studies were conducted in the United States (n = 21), followed by the UK (n = 3). Over half of the studies included Asian/Pacific Islander groups (n = 14), followed by Black groups (n = 12) and Hispanic groups (n = 11). The intervention delivery mode varied across studies-from workshops hosted in a faith community to talk shows on YouTube. Target populations included middle-aged and older adults, caregivers and family members, health students and professionals, and elementary school students. Common content included symptoms and signs of dementia, protective and risk factors, and local resources. The assessment of study outcomes varied across studies. Improvement in dementia knowledge and attitudes towards dementia was reported in many studies. Among the included studies, intervention satisfaction was high. The overall quality of the interventions was low. CONCLUSION: Formally evaluated educational interventions promoting dementia knowledge are at an early stage. Existing published interventions showed adequate acceptability and promise in promoting better understanding and awareness of dementia in minority groups. More well-designed randomized controlled trials are needed.

How good are medical and death records for identifying dementia?

INTRODUCTION: Retrospective studies using administrative data may be an efficient way to assess risk factors for dementia if diagnostic accuracy is known. METHODS: Within-individual clinical diagnoses of Alzheimer's disease (AD) and all-cause dementia in ambulatory (outpatient) surgery, inpatient, Medicare administrative records and death certificates were compared with research diagnoses among participants of Cache County Study on Memory, Health, and Aging (CCSMHA) (1995-2008, N = 5092). RESULTS: Combining all sources of clinical health data increased sensitivity for identifying all-cause dementia (71%) and AD (48%), while maintaining relatively high specificity (81% and 93%, respectively). Medicare claims had the highest sensitivity for case identification (57% and 40%, respectively). DISCUSSION: Administrative health data may provide a less accurate method than a research evaluation for identifying individuals with dementing disease, but accuracy is improved by combining health data sources. Assessing all-cause dementia versus a specific cause of dementia such as AD will result in increased sensitivity, but at a cost to specificity.

IMPaCT: A Pilot Randomized Trial of an Intervention to Reduce Preterm Birth Among Non-Hispanic Black Patients at High Risk.

Introduction: Preterm birth is a major cause of neonatal morbidity and mortality rate. Non-Hispanic black patients disproportionately experience preterm birth and nonadherence to evidence-based preventive measures. Interventions tailored to non-Hispanic black birthing individuals (NHBBIs) that address barriers to preterm birth preventions are urgently needed. Methods: Together with a community-engaged multidisciplinary stakeholder group, we developed an intervention to improve adherence to preterm birth preventions among black pregnant patients with prior preterm birth. The intervention included the following: (1) preterm birth prevention education, (2) an employment navigation toolkit, and (3) encouragement text messages. We piloted the intervention by recruiting self-identified non-Hispanic black patients at or before 20 weeks of gestation with a prior preterm birth and randomizing them to the intervention or an active control. The primary outcomes were feasibility and acceptability. Our secondary outcomes were preliminary efficacy based on birth outcomes, patient experience, and pregnancy-specific anxiety (PSA). Descriptive statistics, analysis of verbatim survey responses, Wilcoxon signed rank, and Fisher's exact were used to describe and compare quantitative and qualitative data. Results: We identified 53 individuals who met the inclusion criteria, 35 were reachable remotely and 30 were enrolled and randomized. More than 80% (n=26) were retained throughout the study, and 100% of participants identified at least one intervention component as helpful. In this small pilot, there were no detectable differences in adherence to preterm birth preventive recommendations. No difference in preterm births, other pregnancy, or patient experience outcomes was detected between the intervention and active control participants. Discussion: The intervention is feasible and acceptable. Larger, appropriately powered studies are needed to assess whether the intervention will decrease PSA and reduce preterm birth. This trial was registered with ClinicalTrials.gov (NCT04933812).

Outcomes among children and adults at risk of severe dengue in Sri Lanka: Opportunity for outpatient case management in countries with high disease burden.

BACKGROUND: Healthcare systems in dengue-endemic countries are often overburdened due to the high number of patients hospitalized according to dengue management guidelines. We systematically evaluated clinical outcomes in a large cohort of patients hospitalized with acute dengue to support triaging of patients to ambulatory versus inpatient management in the future. METHODS/PRINCIPAL FINDINGS: From June 2017- December 2018, we conducted surveillance among children and adults with fever within the prior 7 days who were hospitalized at the largest tertiary-care (1,800 bed) hospital in the Southern Province, Sri Lanka. Patients who developed platelet count ≤100,000/µL (threshold for hospital admission in Sri Lanka) and who met at least two clinical criteria consistent with dengue were eligible for enrollment. We confirmed acute dengue by testing sera collected at enrollment for dengue NS1 antigen or IgM antibodies. We defined primary outcomes as per the 1997 and 2009 World Health Organization (WHO) classification criteria: dengue hemorrhagic fever (DHF; WHO 1997), dengue shock syndrome (DSS; WHO 1997), and severe dengue (WHO 2009). Overall, 1064 patients were confirmed as having acute dengue: 318 (17.4%) by NS1 rapid antigen testing and 746 (40.7%) by IgM antibody testing. Of these 1064 patients, 994 (93.4%) were adults ≥18 years and 704 (66.2%) were male. The majority (56, 80%) of children and more than half of adults (544, 54.7%) developed DHF during hospitalization, while 6 (8.6%) children and 22 (2.2%) adults developed DSS. Overall, 10 (14.3%) children and 113 (11.4%) adults developed severe dengue. A total of 2 (0.2%) patients died during hospitalization. CONCLUSIONS: One-half of patients hospitalized with acute dengue progressed to develop DHF and a very small number developed DSS or severe dengue. Developing an algorithm for triaging patients to ambulatory versus inpatient management should be the future goal to optimize utilization of healthcare resources in dengue-endemic countries.

Health-related quality of life in Chinese workers: a systematic review and meta-analysis.

BACKGROUND: Studies of health-related quality of life among workers have generated varying results. The purpose of this study was to conduct a systematic review to synthesize the scores of health-related quality of life measured by the World Health Organization Quality of Life questionnaire among Chinese workers and compare the results across gender, age, occupation and region. METHODS: Six databases including China National Knowledge Infrastructure, WanFang Data, China Science and Technology Journal Database, PubMed, Web of science and Scopus were searched for relevant publications in both English and Chinese from their inception to February 2021. Inclusion and exclusion criteria were established, and study and participant characters as well as health-related quality of life scores were extracted from included publications. Study quality was assessed by using the Crombie tool. The meta-analysis including individual publications used random-effects models. Subgroups analyses by gender, age, occupation and region were also conducted to explore the source of heterogeneity. RESULTS: One hundred thirty-nine out of 1437 potential publications were included. The pooled mean scores of health-related quality of life were 14.1 for the physical domain (95%CI: 13.9-14.3), 13.7 for the psychological domain (95%CI: 13.5-13.8), 14.0 for the social relationship domain (95%CI: 13.8-14.2), 12.3 for the environment domain (95%CI: 12.1-12.5). No significant statistical difference was found between the different subgroups. Publication bias was present in the independence domain and the pooled scores were corrected to 15.0 (95%CI: 14.6-15.5) using the trim and fill method. Sensitivity analysis suggested that the results of the meta-analysis were stable. Region might be a source of heterogeneity. Workers in northeast China reported higher scores in the social relationship domain, and those in the central region reported lower scores in the environmental domain. CONCLUSIONS: Chinese workers reported lower scores in four health-related quality of life domains than the general population. Region might be a potential influencing factor for workers' scores different, which needs further study. The pooled scores can served as benchmarks for workplace health promotion programes in Chinese workers and global occupational health studies.

Barriers to implementing antimicrobial stewardship programs in three low- and middle-income country tertiary care settings: findings from a multi-site qualitative study.

BACKGROUND: Antimicrobial resistance has been named as one of the top ten threats to public health in the world. Hospital-based antimicrobial stewardship programs (ASPs) can help reduce antimicrobial resistance. The purpose of this study was to determine perceived barriers to the development and implementation of ASPs in tertiary care centers in three low- and middle-income countries (LMICs). METHODS: Interviews were conducted with 45 physicians at tertiary care hospitals in Sri Lanka (n = 22), Kenya (12), and Tanzania (11). Interviews assessed knowledge of antimicrobial resistance and ASPs, current antimicrobial prescribing practices, access to diagnostics that inform antimicrobial use, receptiveness to ASPs, and perceived barriers to implementing ASPs. Two independent reviewers coded the interviews using principles of applied thematic analysis, and comparisons of themes were made across the three sites. RESULTS: Barriers to improving antimicrobial prescribing included prohibitively expensive antimicrobials, limited antimicrobial availability, resistance to changing current practices regarding antimicrobial prescribing, and limited diagnostic capabilities. The most frequent of these barriers in all three locations was limited drug availability. Many physicians in all three sites had not heard of ASPs before the interviews. Improved education was a suggested component of ASPs at all three sites. The creation of guidelines was also recommended, without prompting, by interviewees at all three sites. Although most participants felt microbiological results were helpful in tailoring antibiotic courses, some expressed distrust of laboratory culture results. Biomarkers like erythrocyte sedimentation rate and c-reactive protein were not felt to be specific enough to guide antimicrobial therapy. Despite limited or no prior knowledge of ASPs, most interviewees were receptive to implementing protocols that would include documentation and consultation with ASPs regarding antimicrobial prescribing. CONCLUSIONS: Our study highlighted several important barriers to implementing ASPs that were shared between three tertiary care centers in LMICs. Improving drug availability, enhancing availability of and trust in microbiologic data, creating local guidelines, and providing education to physicians regarding antimicrobial prescribing are important steps that could be taken by ASPs in these facilities.

An Adaptable Framework for Factors Contributing to Medication Adherence: Results from a Systematic Review of 102 Conceptual Frameworks.

OBJECTIVE: To summarize the available conceptual models for factors contributing to medication adherence based on the World Health Organization (WHO)'s five dimensions of medication adherence via a systematic review, identify the patient groups described in available conceptual models, and present an adaptable conceptual model that describes the factors contributing to medication adherence in the identified patient groups. METHODS: We searched PubMed®, Embase®, CINAHL®, and PsycINFO® for English language articles published from inception until 31 March 2020. Full-text original publications in English that presented theoretical or conceptual models for factors contributing to medication adherence were included. Studies that presented statistical models were excluded. Two authors independently extracted the data. RESULTS: We identified 102 conceptual models, and classified the factors contributing to medication adherence using the WHO's five dimensions of medication adherence, namely patient-related, medication-related, condition-related, healthcare system/healthcare provider-related, and socioeconomic factors. Eight patient groups were identified based on age and disease condition. The most universally addressed factors were patient-related factors. Medication-related, condition-related, healthcare system-related, and socioeconomic factors were represented to various extents depending on the patient group. By systematically examining how the WHO's five dimensions of medication adherence were applied differently across the eight different patient groups, we present a conceptual model that can be adapted to summarize the common factors contributing to medication adherence in different patient groups. CONCLUSION: Our conceptual models can be utilized as a guide for clinicians and researchers in identifying the facilitators and barriers to medication adherence and developing future interventions to improve medication adherence. PROTOCOL REGISTRATION: PROSPERO Identifier: CRD42020181316.

Hypertension Care Coordination and Feasibility of Involving Female Community Health Volunteers in Hypertension Management in Kavre District, Nepal: A Qualitative Study.

Background: Hypertension and related complications are major contributors to morbidity and mortality in Nepal. Community health workers have been proposed as promising health cadres to meet the growing healthcare demand for non-communicable disease management in other developing countries. Objective: We aimed to explore existing workflows, needs and challenges for hypertension care coordination and to assess the feasibility of establishing a Female Community Health Volunteer (FCHV)-based hypertension management program in Kavre, Nepal. Design: We conducted one focus group discussion with eight FCHVs and twenty-three in-depth interviews with four FCHVs not attending FGD, nine individuals with hypertension, six health workers, and four health officials in two village development committees of Kavre District, Nepal. Applied thematic analysis was performed using NVivo 12. Results: Health literacy related to hypertension was low among both community members and FCHVs. Delay in treatment initiation and loss to follow-up were common patterns despite anti-hypertensive medication compliance. Major health system-related barriers included underutilization of primary healthcare institutions, communication gaps and lack of grass-roots level educational campaigns. Community pharmacies, monthly health camps and increasing governmental attention to NCDs were favorable for improving hypertension management. This study also supports that FCHVs should be provided with adequate training and financial incentives to promote hypertension education, screening and referral in their catchments. Conclusions: Barriers and facilitators identified in this study provide important implications for future hypertension management in Nepal. We recommend hypertension education and screening across Nepal at a grass-root level through FCHVs. Providing professional training and proper financial incentives for FCHVs are warranted. Highlights: Health literacy related to hypertension was low among both community members and Female Community Health Volunteers in Nepal.Delay in treatment initiation and loss to follow-up were common despite relatively high anti-hypertensive medication compliance.Health system-related barriers in research sites included underutilization of primary healthcare institutions, communication gaps, and lack of grass-roots level educational campaigns.Female Community Health Volunteers should be provided with adequate training and financial incentives to promote hypertension management.

The direct and indirect costs of axial spondyloarthritis (axSpA) in Singapore.

OBJECTIVE: To estimate the economic annual direct and indirect costs of axial spondyloarthritis (axSpA) in Singapore, and to identify factors associated with these costs. METHODS: A retrospective, cross-sectional, Institutional Review Board-approved study was conducted. A questionnaire was administered to the patients between 2013 and 2016 from the Singapore General Hospital (SGH) spondyloarthritis registry. Direct medical costs and indirect costs were estimated using the SGH database and the human capital approach respectively. Multivariate analyses using generalized linear model with gamma distribution and a log-linked function was conducted to identify factors associated with these total, direct and indirect costs. All costs were adjusted to 2017 using the Singapore Consumer Price Index and converted to 2017 US dollars (USD) by purchasing power parity. RESULTS: A total of 135 consecutive patients were included in the study, with a mean age of 40.4 ± 13.2 years. The overall annual total economic cost to society was around USD 74 790 820, with annual direct cost being the main component of total cost (90.8%). Annual direct cost was around USD 67 931 457, while annual indirect cost was around USD 6 855 951. Presence of extra-spinal symptoms (ever) was associated with an increase in total and direct costs. Higher education level and Patient Global Assessment were associated with an increase in indirect costs. Lack of employment was associated with a decrease in indirect costs. CONCLUSION: The disease burden of axSpA in Singapore is not trivial given that the disease is relatively common. This highlights the need for measures to accommodate patients with axSpA economically in Singapore.

Validity and reliability of the Ankylosing Spondylitis Disease Activity Score with C-reactive protein (ASDAS-CRP) and Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) in patients with axial spondyloarthritis (axSpA) in Singapore.

INTRODUCTION: The Ankylosing Spondylitis Disease Activity Score with C-reactive protein (ASDAS-CRP) and Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) are commonly used instruments for measuring disease activity. However, few studies have assessed their psychometric properties in patients with axial spondyloarthritis (axSpA). We aimed to assess the validity and reliability of ASDAS-CRP and BASDAI in patients with axSpA in Singapore. METHODS: Cross-sectional data from 280 patients with axSpA from a dedicated axSpA clinic in a Singapore tertiary referral hospital from 2011 to 2019 were used. Internal consistency was assessed using Cronbach's alpha. Construct validity was assessed through 12 a priori hypotheses by correlation of overall ASDAS-CRP and BASDAI score with other patient-reported outcomes measures (PROMs). Structural validity was evaluated via confirmatory factor analysis using maximum-likelihood method, where Comparative Fit Index (CFI) >0.95, Tucker-Lewis Index (TLI) >0.95, Root Mean Square Error of Approximation (RMSEA) <0.06 and Standardized Root Mean Residuals (SRMR) <0.08 were indicative of good fit. RESULTS: Among 280 patients (78.2% Male; 92.5% Chinese), ASDAS-CRP showed poor internal consistency of 0.33, while BASDAI showed high internal consistency of 0.87. Convergent and divergent construct validity were demonstrated by fulfillment of 11 out of 12 a priori hypotheses when ASDAS-CRP and BASDAI were compared with other PROMs. Our proposed ASDAS-CRP and BASDAI model showed good fit for a 1-factor structure respectively (CFI = 0.993, TLI = 0.984, RMSEA = 0.036, SRMR = 0.026 for ASDAS-CRP; CFI = 0.993, TLI = 0.985, RMSEA = 0.057, SRMR = 0.022 for BASDAI), demonstrating structural validity. CONCLUSION: This study supports the use of both ASDAS-CRP and BASDAI in measuring disease activity in patients with axSpA in Singapore.

A Novel Adaptation of the HOME Inventory for Elders: The Importance of the Home Environment Across the Life Course.

The context in which dependents, regardless of age, receive care affects their health. This study adapted the Home Observation for Measurement of the Environment (HOME) Inventory, originally designed for child development research, to assess the quality of stimulation and support available to elders in their habitual households in Sri Lanka. Whether the adapted domains correlated with indicators of health and well-being in ways consistent with the child development literature was then examined. Through mixed-methods research based on 248 household surveys, four focus groups, and 15 interviews, three domains emerged: Physical Environment, Variety of Stimulation, and Emotional and Verbal Responsiveness. Regression modeling revealed that a higher quality physical home environment correlated with two measures of cognitive function after adjusting for covariates, but no consistent association with two psychological well-being scales. In contrast, higher Variety of Stimulation scores correlated with better cognitive function and lower psychological distress. There was no consistent correlation between Responsiveness and selected health outcomes. Qualitative data indicate that elders are active household contributors who strive to achieve harmonious relations with coresident kin. These findings reveal notable synergies between early and late life efforts to improve cognitive and psychological health, and highlight household considerations for future healthy aging research.

Validity and reliability of the Assessment of Spondyloarthritis International Society Health Index in English-speaking patients with axial spondyloarthritis in Singapore.

OBJECTIVES: To assess the validity and reliability of the Assessment of Spondyloarthritis International Society Health Index (ASAS HI) among patients with axial spondyloarthritis (axSpA) in Singapore. METHODS: We collected data from English-speaking patients with axSpA seen at a dedicated axSpA clinic in a Singapore tertiary referral hospital from 2017 to 2018. Face validity of the English version of ASAS HI was assessed through cognitive debriefing interviews (CDIs). Structural validity was assessed with confirmatory factor analysis. Convergent construct validity was assessed with 12 a priori hypotheses about the magnitude and direction of correlations between the ASAS HI summary score and other patient-reported outcome measures. Internal consistency was assessed using Cronbach's alpha. Test-retest reliability was assessed by intraclass correlation coefficient (ICC). Measurement error was assessed by analyzing smallest detectable change (SDC). RESULTS: Ten patients (age range 22-46 years, 50% male) participated in CDIs and face validity was supported. Among 108 patients (median age: 37 [21-77], 80.6% males), unidimensionality was confirmed (comparative fit index = 0.960, Tucker-Lewis Index = 0.952, root mean square error of approximation = 0.038, standardized root mean residuals = 0.068, model Chi-square test P = 0.1251) in the 17-item ASAS HI. The ASAS HI showed good internal consistency of 0.83 and excellent test-retest reliability (ICC = 0.95; 95% CI 0.91-0.98) when baseline was compared with week 2. SDC was 1.02. Convergent validity was supported as hypotheses were confirmed in 100% of the results. CONCLUSIONS: This study supports the ASAS HI as a valid and reliable measure of health status for use in patients with axSpA in Singapore.

Traditional Chinese medicine (TCM) collaborative care for patients with axial spondyloarthritis (AcuSpA): protocol for a pragmatic randomized controlled trial.

BACKGROUND: Axial spondyloarthritis (AxSpA) is a chronic disease which results in fatigue, pain, and reduced quality of life (QoL). Traditional Chinese medicine (TCM), especially acupuncture, has shown promise in managing pain. Although a TCM collaborative model of care (TCMCMC) has been studied in cancer, there are no randomized controlled trials investigating TCM in AxSpA. Therefore, we will conduct a pragmatic trial to determine the clinical effectiveness, safety, and cost-effectiveness of TCMCMC for patients with AxSpA. We define TCMCMC as standard TCM history taking and physical examination, acupuncture, and TCM non-pharmacological advice and communications with rheumatologists in addition to usual rheumatologic care. The purpose of this paper is to describe the rationale for and methodology of this trial. METHODS/DESIGN: This pragmatic randomized controlled trial will recruit 160 patients who are diagnosed with AxSpA and have inadequate response to non-steroidal anti-inflammatory drugs (NSAIDs). Simple randomization to usual rheumatologic care or the intervention (TCMCMC) with a 1:1 allocation ratio will be used. Ten 30-min acupuncture sessions will be provided to patients assigned to the TCMCMC arm. All participants will continue to receive usual rheumatologic care. The primary endpoint - spinal pain - will be evaluated at week 6. Secondary endpoints include clinical, quality of life, and economic outcome measures. Patients will be followed up for up to 52 weeks, and adverse events will be documented. DISCUSSION: This trial may provide evidence regarding the clinical effectiveness, safety, and cost-effectiveness of a TCMCMC for patients with AxSpA. TRIAL REGISTRATION: ClinicalTrials.gov, NCT03420404 . Registered on 14 February 2018.

Residential Mobility and Cognitive Function Among Middle-Aged and Older Adults in China.

OBJECTIVES: To assess the association between rural and urban residential mobility and cognitive function among middle-aged and older adults in China. METHOD: We used data from the World Health Organization Study on global AGEing and adult health that included adults age 50+ from China ( N = 12,410). We used multivariate linear regressions to examine how residential mobility and age at migration were associated with cognitive function. RESULTS: Urban and urban-to-urban residents had the highest level of cognitive function, whereas rural and rural-to-rural residents had the poorest cognitive function. Persons who migrated to/within rural areas before age 20 had poorer cognitive function than those who migrated during later adulthood. Socioeconomic factors played a major role in accounting for the disparities in cognition; however, the association remained significant after inclusion of all covariates. DISCUSSION: Residential mobility and age at migration have significant implications for cognitive function among middle-aged and older adults in China.

A qualitative study of quality of life domains and subdomains relevant to patients with spondyloarthritis.

AIMS: To identify quality of life (QoL) domains and subdomains relevant to patients with different spondyloarthritis (SpA) subtypes in Singapore, and to assess how identified QoL domains and subdomains map onto currently used patient-reported outcome measures (PROMs). METHODS: Nine focus group discussions (FGDs), including two previously conducted FGDs from the Updating the Psoriatic Arthritis Core Domain Set Study, were conducted with patients with SpA in Singapore. The FGDs were organized by SpA subtype and language spoken. All FGDs were audio-taped, transcribed verbatim. After thematic analysis through open and axial coding, the domains were organized using the World Health Organization Quality of Life (WHOQOL) framework. Identified QoL domains and subdomains were mapped to currently used PROMs. RESULTS: The nine FGDs included 51 patients. In total, 27 domains and 92 subdomains were identified and then organized within the 7 broad categories of the WHOQOL framework. Patients in Singapore were more concerned about "financial resources, " "work satisfaction" and "positive feelings" while less concerned about "freedom, physical safety and security" than patients in Western countries. "Home environment" and "work satisfaction" emerged as unique QoL domains relevant to patients with axial SpA (axSpA). PROMs for psoriatic arthritis (PsA) can capture both identified domains of PsA and axSpA. CONCLUSIONS: A wide range of QoL domains and subdomains are relevant to SpA patients in Singapore, and there appears to be minimal differences in their relative importance between SpA subtypes. This study supports the development and validation of common QoL-specific PROMs for usage in SpA.

Modifying the Environment and Policy Assessment and Observation (EPAO) to better capture feeding practices of family childcare home providers.

OBJECTIVE: To describe the modification and validation of an existing instrument, the Environment and Policy Assessment and Observation (EPAO), to better capture provider feeding practices. DESIGN: Modifications to the EPAO were made, validity assessed through expert review, pilot tested and then used to collect follow-up data during a two-day home visit from an ongoing cluster-randomized trial. Exploratory factor analysis investigated the underlying factor structure of the feeding practices. To test predictive validity of the factors, multilevel mixed models examined associations between factors and child's diet quality as captured by the Healthy Eating Index-2010 (HEI-2010) score (measured via the Dietary Observation in Childcare Protocol). SETTING: Family childcare homes (FCCH) in Rhode Island and North Carolina, USA.ParticipantsThe modified EPAO was pilot tested with fifty-three FCCH and then used to collect data in 133 FCCH. RESULTS: The final three-factor solution ('coercive control and indulgent feeding practices', 'autonomy support practices', 'negative role modelling') captured 43 % of total variance. In multilevel mixed models adjusted for covariates, 'autonomy support practices' was positively associated with children's diet quality. A 1-unit increase in the use of 'autonomy support practices' was associated with a 9·4-unit increase in child HEI-2010 score (P=0·001). CONCLUSIONS: Similar to the parenting literature, constructs which describe coercive controlling practices and those which describe autonomy-supportive practices emerged. Given that diets of pre-schoolers in the USA remain suboptimal, teaching childcare providers about supportive feeding practices may help improve children's diet quality.

Gender differences in the association between migration and cognitive function among older adults in China and India.

OBJECTIVE: This study aims to examine gender differences in the association between migration and cognitive function among adults in China and India. METHODS: Data from the World Health Organization Study on global AGEing and adult health (SAGE) study were used that included adults aged 50 + from China (N = 12,937) and India (N = 6244). Migration status included: urban residents, rural residents, urban-to-urban, rural-to-urban, rural-to-rural, and urban-to-rural migrants. Cognitive function was assessed by immediate and delayed recall tests, digit span tests, and verbal fluency test. Ordinary least square regression models were used to adjust for sociodemographic characteristics, psychosocial factors, health behaviors, and physical health status. RESULTS: Controlling for multiple covariates, significant differences in cognitive function were found between men and women, and across migration groups. A consistent female disadvantage was found in China and India for cognitive function. Women who were rural residents or rural-to-rural migrants had the poorest cognitive function in both the Chinese and the Indian samples. Among males in China, rural residents had poorer cognitive function than urban residents, while urban-to-urban migrants had highest cognition scores; however, for male counterparts in India, rural-to-rural migrants had the poorest cognitive function. CONCLUSIONS: The results suggest that the association between migration and cognitive function differs by gender and country. In our study populations, major sociodemographic characteristics play a key role in accounting for the differences in cognitive function.

Anti-hypertensive medications and injurious falls in an older population of low socioeconomic status: a nested case-control study.

BACKGROUND: This study aimed to determine whether the number of anti-hypertensive medication classes or any change in anti-hypertensive medication were associated with injurious fall among the community-dwelling older population of low socioeconomic status. METHODS: Using data from electronic medical records, we performed a nested case-control study among older Singapore residents (≥60) of low socioeconomic status (N = 210). Controls (n = 162) were matched to each case (n = 48) by age and gender. Variables with p < 0.10 in univariate analysis were included in multivariate analysis. We used conditional logistic regression to assess the associations of the number of anti-hypertensive medication classes and change in anti-hypertensive medication with injurious falls. We also performed stepwise regressions as sensitivity analyses. p < 0.05 was considered statistically significant. RESULTS: The mean (±SD) age of participants was 78.1 (± 8.33) years; 127 (60.4%) were female, 189 (90.0%) were Chinese. Those on ≥2 anti-hypertensive medication classes had an increased risk of experiencing an injurious fall compared to those not on any anti-hypertensive medication (OR = 5.45; CI:1.49-19.93; p = 0.01). Among those who were taking anti-hypertensive medication, those who had a change in the medication 180-day prior to injurious fall had a significantly increased risk of experiencing an injurious fall compared to those that did not report any change in anti-hypertensive medication (OR = 3.88; CI:1.23-12.19; p = 0.02). Sensitivity analyses generated consistent findings. CONCLUSION: Both ≥2 anti-hypertensive medication classes and change in anti-hypertensive medication were associated with an increased risk of experiencing an injurious fall among the older population of low socioeconomic status. Our findings could guide prescribers to exercise caution in the initiation of anti-hypertensive medications or in making medication changes, especially among the older population of low socioeconomic status.