Does social participation reduce the risk of functional disability among older adults in China? A survival analysis using the 2005-2011 waves of the CLHLS data.

BACKGROUND: Existing studies in developed countries show that social participation has beneficial effects on the functional ability of older adults, but research on Chinese older people is limited. This study examined the effects of participating in different types of social activities on the onset of functional disability and the underlying behavioral and psychosocial mechanisms among older adults aged 65 and older in China. METHODS: The 2005, 2008, and 2011 waves of the Chinese Longitudinal Health Longevity Study were used. Life table analysis and discrete time hazard models were adopted to examine the relationship between social participation and functional disability. Social participation was defined as the frequencies of engaging in group leisure-time activities (i.e., playing cards/mahjong) and organized social activities, involving in informal social interactions (i.e., number of siblings frequently visited), and participating in paid jobs. Extensive social participation was measured by a composite index by adding up the four types of social activities that an older person was engaged in. RESULTS: After controlling for the effect of socio-demographic characteristics, health status, and health behavioral factors, extensive social participation is associated with a significant reduced risk for the onset of functional disability (hazard ratio [HR] = 0.92, p < 0.001). Different types of social participation affect the risk of functional decline through different mechanisms. Frequent playing of cards/mahjong is a protective factor for functional decline (HR = 0.78, p < 0.001), and the relationship is partially mediated by cognitive ability and positive emotions (accounting for 18.9% and 7.0% of the association, respectively). Frequent participation in organized social activities is significantly related to a reduced risk of functional decline (HR = 0.78, p < 0.001), and the association is mediated by physical exercises and cognitive ability (accounting for 25.7% and 17.7% of the association, respectively). Frequent visits from siblings has a strong inverse relationship with functional decline (HR = 0.75, p < 0.001). However, no significant association between paid job and functional decline is observed. CONCLUSION: Extensive social participation, regular engagement in group leisure-time activities, organized social activities, and informal social interactions in particular may have beneficial effects on the functional health of older adults through behavioral and psychosocial pathways. The findings shed light for the importance of promoting social participation among older adults.

How China's new health reform influences village doctors' income structure: evidence from a qualitative study in six counties in China.

BACKGROUND: In 2009, health-care reform was launched to achieve universal health coverage in China. A good understanding of how China's health reforms are influencing village doctors' income structure will assist authorities to adjust related polices and ensure that village doctors employment conditions enable them to remain motivated and productive. This study aimed to investigate the village doctors' income structure and analyse how these health policies influenced it. METHODS: Based on a review of the previous literature and qualitative study, village doctors' income structure was depicted and analysed. A qualitative study was conducted in six counties of six provinces in China from August 2013 to January 2014. Forty-nine village doctors participated in in-depth interviews designed to document their income structure and its influencing factors. The themes and subthemes of key factors influencing village doctors' income structure were analysed and determined by a thematic analysis approach and group discussion. RESULTS: Several policies launched during China's 2009 health-care reform had major impact on village doctors. The National Essential Medicines System cancelled drug mark-ups, removing their primary source of income. The government implemented a series of measures to compensate, including paying them to implement public health activities and provide services covered by social health insurance, but these have also changed the village doctors' role. Moreover, integrated management of village doctors' activities by township-level staff has reduced their independence, and different counties' economic status and health reform processes have also led to inconsistencies in village doctors' payment. These changes have dramatically reduced village doctors' income and employment satisfaction. CONCLUSIONS: The health-care reform policies have had lasting impacts on village doctors' income structure since the policies' implementation in 2009. The village doctors have to rely on the salaries and subsidies from the government after the drug mark-up was cancelled. China's national health reforms are attempting to draw village doctors into the national health workforce, but the policies have impacted their income and independence. Further research into these concerns and monitoring of measures to adequately compensate village doctors should be undertaken. Reasonable compensation strategies should be established, and sufficient subsidies should be allocated in a timely manner.

Health providers' perspectives on delivering public health services under the contract service policy in rural China: evidence from Xinjian County.

BACKGROUND: To effectively provide public health care for rural residents, the Ministry of Health formally unveiled the contract service policy in rural China in April 2013. As the counterpart to family medicine in some developed countries, the contract service established a compact between village doctors and local governments and a service agreement between doctors and their patients. This study is a rare attempt to explore the perspectives of health providers on the contract service policy, and investigate the demand side's attitude toward the public health services delivered under the contract policy. This evidence from Xinjian County, Jiangxi Province, the first and most representative pilot site of the contract service, could serve as a reference for policymakers to understand the initial effects of the policy, whereby they can regulate and amend some items before extending it to the whole country. METHODS: Official documents were collected and semi-structured interviews with human resources and villagers in Xinjian County were conducted in September 2013. A purposive sampling method was used, and eight towns from the total 18 towns in Xinjian County were selected. Ultimately, eight managers (one in each township health center), 20 village doctors from eight clinics, and 11 villagers were interviewed. A thematic approach was used to analyze the data, which reflected the people's experiences brought about by the implementation of the contract service policy. RESULTS: While the contract service actually promoted the supply side to provide more public health services to the villagers and contracted patients felt satisfied with the doctor-patient relationship, most health providers complained about the heavy workload, insufficient remuneration, staff shortage, lack of official identity and ineffective performance appraisal, in addition to contempt from some villagers and supervisors after the implementation of the contract service. CONCLUSIONS: Contract service is a crucial step for the government to promote public health services in rural areas. To inspire the positive perspective and optimal work performance of the health workforce, it is imperative for the Chinese government to fortify financial support to health providers, adopt an advanced management model and escalate administrative capacity.

Aging village doctors in five counties in rural China: situation and implications.

BACKGROUND: The aging population, rapid urbanization, and epidemiology transition in China call for the improvement and adaptation of the health workforce, especially in underserved rural areas. The aging of village doctors (the former "barefoot doctors") who have served the rural residents for many decades has become a warning signal for the human resources for health in China. This study aims to investigate the village doctors' aging situation and its implications in rural China. METHODS: The data reviewed were obtained from the baseline survey of a longitudinal study of rural health workforce in five counties in rural China in 2011. Using a stratified multi-stage cluster sampling process, the baseline data was collected through the self-administered structured Village Doctor Questionnaire. Descriptive analyses, correlation analyses, and multivariate linear regression with interaction terms were conducted with the statistics software Stata 12.0. RESULTS: The average age of the 1,927 village doctors was 49.3 years (95% CI 48.8 to 49.9), 870 (45.2%) of whom were aging (50 years or older). Both the age and the recruitment time of the village doctors were demonstrated to have a bimodal distribution. A greater proportion of the male village doctors were aging. Furthermore, aging of the village doctors was significantly correlated to their education level, type of qualification, practicing methods, and their status as village clinic directors (P <0.05, respectively). As shown in the regression models, aging village doctors provided significantly more outpatient services to rural residents (P <0.01) but without an increase in income, and their expected pension was lower (P <0.01), compared with their non-aging counterparts. CONCLUSIONS: Aging of village doctors is a serious and imperative issue in China, which has a complex and profound impact on the rural health system. Greater attention should be paid to the construction of the pension system and the replenishment of the village doctors with qualified medical graduates.

Integrating gender and rights into sexuality education: field reports on using It's All One.

International policy agreements, along with emerging evidence about factors influencing programme effectiveness, have led to calls for a shift in sexuality education toward an approach that places gender norms and human rights at its heart. Little documentation exists, however, about the degree to which this shift is actually taking place on the ground or what it entails. Field experiences in using new curriculum tools, such as It's All One, offer one lens onto these questions. To gain a sense of practitioners' experience with this tool, a two-part exercise was conducted. First, responses from an on-line survey of It's All One users were synthesized. Additionally, five programmes were selected for documentation, including two school-based programmes (Nigeria, China), two reaching extremely vulnerable youth (Haiti, Guatemala), and one reaching adolescents from a polygamous Mormon community (United States). Findings suggest the shift to an empowerment approach is indeed taking place in diverse geographic and programmatic contexts, and that It's All One has strengthened the ways their programmes address gender, foster young people's critical thinking skills and use interactive teaching methods. A common challenge across many programmes is strengthening teacher capacity. Recommendations for further implementation and research are presented.

Longitudinal study of rural health workforce in five counties in China: research design and baseline description.

BACKGROUND: The village doctors have served rural residents for many decades in China, and their role in rural health system has been highly praised in the world; unfortunately, less attention has been paid to the health workforce during the ambitious healthcare reform in recent years. Therefore, we conducted a longitudinal study to explore the current situation and track the future evolution of the rural healthcare workforce. METHODS: The self-administered structured Village Clinic Questionnaire and Village Doctor Questionnaire, which were modified from the official questionnaires of the Ministry of Health, were constructed after three focus groups, in-depth interviews in Hebei Province, and a pilot survey in Sichuan Province. Using a stratified multistage cluster sampling process, we gathered baseline data for a longitudinal survey of village doctors, village clinics from Changshu County, Liyang County, Yongchuan District, Mianzhu County, and Jingning County in China in 2011. Well-trained interviewers and strict procedures were employed to ensure the quality of this survey. Descriptive and correlation analyses were performed with Stata 12.0. RESULTS: After four months of surveying, 1,982 Village Doctor Questionnaires were collected, and the response rate was 88.1%. There were 1,507 (76.0%) male and 475 (24.0%) female doctors, with an average age of 51.3 years. The majority of village doctors (58.5%) practiced both western medicine and Traditional Chinese Medicine, and 91.2% of the doctors received their education below college level. Their practice methods were not correlated with education level (P = 0.43), but closely related to the way they obtained their highest degree (that is, prior to starting work or as on-the-job training) (P < 0.01). The mean income of the village doctors was 1,817 (95% CI 1,733 to 1,900) RMB per month in 2011; only 757 (41.3%) doctors had pensions, and the self-reported expected pension was 1,965 RMB per month. CONCLUSIONS: Village doctors in rural China are facing critical challenges, including aging, gender imbalance, low education, and a lack of social protection. This study may be beneficial for making better policies for the development of the health workforce and China's healthcare reform.

Gender inequality increases women's risk of hiv infection in Moshi, Tanzania.

This study examined the hypothesis that multiple dimensions of gender inequality increase women's risk for HIV infection using a population-based survey of 1418 women aged 20 to 44 in Moshi, Tanzania. Three forms of HIV exposures were assessed reflecting gender power imbalance: economic exposures (age difference between partners and partner's contributions to children's expenses), physical exposures (coerced first sex and intimate partner violence) and social exposures (ever had problems conceiving). Behavioural risk factors included number of sexual partners for women in the last three years, partner had other wives or girlfriends, non-use of condom and alcohol use at least once a week in the last 12 months. Multivariate logistic regression analysis showed that a woman had a significantly elevated risk for HIV if she had a partner more than 10 years older (OR=2.5), her partner made low financial contributions to children's expenses (OR=1.7), or she experienced coerced first sex before age 18 years (OR=2.0) even after taking into account the effects of risk behaviour factors. The association between ever had problem conceiving and HIV infection was explained away by risk behaviour factors. The findings lend support to the hypothesis that economic deprivation and experience of sexual violence increase women's vulnerability to HIV, providing further evidence for extending the behavioural approach to HIV interventions to incorporate women's economic empowerment, elimination of gender-based violence and promotion of changing attitudes and behaviours among men.

Socioeconomic differentials in smoking duration among adult male smokers in China: result from the 2006 China Health and Nutrition Survey.

BACKGROUND: A smoker's risk of diseases and death from smoking is closely related to his/her smoking duration. But little is known about the average length of smoking and the association between smoking duration and socio-economic status (SES) among Chinese smokers. METHODS: A sample of male ever smokers (N = 2,637) aged 18+ years was drawn from the 2006 China Health and Nutrition Survey to examine the average length of smoking and socioeconomic differentials in smoking duration. Kaplan-Meier analysis was used to obtain median smoking duration. Log-logistic regression models were employed to estimate the relative duration of smoking, adjusted for demographic characteristics, smoking history, and health status. RESULTS: Results showed that Chinese male ever smokers aged 18 years and older had a median duration of smoking of 58 years (95% CI: 56-61). Male ever smokers with a lower status job (i.e. farmers, manual and skilled workers, service workers, and office staff) had a significantly longer duration of smoking than those with a professional or administrative job after adjusted for demographic characteristics, smoking history, and health status. Individuals who earned the lowest income and who had no education or were being illiterate smoked for 11% and 14% longer, respectively, relative to those who had the highest income or who had college or above education. CONCLUSION: The findings demonstrated the problem of long smoking duration and a pattern of social disparities in smoking duration among Chinese male smokers. Social disparities in smoking behavior may exacerbate the already existing social inequalities in health. Thus, policies and interventions to promote smoking cessation should pay more attention to disadvantaged social groups.

Gaps in the 2010 measles SIA coverage among migrant children in Beijing: evidence from a parental survey.

China suffers from high incidence of measles partly due to high population mobility and low vaccination rates among migrants. In this study, we assessed the vaccination coverage of the nationwide measles supplementary immunization activity (SIA) of 2010 and its determinants among migrant children in Beijing. Information was collected through face-to-face interviews with the caregivers of 589 migrant children at train and long-distance bus stations in January 2011, when migrants were traveling home for the Chinese New Year holiday. We estimated that 83.4% of migrant children aged 8 months to 14 years received the measles vaccine during the SIA. This estimated coverage is lower than the official report of 96% among all eligible children in Beijing. Factors associated with being unvaccinated through the SIA included children being at home or in the kindergarten, living in a single-child family, and having a parent who was unaware of the SIA or who had a low level of trust in the government-administered measles campaign. We recommend more focused targeting on migrant children in future measles vaccination campaigns, improved immunization service delivery in unregulated migrant-run kindergartens and at the community level, as well as development of more effective communication methods to reach disadvantaged migrants.