Residents' willingness towards first-contact with primary health care under uncertainty in healthcare: a cross-sectional study in rural China.

OBJECTIVE: To estimate Chinese rural residents' willingness degree of initially contacting primary healthcare (PHC) under uncertainty in healthcare and to explore its influencing factors. SETTING: This study collected primary data from rural residents in Dangyang, Hubei Province in China. PARTICIPANTS: The study investigated 782 residents and 701 finished the survey. The response rate was 89.64%. A further 27 residents failed the internal consistency test, so the effective sample size was 674. DESIGN: In this cross-sectional study, residents' willingness was reflected by the threshold of disease severity for PHC (TDSP), the individual maximal disease scope for considering PHC based on residents' decision-making framework. TDSP was measured through scenario tests. Univariate analysis and unordered multiple logistic regression were used to explore the influencing factors of three-level TDSP: low, general, and high. RESULTS: Only 28.2% of respondents had high TDSP and high willingness towards PHC. Compared with general TDSP, respondents who were younger than 40 (OR 7.344, 95% CI 2.463 to 21.894), rich (OR 1.913, 95% CI 1.083 to 3.379), highly risk-averse (OR 1.958, 95% CI 1.016 to 3.774), had substitute medical decision-maker (OR value of parent/child was 2.738, 95% CI 1.386 to 5.411) and had no visits to PHC in the last 6 months (OR 2.098, 95% CI 1.316 to 3.346) tended to have low TDSP and low willingness towards PHC. Compared with general TDSP, no factors were found to significantly influence respondents' high TDSP. CONCLUSIONS: TDSP can be a good indicator of residents' willingness. TDSP results demonstrate rural residents' generally low willingness towards first-contact with PHC that some residents refuse to consider PHC even for mild diseases. This study provides practical significance for elaborating the underutilisation of PHC from resident decision-making and offers advice to policymakers and researchers for future modifications.

Comprehensive competitiveness assessment of four typical municipal sludge treatment routes in China based on environmental and techno-economic analysis.

To find a sustainable and effective municipal sludge treatment route requires a systematic assessment of the comprehensive competitiveness of diverse sludge treatment routes. Four typical treatment routes in China including co-incineration in coal power plants (CIN), mono-incineration (IN), anaerobic digestion (AD) and pyrolysis (PY) were selected in this study. A novel assessment model integrating life cycle assessment (LCA), techno-economic analysis (TEA) with analytic hierarchy process (AHP)-Entropy method was established, and comprehensive competitiveness indicated by comprehensive index (CI) of the four routes was deeply evaluated. Results displayed CIN route (CI = 0.758) showed the best comprehensive performance for its best environmental and economic performance. This was followed by PY route (CI = 0.691) and AD route (CI = 0.570), indicating the enormous potential of sludge PY technology. IN route showed the worst comprehensive performance (CI = 0.186) owing to its high environmental impact and lowest economic benefit. It was noted that greenhouse gas emissions and severe toxic potential were the main environmental challenges faced by sludge treatment. Besides, result of sensitivity analysis revealed that the comprehensive competitiveness of diverse sludge treatment routes was improved with the increase of sludge organic content and sludge reception fee.

Drivers of high-cost persistence in rural China: A population-based retrospective study.

Purpose: High-cost patients account for over 70% of total health expenditures in rural China and have become a key focus of health insurers. Persistently high-cost patients constitute a substantial proportion of medical resources. Hence, exploring high-cost persistence (HCP) and what drives it is considered meaningful and necessary. Patients and methods: A population-based retrospective study was carried out. The annual healthcare utilization data of Dangyang New Rural Cooperative Medical Scheme from 2012 to 2017 were analyzed. Patients in the top 10% of spending in a given year were considered high-cost patients. Persistence level was estimated using Markov matrices. A total of 19,405 patients categorized as high-cost patients in 2016 were divided into two groups according to whether or not they kept high-cost status in 2017. Finally, a multilevel logistic regression model was used in examining the determinants of HCP. Results: On average, about 31.48% of high-cost patients each year still maintained high-cost status in the subsequent year from 2012 to 2017. The elderly (OR = 2.150), families with more non-labor members (OR = 2.307), families applying for subsistence allowances (OR = 1.245), and patients with blood and immune diseases (OR = 2.614) or malignant tumors (OR = 2.077) were more likely to maintain high-cost status. Hospitalization frequency was found to be a mediator. Conclusion: About one-third of high-cost patients in a given year had persistently high cost status in the subsequent year. Health status and family support were considered the main drivers of HCP. High inpatient service utilization as a mediator was a prominent manifestation of persistently high-cost patients. The accurate identification of persistently high-cost patients is the basis for our management.

Structure and distribution changes of Eucalyptus hemicelluloses during hydrothermal and alkaline pretreatments.

Eucalyptus wood was pretreated with an integrated process based on hydrothermal and alkaline pretreatments. The structural changes of hemicelluloses during the pretreatments and the components of the hydrolysates were comprehensively characterized. Sugar and spectral analyses indicated that the hemicelluloses remained in the residues obtained at hydrothermal pretreatment under low temperatures were mainly composed of a (1 → 4)-ß-D-Xylp backbone with 4-O-methyl-α-D-glucuronic acids attached at O-2 of the xylose together with various monosaccharides of rhamnose, arabinose, galactose, glucose, and mannose. The pretreatments resulted in serious degradation of hemicelluloses at high pretreatment temperatures. The distribution changes of the hemicelluloses in the cell walls during the integrated pretreatments were detected by Confocal Raman Microscopy, which revealed that the dissolution of hemicelluloses in different morphological regions was inhomogeneous, and the a large portion of hemicelluloses were removed from the secondary cell wall regions during the pretreatments.

Revealing the structure and distribution changes of Eucalyptus lignin during the hydrothermal and alkaline pretreatments.

An integrated pretreatment process based on hydrothermal pretreatment (HTP) followed by alkaline pretreatment has been applied to treat Eucalyptus. The chemical composition and structure changes of lignin during the pretreatment were comprehensively characterized. The surface morphology of the cell walls and lignin distribution of the pretreated Eucalyptus were detected by scanning electron and confocal Raman microscopies. It was found that the chemical bonds between lignin and hemicelluloses were cleaved during the pretreatment. The results also indicated that the contents of ß-O-4', ß-ß', and ß-5' linkages were decreased with the increase of hydrothermal pretreatment temperature and the cleavage of ß-O-4' linkages in lignin was accompanied with repolymerization reactions. 31P NMR analysis showed that the content of aliphatic OH was reduced as the temperature increased and the total phenolic OH was elevated and then declined with the increase of temperature. Raman spectra analysis revealed that the dissolution rate of lignin in the secondary wall regions was faster than that in cell corner middle lamella regions during the pretreatment. These results will enhance the understanding of the cell wall deconstruction during the pretreatment and the mechanism of the integrated pretreatment process acting on Eucalyptus.

Structural elucidation of Eucalyptus lignin and its dynamic changes in the cell walls during an integrated process of ionic liquids and successive alkali treatments.

An integrated process based on ionic liquids ([Bmim]Cl and [Bmim]OAc) pretreatment and successive alkali post-treatments (0.5, 2.0, and 4.0% NaOH at 90°C for 2h) was performed to isolate lignins from Eucalyptus. The structural features and spatial distribution of lignin in the Eucalyptus cell wall were investigated thoroughly. Results revealed that the ionic liquids pretreatment promoted the isolation of alkaline lignin from the pretreated samples without obvious structural changes. Additionally, the integrated process resulted in syringyl-rich lignin macromolecules with more ß-O-4' linkages and less phenolic hydroxyl groups. Confocal Raman microscopy analysis showed that the dissolution behavior of lignin was varied in the morphologically distinct regions during the successive alkali treatments, and lignin dissolved was mainly stemmed from the secondary wall regions. These results provided some useful information for understanding the mechanisms of delignification during the integrated process and enhancing the potential utilizations of lignin in future biorefineries.

Evaluation of the two-step treatment with ionic liquids and alkali for enhancing enzymatic hydrolysis of Eucalyptus: chemical and anatomical changes.

BACKGROUND: The biomass recalcitrance resulting from its chemical compositions and physical structures impedes the conversion of biomass into fermentable sugars. Pretreatment is a necessary procedure to increase the cellulase accessibility for bioconversion of lignocelluloses into bioethanol. Alternatively, ionic liquids, a series of promising solvents, provide unique opportunities for pretreating a wide range of lignocellulosic materials. In this study, a two-step treatment including ionic liquids pretreatment and successive alkali fractionations was performed on Eucalyptus to achieve a high enzymatic digestibility. The compositional and structural changes of Eucalyptus cell walls and their possible effect on saccharification ratio were comprehensively investigated. RESULTS: After the ionic liquids pretreatment, the cell walls became loose and even swelled, accompanying with the decrease of cellulose crystallinity. As compared to the simplex ionic liquids pretreatment, the integrated process resulted in the significant removal of hemicelluloses and lignin, enhancing the disruption of the cell walls and increasing the exposure of cellulose, which led to a higher conversion of cellulose to glucose. The glucose yield of Eucalyptus underwent the combination of [Bmim]OAc and alkali treatments reached the maximum (90.53 %), which was 6.6 times higher than that of the untreated Eucalyptus. The combination of chemical compositions and physical structure of Eucalyptus affected the efficiency of cellulose enzymatic hydrolysis. Especially, the changes of cellulose crystallinity played a major role in enhancing the enzymatic digestibility of Eucalyptus in this study. CONCLUSIONS: The two-step treatment with ionic liquids pretreatment and successive alkali fractionation can be considered as a promising method to improve the conversion of cellulose to glucose. The detailed information obtained about chemical and anatomical changes was helpful to understand the underlying mechanism of the integrated treatment process acting on Eucalyptus for enhancing enzymatic digestibility.