The effect of a tailored message package for reducing antibiotic use among respiratory tract infection patients in rural Anhui, China: a cluster randomized controlled trial protocol.

BACKGROUND: Antibiotics are over-used for patients with respiratory tract infections (RTIs) in primary care, especially in the rural areas of China. METHODS: A cluster randomized controlled trial (RCT) will be carried out to estimate the effectiveness of a tailored message package for educating patients to reduce antibiotic use for symptomatic respiratory tract infections (RTIs). In the intervention group, patients will receive 12 short messages in 12 consecutive days. The whole process of the message design, modification, translation (of substitution variables), and sending will be facilitated by a user-friendly mini-computer program. The primary measure for assessment is the reduction in number of days in which antibiotics are used by patients with symptomatic RTIs. The secondary measures include (1) patients' knowledge about and attitude toward antibiotics; (2) patients' quality of life (EQ-5D-5L) and symptom severity and duration; (3) times of re-visits to clinics and antibiotics re-prescription for the same RTI episode; and (4) times of re-occurrence of RTIs and related health service seeking and antibiotics consumption. DISCUSSION: This study will determine the efficacy of a 12-message intervention to educate patients to reduce excessive antibiotic use in rural China. TRIAL REGISTRATION: ISRCTN29801086 . Registered on 23 September 2022.

Usefulness of Self-Assessment of Gastrointestinal Symptoms: Web-Based Study in Anhui, China.

BACKGROUND: Gastrointestinal symptoms (GISs) are caused by a combination of biopsychosocial factors and are highly prevalent worldwide. Given their complex nature, coupled with ineffective communication of diagnoses by physicians, patients with intimate GISs often feel stigmatized. This, in turn, can inhibit their ability to express their thoughts and feelings adequately, leading them to over- or underreport their symptoms. Moreover, selective service-seeking for and reporting of GISs have a direct bearing on the stage of disease at presentation and, consequently, on the overall prognosis. OBJECTIVE: This study aimed to investigate the usefulness of a web-based self-assessment of GISs as a supplementary means to cope with potential over- or underreporting during routine consultations. METHODS: GIS data were collected using a novel web-based self-assessment tool (n=475) and from nonparticipative observation of doctor-patient consultations (n=447) and household surveys (n=10,552) in Anhui, China. Data analysis focused primarily on the description of the composition of respondents and the occurrence rates of GISs by sociodemographics, and by symptom solicitation methods and settings. Chi-square power tests were used when necessary to compare differences in the occurrence rates between relevant groups. The level of significance for the 2-sided test was set at α<.05. RESULTS: The average occurrence rates of both upper and lower GISs derived from the web-based self-assessment were higher than those from the observation (upper GISs: n=661, 20.9% vs n=382, 14.2%; P<.001; lower GISs: n=342, 12.9% vs n=250, 10.8%; P=.02). The differences in 6 of the 9 upper GISs and 3 of the 11 lower GISs studied were tested with statistical significance (P<.05); moreover, a higher frequency rate was recorded for symptoms with statistical significance via self-assessment than via observation. For upper GISs, the self-assessed versus observed differences ranged from 17.1% for bloating to 100% for bad mood after a meal, while for lower GISs, the differences ranged from -50.5% for hematochezia or melena to 100% for uncontrollable stool. Stomachache, regurgitation, and dysphagia had higher occurrence rates among participants of the self-assessment group than those of the household survey group (20% vs 12.7%, 14% vs 11%, and 3% vs 2.3%, respectively), while the opposite was observed for constipation (5% vs 10.9%), hematochezia or melena (4% vs 5%), and anorexia (4% vs 5.2%). All differences noted in the self-assessed occurrence rates of specific, persistent GISs between sociodemographic groups were tested for nonsignificance (P>.05), while the occurrence rates of any of the 6 persistent GISs among respondents aged 51-60 years was statistically higher than that among other age groups (P=.03). CONCLUSIONS: The web-based self-assessment tool piloted in this study is useful and acceptable for soliciting more comprehensive GISs, especially symptoms with concerns about stigmatization, privacy, and shame. Further studies are needed to integrate the web-based self-assessment with routine consultations and to evaluate its efficacy.

Differentiated Effects and Determinants of Home Blood Pressure Telemonitoring: Three-Year Cohort Study in Jieshou, Anhui, China.

BACKGROUND: Home blood pressure telemonitoring (HBPT) is witnessing rapid diffusion worldwide. Contemporary studies documented mainly short-term (6-12 months) effects of HBPT, and there are limited data about its uptake. OBJECTIVE: The aim of this study was to explore the 3-year use and determinants of HBPT, and the interactions with systolic and diastolic blood pressure (SBP/DBP) and overall blood pressure (BP) control rate. METHODS: HBPT records were obtained from a 3-year cohort of 5658 patients with hypertension in Jieshou, Anhui, China, and data from a structured household survey of a random sample (n=3005) of the cohort. The data analysis comprised (1) timeline trajectories of the rates of monthly active HBPT and mean SBP/DBP for overall and subgroups of patients with varied start-month SBP/DBP; and (2) multivariable linear, logistic, and percentile regression analyses using SBP/DBP, BP control rate, and yearly times of HBPT as the dependent variable, respectively. RESULTS: HBPT was followed by mixed changes in mean monthly SBP/DBP for varied patient groups. The magnitude of changes ranged from -43 to +39 mmHg for SBP and from -27 to +15 mmHg for DBP. The monthly rates of active HBPT all exhibited a rapid and then gradually slower decline. When controlled for commonly reported confounders, times of HBPT in the last year were found to have decreasing correlation coefficients for SBP/DBP (from 0.16 to -0.35 and from 0.11 to -0.35, respectively) and for BP control rate (from 0.53 to -0.62). CONCLUSIONS: HBPT had major and "target-converging" effects on SBP/DBP. The magnitude of changes was much greater than commonly reported. BP, variation in BP, and time were the most important determinants of HBPT uptake. Age, education, duration of hypertension, family history, and diagnosis of hypertension complications were also linked to the uptake but at weaker strength. There is a clear need for differentiated thinking over the application and assessment of HBPT, and for identifying and correcting/leveraging potential outdated/new opportunities or beliefs.

Differences in service and antibiotics use following symptomatic respiratory tract infections between 2016 and 2021 in rural Anhui, China.

In the past 10-15 years, the government of China has made various efforts in tackling excessive antibiotics use. Yet, little is known about their effects at rural primary care settings. This study aimed to determine the impact of government policies and the COVID-19 pandemic on antibiotic prescribing practices at such settings utilizing data from separate studies carried out pre- and during the pandemic, in 2016 and 2021 in Anhui province, China, using identical sampling and survey approaches. Data on antibiotics prescribed, diagnosis, socio-demographic, etc., were obtained through non-participative observation and a structured exit survey. Data analysis comprised mainly descriptive comparisons of 1153 and 762 patients with respiratory infections recruited in 2016 and 2021, respectively. The overall antibiotics prescription rate decreased from 89.6% in 2016 to 69.1% in 2021, and the proportion of prescriptions for two or more classes of antibiotics was estimated as 35.9% in 2016 and 11.0% in 2021. There was a statistically significant decrease in the number of days from symptom onset to clinic visits between the year groups. In conclusion, measures to constrain excessive prescription of antibiotics have led to some improvements at the rural primary care level, and the COVID-19 pandemic has had varying effects on antibiotic use.

Antibiotic Stewardship in Retail Pharmacies and the Access-Excess Challenge in China: A Policy Review.

In China, efforts to restrict excessive antibiotic consumption may prevent sufficient access to these life-saving drugs among the most deprived in society because of the weak primary health care system. This makes antibiotic stewardship in the retail pharmacy sector a particular challenge. We conducted an analysis to examinate policies on antibiotic sales in retail pharmacies in China and how tensions between 'excess' and 'access' are managed. The analysis was guided by the Walt and Gilson health policy analysis triangle to systematically analyse policies based on the content of policies, contexts, governance processes, and actors. Nine research studies and 25 documents identified from national and international sources were extracted, grouped into categories, and examined within and across records and categories. As of 2020, eight key policies have been introduced in China that focus on two areas: dispending prescribed medicines or antimicrobials with a prescription and having a licensed pharmacist present in the retail pharmacies, with approaches having changed over time. Inappropriate sales of antibiotics are still common in retail pharmacies, which can be linked to the lack of consistency and enforcement of published policies, the profit-driven nature of retail pharmacies, and the displacement of the demand for antibiotics from clinical into less regulated settings.

Cluster randomised controlled trial to assess a tailored intervention to reduce antibiotic prescribing in rural China: study protocol.

INTRODUCTION: Up to 80% of patients with respiratory tract infections (RTI) attending healthcare facilities in rural areas of China are prescribed antibiotics, many of which are unnecessary. Since 2009, China has implemented several policies to try to reduce inappropriate antibiotic use; however, antibiotic prescribing remains high in rural health facilities. METHODS AND ANALYSIS: A cluster randomised controlled trial will be carried out to estimate the effectiveness and cost effectiveness of a complex intervention in reducing antibiotic prescribing at township health centres in Anhui Province, China. 40 Township health centres will be randomised at a 1:1 ratio to the intervention or usual care arms. In the intervention group, practitioners will receive an intervention comprising: (1) training to support appropriate antibiotic prescribing for RTI, (2) a computer-based treatment decision support system, (3) virtual peer support, (4) a leaflet for patients and (5) a letter of commitment to optimise antibiotic use to display in their clinic. The primary outcome is the percentage of antibiotics (intravenous and oral) prescribed for RTI patients. Secondary outcomes include patient symptom severity and duration, recovery status, satisfaction, antibiotic consumption. A full economic evaluation will be conducted within the trial period. Costs and savings for both clinics and patients will be considered and quality of life will be measured by EuroQoL (EQ-5D-5L). A qualitative process evaluation will explore practitioner and patient views and experiences of trial processes, intervention fidelity and acceptability, and barriers and facilitators to implementation. ETHICS AND DISSEMINATION: Ethical approval was obtained from the Biomedical Research Ethics Committee of Anhui Medical University (Ref: 20180259); the study has undergone due diligence checks and is registered at the University of Bristol (Ref: 2020-3137). Research findings will be disseminated to stakeholders through conferences and peer-reviewed journals in China, the UK and internationally. TRIAL REGISTRATION NUMBER: ISRCTN30652037.

The impact of COVID-19 on primary health care and antibiotic prescribing in rural China: qualitative study.

BACKGROUND: In China, the primary health care (PHC) system has been designated responsible for control and prevention of COVID-19, but not treatment. Suspected COVID-19 cases presenting to PHC facilities must be transferred to specialist fever clinics. This study aims to understand the impact of COVID-19 on PHC delivery and on antibiotic prescribing at a community level in rural areas of central China. METHODS: Qualitative semi-structured interviews were conducted with 18 PHC practitioners and seven patients recruited from two township health centres and nine village clinics in two rural residential areas of Anhui province. Interviews were transcribed verbatim and analysed thematically. RESULTS: PHC practitioners reported a major shift in their work away from seeing and treating patients (due to government-mandated referral to specialist Covid clinics) to focus on the key public health roles of tracing, screening and educating in rural areas. The additional work, risk, and financial pressure that PHC practitioners faced, placed considerable strain on them, particularly those working in village clinics. Face to face PHC provision was reduced and there was no substitution with consultations by phone or app, which practitioners attributed to the fact that most of their patients were elderly and not willing or able to switch. Practitioners saw COVID-19 as outside of their area of expertise and very different to the non-COVID-19 respiratory tract infections that they frequently treated pre-pandemic. They reported that antibiotic prescribing was reduced overall because far fewer patients were attending rural PHC facilities, but otherwise their antibiotic prescribing practices remained unchanged. CONCLUSIONS: The COVID-19 pandemic had considerable impact on PHC in rural China. Practitioners took on substantial additional workload as part of epidemic control and fewer patients were seen in PHC. The reduction in patients seen and treated in PHC led to a reduction in antibiotic prescribing, although clinical practice remains unchanged. Since COVID-19 epidemic control work has been designated as a long-term task in China, rural PHC clinics now face the challenge of how to balance their principal clinical and increased public health roles and, in the case of the village clinics, remain financially viable.

Dose-Effect Relationship Between Gastric Cancer and Common Digestive Tract Symptoms and Diagnoses in Anhui, China.

BACKGROUND: Early prevention and diagnosis are key to reducing the huge burden of gastric cancer (GC). Nearly half of the population worldwide are suffering from some form of digestive tract conditions (symptoms/diagnoses, DTCs) but their relations with GC are not well understood. We aim to explore the relationships (especially dose-effect relationships) between GC and DTCs. METHODS: This study used data from a community-based case-control study in Anhui, China during 2016-2019 and performed multivariate conditional logistic regression modeling of the associations between GC and DTCs. RESULTS: A total of 2255 participants (451 cases and 1804 controls) completed the study. Statistically significant relations (P<0.05) were found between GC and the presence of gastroesophageal reflux [odds ratio (OR)=1.41], odynophagia (OR=1.87), stomach discomfort (OR=1.86), poor appetite (OR=2.01) and Helicobacter pylori (H. pylori) infection (OR=4.39). When the DTCs were divided into duration grades, all these ORs presented an increasing trend (P<0.05), being 1.89 to 2.45 for gastroesophageal reflux, 1.63 to 3.78 for stomach discomfort, 2.36 to 5.29 for poor appetite, and 3.95 to 10.03 for H. pylori infection. When the DTCs were divided into severity grades, the ORs also witnessed an increasing trend (P<0.05), being 1.69 to 2.52 for gastroesophageal reflux, 2.44 to 3.56 for stomach discomfort, and 2.22 to 2.75 for poor appetite. When the DTCs were divided into duration-severity grades, the ORs displayed a much steeper increasing trend, being 0.49 to 4.96 for gastroesophageal reflux, 1.50 to 6.33 for odynophagia, 0.47 to 3.32 for stomach discomfort, and 0.40 to 10.47 for poor appetite. In contrast, the ORs for the lower DTCs were generally tested without statistical significance. CONCLUSION: The study revealed consistent dose-effect associations between GC and duration of gastroesophageal reflux, stomach discomfort, poor appetite, and H. pylori infection; severity of gastroesophageal reflux, stomach discomfort and poor appetite; and duration-severity of gastroesophageal reflux, odynophagia, stomach discomfort and poor appetite. These should inform future prevention, diagnosis and further research in patients with GC.

Clinical diagnosis and treatment of common respiratory tract infections in relation to microbiological profiles in rural health facilities in China: implications for antibiotic stewardship.

BACKGROUND: This paper tries to describe prevalence and patterns of antibiotics prescription and bacteria detection and sensitivity to antibiotics in rural China and implications for future antibiotic stewardship. METHODS: The study was implemented in one village clinic and one township health center in each of four rural residential areas in Anhui Province, China. It used mixed-methods comprising non-participative observations, exit-survey and microbiological study. Observations were conducted to record clinical diagnosis and antibiotic prescription. Semi-structured questionnaire survey was used to collect patient's sociodemographic information and symptoms. Sputum and throat swabs were collected for bacterial culture and susceptibility testing. RESULTS: A total of 1068 (51.0% male vs 49.0% female) patients completed the study with diagnosis of respiratory tract infection (326,30.5%), bronchitis/tracheitis (249,23.3%), pharyngitis (119,11.1%) and others (374, 35.0%). They provided 683 sputum and 385 throat swab specimens. Antibiotics were prescribed for 88% of the RTI patients. Of all the specimens tested, 329 (31%) were isolated with bacteria. The most frequently detected bacteria were K. pneumonia (24% in all specimens), H. influenza (16%), H. parainfluenzae (15%), P. aeruginosa (6%), S.aureus (5%), M. catarrhalis (3%) and S. pneumoniae (2%). CONCLUSIONS: The study establishes the feasibility of conducting microbiological testing outside Tier 2 and 3 hospitals in rural China. It reveals that prescription of antibiotics, especially broad-spectrum and combined antibiotics, is still very common and there is a clear need for stewardship programs aimed at both reducing the number of prescriptions and promoting single and narrow-spectrum antibiotics.

Personalized hypertension management based on serial assessment and telemedicine (PHMA): a cluster randomize controlled trial protocol in Anhui, China.

BACKGROUND: Despite tremendous investment worldwide, hypertension treatment and control rates remain low. The complexity and long-term dynamics of influencing factors make personalized management inevitable and challenging. This protocol describes Personalized Hypertension Management in Anhui, China (PHMA), a project that uses a package of innovative approaches in tailoring interventions to individual patient's dynamic complications and contexts. METHODS/DESIGN: PHMA strives to reduce hypertension harms by eight "objective behaviors" (e.g., self-monitoring and reporting, healthy diet, physical exercise/activities). These objective behaviors are promoted through five intervention measures: support for self- monitoring, supervised machine communications, daily education or reminder messages, weekly blood pressure notification, and quarterly signed feedback. PHMA uses ten categories and over 300 variables in selecting and refining intervention procedures and content for individual patients. Efficacy of the intervention package is evaluated using a cluster randomized controlled trial design involving a total of 60 site communities and 3352 hypertension patients. Primary measure for the evaluation is systolic and diastolic blood pressure; while secondary evaluation measures include quality of life (EQ5D-5L), occurrence of hypertension-related complications (such as cerebral hemorrhage, coronary heart disease, myocardial or cerebral infarction), healthcare utilization and scores of objective behaviors. DISCUSSION: PHMA uses novel, low cost and sustainable approaches to tailor interventions to the dynamic conditions and contexts of individual patients. Unlike contemporary approaches to hypertension management which are mainly population based, each participant patient in PHMA applies a unique intervention package and all messages, feedbacks and other materials sent out to individual patients are different from each other. PHMA is the first project that adopts comprehensive tailoring and if proved effective, it should have important implications for future research, practice and policy-making. Trial registration ISRCTN10999269. July 17, 2020; https://doi.org/10.1186/ISRCTN10999269 .

Prevalence of respiratory tract infections and influencing factors: A cross-sectional survey in Anhui Province, China.

OBJECTIVES: This study used available data to analyze the prevalence and influencing factors of various Respiratory tract infections (RTIs), to better our understanding of the local and national epidemiology, and to inform future prevention and control programs. DESIGN: We used a structured questionnaire to solicit information about social demographics and symptoms of the last RTI administered with stratified clustered randomized sampling. Descriptive analysis was used to investigate the reported symptoms, and multivariate logistic regression models to identify relationships between the prevalence and influencing factors of common RTIs. RESULTS: The study documented a prevalence rate of 1.5% for common cold, 0.5% for influenza, and 0.9% for 9-AURTIs (nine acute upper RTIs, including acute pharyngitis, sore throat, acute tonsillitis, acute suppurative tonsillitis, acute laryngitis, acute bronchitis, acute pharyngitis, acute upper RTI, and viral upper RTI), adding up to 3.4% of overall RTIs in the past 2 weeks. Results also revealed a L-shaped trend along age-axis for all the RTIs, and marginal to moderate associations between RTIs and other commonly researched factors (education, body mass index, sex, and annual income), as well as environmental and behavior factors. CONCLUSIONS: RTIs in Anhui, China are common and associated with a variety of socio-demographic, behavioral, and environmental factors. RTIs merit better epidemiological understanding and added interventions tailored to efforts in reducing their health and economic burden. These understandings and efforts are especially relevant for public health nurses since most RTI patients are treated in community settings.

Characteristics and implications of insurance-reimbursed inpatient care for gastric and oesophageal cancers in Anhui, China.

BACKGROUND: This study aimed to identify characteristics and trends in insurance-reimbursed inpatient care (NRIC) for gastric and oesophageal cancers and inform evaluation of medical systems reform. METHODS: The study extracted routinely collected records of claims for reimbursement from the New Rural Cooperative Medical System (NRCMS) in Anhui Province, China and performed descriptive and regression discontinuity analysis. RESULTS: From 2013 to 2017, NRIC in terms of person-time per million people (pmp) increased 5.60 and 20.62 times for gastric and oesophageal cancers, respectively. Total expense per episode for gastric and oesophageal cancers increased from 1130.25 and 22 697.99 yuan to 12 514.98 and 24 639.37 yuan, respectively. The ratio of out-of-pocket expenses per inpatient care episode to annual disposable income per capita was 0.43 for gastric cancer and 0.91 for oesophageal cancer and decreased by 0.17 and 0.47, respectively. Regression discontinuity modelling revealed that, when controlled for disposable income, illiteracy rate and months from start time, the treatment variable was significantly associated with person-times of NRIC pmp (ß=0.613, p=0.000), length of stay per 105 people (ß=-52.990, p=0.000) and total expenses per NRIC episode (ß=2.431, p=0.000). CONCLUSIONS: The study period witnessed substantial achievements in benefits to patients, inpatient care efficiency and equity. These achievements may be attributed mainly to the recent reforms launched in Anhui province, China.

Trajectories of symptoms and healthcare use following respiratory tract infections in rural Anhui, China：a cross-sectional study.

BACKGROUND: Respiratory tract infections (RTIs) are important health problems with high incidence and consequent economic costs. The study aimed to analyze trajectories of experienced RTI symptoms and use of healthcare and antibiotics. METHOD: The study adopted a cross-sectional design and face-face interview using a structured questionnaire. The questionnaire comprised: a) social demographics; b) last episode of symptomatic RTIs; c) responses to the RTIs; d) antibiotics obtained from clinics and medicine shops for the RTIs. The study subjects were residents in randomly selected villages in Anhui, China. The study settings were the residents households. Descriptive analyses were conducted to draw symptoms trajectory and identify relationship between healthcare seeking and symptoms and common sociodemographic variables. RESULT: A total 91.1% (1968) of 2160 eligible residents completed the interview who reported 1.83 episodes of RTIs in the pass year on average. Over half (54.8%) of these RTI episodes had led to visit to clinics for professional care and 51.9%, to use of antibiotics. The trajectories of common RTI symptoms featured a sharp increase and peak followed by a long tail along the days after onset of the infection. Over 60.5% of healthcare-seeking happened between two days before and one day after the symptoms peak. The study also revealed interesting pattern in the timing of different type of treatment following, e.g., taking leftover medicine and antibiotics happened the earliest and seeking professional help and getting antibiotics from clinics, the latest. CONCLUSION: RTIs incur a large volume of healthcare-seeking and antibiotics use and there is an urgent need for effective education measures on proper service especially antibiotics use. Patients' reported RTI symptoms manifest peculiar trajectories and their retrospective recall of the course of prior RTI episodes and associated actions may guide their future responses to similar infections. Knowledge of these may help inform doctors about patient expectations, enabling them better manage shared decision- making around antibiotic treatment.

Patients without records and records without patients: review of patient records in primary care and implications for surveillance of antibiotic prescribing in rural China.

BACKGROUND: We need to monitor patterns of antibiotic prescribing in order to develop and evaluate antibiotic stewardship interventions in rural China. As part of a multidisciplinary study of antibiotic use in Anhui Province we assessed the validity of electronic records (e-records) as a source of surveillance data. METHODS: One township healthcare centre and one village clinic were selected in each of three different counties. Patients with symptoms of Upper Respiratory Tract Infection (URTI), exacerbation of Chronic Obstructive Pulmonary Disease (COPD) or Urinary Tract Infection (UTI) were recruited consecutively. Researchers observed and documented clinic consultations and interviewed each of the study participants. E-records were compared to clinic observations and patient interviews. RESULTS: A total of 1030 patients were observed in clinic. Antibiotics were prescribed in 917 (89%) of consultations. E-records were created only for individuals with health insurance, with considerable between-site variation in completeness (0 to 98.7% of clinic consultations) and in the timing of documentation (within-consultation up to weeks afterwards). E-record accuracy was better in relation to antibiotics (82.8% of e-records accurately recorded what was prescribed in clinic) than for diagnosis and symptoms (45.0 and 1.1% accuracy). Only 31 participants (3.0%) presented with UTI symptoms. CONCLUSIONS: We have confirmed very high rates of outpatient antibiotic prescribing in rural Anhui province. E-records could provide useful information to inform stewardship interventions, however they may be inaccurate and/or biased. Public Health authorities should focus on improving technical infrastructure and record-keeping culture in outpatient settings. Further research is needed into community treatment of UTIs.

Health service utilization following symptomatic respiratory tract infections and influencing factors among urban and rural residents in Anhui, China.

AIM: This study seeks to identify healthcare utilization patterns following symptomatic respiratory tract infections (RTIs) and the variables that may influence these patterns. BACKGROUND: RTIs are responsible for the bulk of the primary healthcare burden worldwide. Yet, the use of health services for RTIs displays great discrepancies between populations. This research examines the influence of social demographics, economic factors, and accessibility on healthcare utilization following RTIs. METHODS: Structured interviews were administered by trained physicians at the households of informants selected by cluster randomization. Descriptive and multivariate binary logistic regression analysis was performed to assess healthcare utilization and associated independent variables. FINDINGS: A total of 60 678 informants completed the interviews. Of the 2.9% informants exhibiting upper RTIs, 69.5-73.9% sought clinical care. Healthcare utilization rates for common cold, influenza, nine acute upper RTIs, and overall RTIs demonstrate statistically significant associations with the variables of age, type of residence, employment, medical insurance, annual food expenditure, distance to medical facilities, and others. The odds ratios for healthcare utilization rates varied substantially, ranging from 0.026 to 9.364. More than 69% of informants with RTIs sought clinical interventions. These findings signify a marked issue with the large amount of healthcare for self-limited RTIs.

Pathways to optimising antibiotic use in rural China: identifying key determinants in community and clinical settings, a mixed methods study protocol.

INTRODUCTION: This study aims to investigate patterns of antibiotic treatment-seeking, describe current levels of and drivers for antibiotic use for common infections (respiratory tract and urinary tract infections) and test the feasibility of determining the prevalence and epidemiology of antimicrobial resistance (AMR) in rural areas of Anhui province, in order to identify potential interventions to promote antibiotic stewardship and reduce the burden of AMR in China. METHODS AND ANALYSIS: We will conduct direct observations, structured and semistructured interviews in retail pharmacies, village clinics and township health centres to investigate treatment-seeking and antibiotic use. Clinical isolates from 1550 sputum, throat swab and urine samples taken from consenting patients at village and township health centres will be analysed to identify bacterial pathogens and ascertain antibiotic susceptibilities. Healthcare records will be surveyed for a subsample of those recruited to the study to assess their completeness and accuracy. ETHICS AND DISSEMINATION: The full research protocol has been reviewed and approved by the Biomedical Ethics Committee of Anhui Medical University (reference number: 20170271). Participation of patients and doctors is voluntary and written informed consent is sought from all participants. Findings from the study will be disseminated through academic routes including peer-reviewed publications and conference presentations, via tailored research summaries for health professionals, health service managers and policymakers and through an end of project impact workshop with local and regional stakeholders to identify key messages and priorities for action.

Psychological factors and demands for breast and cervical cancer screening.

OBJECTIVE: The study aims to investigate relationships between demands for breast and cervical cancer screening (BCS/CCS) and related health beliefs. METHODS: The study used cluster-randomized sampling and collected data about demands for BCS/CCS and constructs of health beliefs model (HBM). It calculated indices of perceived risk and seriousness of the cancers and perceived effectiveness, benefits and difficulties of the screening; and performed descriptive and multivariate regression analysis of the demands and the HBM constructs. RESULTS: Less than 23.7% of respondents (N = 805) had ever undertaken BCS/CCS but 62.7% reported willingness to receive the service. Demands for BCS/CCS illustrated negative associations (Beta = -0.11 and -0.10) with age but positive (Beta = 0.15 and 0.11) links with education. The absolute values of standardized regression coefficients between the demand and the HBM constructs added up to 0.69 for BCS and 0.64 for CCS respectively, being 4-40 times that of age and education. CONCLUSIONS: Models incorporating all HBM constructs have substantially greater power than commonly researched single factors in explaining BCS/CCS demands. PRACTICE IMPLICATIONS: Comprehensive BCS/CCS promotion addressing all HBM constructs in a synergetic way may prove to be more effective.

How patients' experiences of respiratory tract infections affect healthcare-seeking and antibiotic use: insights from a cross-sectional survey in rural Anhui, China.

OBJECTIVE: To investigate the occurrence of reported respiratory tract infection (RTI) symptoms and their effects on use of self and professional care among patients in the community. DESIGN: A cross-sectional retrospective household survey. SETTING: 12 administrative villages from rural Anhui, China. PARTICIPANTS: 2160 rural adult residents aged ≥18 years registered as rural residents and actually living in the sampled villages when this study was conducted. METHOD: The respondents were recruited using stratified-clustered randomised sampling. A structured questionnaire was deployed to solicit information about social demographics, symptoms of last RTI and healthcare-seeking following the RTI. Descriptive analyses were performed to investigate the reported symptoms, and multivariate logistic regression models were developed to identify relationships between number of concurrent symptoms and healthcare-seeking and antibiotics use. RESULTS: A total of 1968 residents completed the survey, resulting in a response rate of 91.1%. The number of concurrent symptoms showed a clear increasing trend with seeking help from clinics and being prescribed antibiotics. Multivariate regression revealed statistically significant associations between the following: (a) visiting clinics and education (OR=0.790), sore throat (OR=1.355), cough (OR=1.492), shortness of breath (OR=1.707) and fever (OR=2.142); (b) buying medicine from shops without prescription and education (OR=1.230) and cough (OR=1.452); (c) getting antibiotics at clinics and sore throat (OR=2.05) and earache and/or tinnitus (OR=4.884); and (d) obtaining antibiotics at medicine shops and productive cough (OR=1.971). CONCLUSIONS: Reported RTI symptoms play an important role in shaping both patient- and doctor-led responses.

Web-Based Just-in-Time Information and Feedback on Antibiotic Use for Village Doctors in Rural Anhui, China: Randomized Controlled Trial.

BACKGROUND: Excessive use of antibiotics is very common worldwide, especially in rural China; various measures that have been used in curbing the problem have shown only marginal effects. OBJECTIVE: The objective of this study was to test an innovative intervention that provided just-in-time information and feedback (JITIF) to village doctors on care of common infectious diseases. METHODS: The information component of JITIF consisted of a set of theory or evidence-based ingredients, including operation guideline, public commitment, and takeaway information, whereas the feedback component tells each participating doctor about his or her performance scores and percentages of antibiotic prescriptions. These ingredients were incorporated together in a synergetic way via a Web-based aid. Evaluation of JITIF adopted a randomized controlled trial design involving 24 village clinics randomized into equal control and intervention arms. Measures used included changes between baseline and endpoint (1 year after baseline) in terms of: percentages of patients with symptomatic respiratory or gastrointestinal tract infections (RTIs or GTIs) being prescribed antibiotics, delivery of essential service procedures, and patients' beliefs and knowledge about antibiotics and infection prevention. Two researchers worked as a group in collecting the data at each site clinic. One performed nonparticipative observation of the service process, while the other performed structured exit interviews about patients' beliefs and knowledge. Data analysis comprised mainly of: (1) descriptive estimations of beliefs or knowledge, practice of indicative procedures, and use of antibiotics at baseline and endpoint for intervention and control groups and (2) chi-square tests for the differences between these groups. RESULTS: A total of 1048 patients completed the evaluation, including 532 at baseline (intervention=269, control=263) and 516 at endpoint (intervention=262, control=254). Patients diagnosed with RTIs and GTIs accounted for 76.5% (407/532) and 23.5% (125/352), respectively, at baseline and 80.8% (417/532) and 19.2% (99/532) at endpoint. JITIF resulted in substantial improvement in delivery of essential service procedures (2.6%-24.8% at baseline on both arms and at endpoint on the control arm vs 88.5%-95.0% at endpoint on the intervention arm, P<.001), beliefs favoring rational antibiotics use (11.5%-39.8% at baseline on both arms and at endpoint on the control arm vs 19.8%-62.6% at endpoint on the intervention arm, P<.001) and knowledge about side effects of antibiotics (35.7% on the control arm vs 73.7% on the intervention arm, P<.001), measures for managing or preventing RTIs (39.1% vs 66.7%, P=.02), and measures for managing or preventing GTIs (46.8% vs 69.2%, P<.001). It also reduced antibiotics prescription (from 88.8%-62.3%, P<.001), and this decrease was consistent for RTIs (87.1% vs 64.3%, P<.001) and GTIs (94.7% vs 52.4%, P<.001). CONCLUSIONS: JITIF is effective in controlling antibiotics prescription at least in the short term and may provide a low-cost and sustainable solution to the widespread excessive use of antibiotics in rural China.

Pathways and cost-effectiveness of routine lung cancer inpatient care in rural Anhui, China: a retrospective cohort study protocol.

INTRODUCTION: Routine inpatient care (RIC) for patients with cancer forms various pathways of clinical procedures. Although most individual procedures comprising the pathways have been tested via clinical trials, little is known about the collective cost and effectiveness of the pathways as a whole. This study aims at exploring RIC pathways for patients with lung cancer from rural Anhui, China, and their determinants and economic impacts. METHODS AND ANALYSIS: The study adopts a retrospective cohort design and proceeds in five steps. Step 1 defines the four main categories of study variables, including clinical procedures, direct cost and effectiveness of procedures, and factors affecting use of these procedures and their cost and effectiveness. Step 2 selects a cohort of 5000 patients with lung cancer diagnosed between 1 July 2015 and 30 June 2016 from rural Anhui by clustered random sampling. Step 3 retrieves the records of all the inpatient care episodes due to lung cancer and extracts data about RIC procedures, proximate variables (eg, Karnofsky Performance Status, Lung Function Score) of patient outcomes and related factors (eg, stage of cancer, age, gender), by two independent clinician researchers using a web-based form. Step 4 estimates the direct cost of each of the RIC procedures using micro-costing and collects data about ultimate patient outcomes (survival and progression-free survival) through a follow-up survey of patients and/or their close relatives. Step 5 analyses the data collected and explores pathways of RIC procedures and their relations with patient outcomes, costs, cost:effect ratios, and a whole range of clinical and sociodemographic factors using multivariate regression and path models. ETHICS AND DISSEMINATION: The study protocol has been approved by an authorised ethics committee of Anhui Medical University (reference number: 20170312). Findings from the study will be disseminated through conventional academic routes such as peer-reviewed publications and presentations at regional, national and international conferences. TRIAL REGISTRATION NUMBER: ISRCTN25595562.