Fear of falling as a mediator in the association between social frailty and health-related quality of life in community-dwelling older adults.

BACKGROUND: Social frailty is associated with Fear of Falling (FoF) and health-related quality of life (HrQoL). However, how social frailty simultaneously influences FoF and HrQoL remains unclear. The study aims to understand the links between social frailty, FoF, and HrQoL in older adults and the mediating role of FoF in the relations between social frailty and HrQoL. METHODS: In this cross-sectional survey, 1,933 community-dwelling older adults from Changhua County, Taiwan, were interviewed using a self-administrated questionnaire. In total, 1,251 participants with complete data were included for analysis. Data were analyzed using the SPSS PROCESS macro. A simple mediation was employed using social frailty as the independent variable, FoF as the mediator variable, and HrQoL as the outcome variable. RESULTS: Social frailty was associated with HrQoL and indirectly with HrQoL through FoF, and FoF was directly associated with HrQoL. Of the 5-item social frailty index, "going out less frequently" was correlated with HrQoL and indirectly with HrQoL through FoF. Individuals who felt unhelpful toward family or friends had the worst physical HrQoL and did not talk to someone daily had the most negative influence on mental HrQoL. CONCLUSIONS: Social frailty can directly and indirectly, through FoF decrease HrQoL. It also emphasizes the importance of social connectivity in reducing the risk of falls. This study points to the need for social connectivity and fall prevention programs as essential components of strategies to enhance the health and well-being of community-dwelling older adults.

Measuring adolescent health literacy in Taiwan: validation of the health literacy assessment scale for adolescents.

BACKGROUND: This study aimed to validate the Chinese version of the Health Literacy Assessment Scale for Adolescents (HAS-A) and conduct a comparative analysis of adolescent health literacy between Taiwan and other countries. METHODS: The Chinese version of the HAS-A was completed by 2,312 adolescents in the fifth and sixth grades of a primary school. Psychometric properties were examined using consistent internal reliability and confirmatory factor analysis. These assessments were compared with the results from different regions to explore health literacy inequality. RESULTS: Construct validity was good, and internal consistency was acceptable. The scale, particularly regarding communication health literacy, was associated with parents' socioeconomic status, and family income had a more significant impact on children's health literacy than community income. Health literacy disparities appear in different countries, with Taiwan exhibiting the lowest level of communication health literacy. CONCLUSION: The results indicate that the HAS-A is a valuable tool for assessing the health literacy of 10-11-year-old adolescents and can uncover health literacy inequality among different regions.

Associations of health literacy, personality traits, and pro-individualism with the willingness to complete advance directives in Taiwan.

BACKGROUND: Studies indicated that patients with advance directives (ADs) have a generally better quality of life near death. Yet, the concept of ADs is relatively new in East Asian countries. This study examined the associations between health literacy, pro-individualism in end-of-life (EOL) decisions (i.e., EOL pro-individualism), and master-persistence personality traits with the willingness to complete ADs. METHODS: The data is from a representative data of 1478 respondents from the 2022 Taiwan Social Change Survey. Generalized structural equation modeling (GSEM) was used to conduct path analysis. RESULTS: Nearly half of the respondents (48.7%) were willing to complete ADs. Health literacy has direct and indirect effects through EOL pro-individualism values on the willingness to complete ADs. Noncognitive factors such as mastery-persistence personality traits and EOL pro-individualism values enhanced the willingness to complete ADs. CONCLUSION: A personalized communication strategy, mindful of personality dimensions and cultural values, can address individual fears and concerns, promoting the benefits of advance care planning (ACP). These influences can provide a roadmap for healthcare providers to customize their approach to ACP discussions, improving patient engagement in AD completion.

Perceived Causes of Cancer and Corresponding Behavioral Changes: A Qualitative Study on Breast Cancer Survivors in Taiwan.

OBJECTIVES: Breast cancer is the most common cancer among women in Taiwan, and treatment and coping with the disease become prominent features in a survivor's life. Here, we examined Taiwanese survivors' perceived causes of breast cancer, the influence of support networks on their perceptions, and the behavioral changes they made to prevent recurrences. METHODS: In this qualitative study, we used an explanatory approach involving semi-structured in-depth interviews based on grounded theory. We recruited (via physician referrals) 29 survivors aged ≥20 who had received their initial diagnosis at least 6 months earlier. RESULTS: Although the participants had made behavioral changes in many areas of their lives after diagnosis, most still believed that "stress and emotions" were the most crucial factor in causing cancer. They strongly emphasized reducing stress levels to prevent recurrences. However, when maintaining healthy behaviors became stressful, they chose to level off healthy lifestyles for the sake of their emotional well-being. They made career changes to improve their quality of life yet continued to experience a deep fear of recurrence. Adopting behavioral changes leading to healthy lifestyles and following regular follow-ups helped to reduce their anxiety concerning recurrence. CONCLUSION: The participants' behavioral changes were strongly associated with the perceived causes of cancer. Health-promotion programs aimed at breast cancer prevention should focus on participants' subjective perception of the cause of cancer.

'I Knew I Should Stop, but I Couldn't Control Myself': a qualitative study to explore the factors influencing adolescents' consumption of sugar-sweetened beverages and sugary snacks from a socio-ecological perspective.

OBJECTIVE: To explore the factors influencing Taiwanese adolescents' consumption of sugar-sweetened beverages (SSB) and sugary snacks from a socio-ecological perspective. DESIGN: This study adopted a qualitative design by using face-to-face, in-depth interviews guided by a semistructured questionnaire. SETTING: Eight junior high schools in New Taipei City and Changhua County, Taiwan, September to November 2018. PARTICIPANTS: Fifty-nine participants aged 12-14 years participated in this study. RESULTS: Reflexive thematic analysis was used to analyse the data. This study identified four themes to address the multifaceted factors that influence adolescents' consumption of SSB and sugary snacks. At the intrapersonal level, physiological factors, psychological factors, individual economic factors and taste preferences were mentioned in connection with people's consumption of SSB and sugary snacks. Positive or negative influences of parents, siblings, peers and teachers on SSB and sugary snack intake were identified at the interpersonal level. The availability of SSB and sugary snacks at home, their availability in vending machines or in school stores in the school environment and participants' access to convenience stores and hand-shaken drink shops in the broader community influenced SSB and sugary snack consumption. Additionally, food culture and food advertising were identified as influencing societal factors. CONCLUSIONS: Overall, this qualitative study determined not only that the consumption of SSB and sugary snacks is influenced by intrapersonal factors but also that interpersonal, environmental and societal factors affect adolescents' increased sugar intake. The findings are helpful to broaden the options for designing and developing interventions to decrease SSB and sugary snack consumption by adolescents.

Sex differences in the association between sugar-sweetened beverages consumption and metabolic risks among the working-age population in Taiwan.

OBJECTIVE: Sugar-sweetened beverages (SSBs) are linked to increased metabolic risk. However, the sex differences in the relationship between SSB intake and adverse health effects remain unclear. Therefore, the present study examined the association between SSB consumption and metabolic risks among working-age males and females from Taiwanese communities. DESIGN: A community-based study utilized data from a comprehensive health screening project conducted by the Public Health Bureau in Changhua County, Taiwan. Metabolic risks included waist circumference, systolic blood pressure, diastolic blood pressure, total cholesterol, triglycerides, low-density lipoprotein cholesterol (LDL), and fasting glucose level using serum tests. SETTING: Participants were recruited in Changhua County, Taiwan. PARTICIPANTS: Between 2005 and 2014, 92,724 citizens participated in the health screening; our data analysis included 75,278 respondents between 30 and 64. RESULTS: The results showed that the frequency of SSB consumption was associated with abnormal waist circumference and elevated total cholesterol, triglycerides, LDL, and glucose in both men and women. Increased SSB consumption frequency was associated with elevated glucose and hypertension in women. Even a slight increase in SSB intake frequency was related to raising the metabolic risks. Similar patterns were evident when models included body mass index (BMI); however, the associations were attenuated. In the BMI-stratified subgroup analysis, the relationship between SSB consumption and metabolic risks was more pronounced in participants without obesity. CONCLUSION: The present study suggests that SSB consumption carries metabolic risk among working-age Taiwanese, particularly women and those without obesity. Health promotion programs should raise awareness of the health hazards associated with SSBs.

Differing determinants of disability trends among men and women aged 50 years and older.

BACKGROUND: Researchers have emphasized the importance of examining how different factors affect men's and women's functional status over time. To date, the literature is unclear about whether sex affects the rate of change in disability in middle to older age. Researchers have further emphasized the importance of examining how different factors affect men's and women's functional status over time. We examined (a) sex differences in disability trends and (b) the determinants of the rate of change in disability for men and women 50 years and older. METHODS: This study utilized the Taiwan Longitudinal Study on Aging Survey, a nationally representative database (four waves of survey data 1996-2007, N = 3429). We modeled and compared the differences in disability trends and the influences of determinants on trends among men and women using multiple-indicator and multiple-group latent growth curves modeling (LGCM). Equality constraints were imposed on 10 determinants across groups. RESULTS: Once disability began, women progressed toward greater disability 18% faster than men. Greater age added about 1.2 times the burden to the rate of change in disability for women than men (p < 0.001). More comorbidities also added significantly more burden to baseline disability and rate of change in disability among women than men (p < 0.001), but women benefited more from higher education levels in lower baseline disability and slower rate of change. Having a better social network was associated with lower baseline disability among women only (p < 0.05). For both men and women, physically active leisure-time activities were beneficial in lower baseline disability (p men and women < 0.001) and rate of change in disability (p men < 0.01; p women < 0.05), with no significant differences between groups. CONCLUSIONS: Age may widen the sex gap in the rate of change in disability. However, both sexes benefit from participating in leisure-time activities. Promoting health literacy improves health outcomes and physical function among women.

Associations of sugar-sweetened beverage knowledge, self-efficacy, and perceived benefits and barriers with sugar-sweetened beverage consumption in adolescents: A structural equation modeling approach.

This study was performed to investigate the predictors of sugar-sweetened beverage (SSB) consumption in adolescents, including knowledge of SSBs, self-efficacy, and perceived benefits and barriers, using the structural equation modeling approach. This cross-sectional study was conducted from March to June 2019 in New Taipei City, Taiwan. The participants were 633 adolescents from 23 classes at three junior high schools in New Taipei City. A structured self-administered questionnaire was developed for data collection. The overall model predicted SSB consumption well, suggesting that SSB consumption was associated with self-efficacy and perceived barriers and benefits. Self-efficacy was the strongest predictor of SSB consumption. Both perceived barriers and self-efficacy sequentially and fully mediated the effect of knowledge on SSB consumption. This study confirms that self-efficacy is associated with SSB intake in both male and female adolescents. However, knowledge of SSBs was not associated with SSB consumption. Relying on nutritional education alone may not be adequate to change SSB consumption. The results suggest that future health promotion programs should improve self-efficacy to decrease SSB consumption in adolescents.

Gender differences in the intention to withhold life-sustaining treatments involving severe dementia for self and on behalf of parent or spouse.

BACKGROUND: Few studies have explored gender differences in the attitudes toward advanced care planning and the intention to withhold life-sustaining treatments (LSTs) involving severe dementia in Asian countries. We examined gender differences in the attitude toward the Patient Autonomy Act (PAA) in Taiwan and how the gender differences in these attitudes affect the intention to withhold LSTs for severe dementia. We also investigated self-other differences in the intention to withhold LSTs between genders. METHODS: Between March and October 2019, a structured questionnaire was distributed to hospitalized patients' family members through face-to-face contact in an academic medical center. Exploratory factor analysis and independent and paired-sample t-tests were used to describe gender differences. Mediation analyses controlled for age, marital status, and education level were conducted to examine whether the attitude toward the PAA mediates the gender effect on the intention to withhold LSTs for severe dementia. RESULTS: Eighty respondents filled out the questionnaire. Exploratory factor analysis of the attitude toward the PAA revealed three key domains: regarding the PAA as (1) promoting a sense of abandonment, (2) supporting patient autonomy, and (3) contributing to the collective good. Relative to the men, the women had lower average scores for promoting a sense of abandonment (7.48 vs. 8.94, p = 0.030), higher scores for supporting patient autonomy (8.74 vs. 7.94, p = 0.006), and higher scores for contributing to the collective good (8.64 vs. 7.47, p = 0.001). Compared with the women, the men were less likely to withhold LSTs for severe dementia (15.84 vs. 18.88, p = 0.01). Mediation analysis revealed that the attitude toward the PAA fully mediated the gender differences in the intention to withhold LSTs for severe dementia. Both men and women were more likely to withhold LSTs for themselves than for their parents. Compared with the women, the men were more likely to withhold resuscitation for themselves than for their parents (p = 0.05). Women were more likely to agree to enteral tube feeding and a tracheotomy for their husbands than for themselves; men made consistent decisions for themselves and their wives in those LST scenarios. CONCLUSION: Gender influences the attitude toward advanced care planning and consequently affects the intention to withhold LSTs, indicating that there may be a difference in how men and women perceive EOL decision-making for severe dementia in Taiwan. Further studies are warranted.

Social alienation of adolescents with obesity in classrooms: A multilevel approach.

INTRODUCTION: Adolescents with obesity are more likely to be isolated by peers, but whether they also choose to disengage from their peers remains unclear. METHODS: This study examined a sample of 646 adolescents between the age of 13 and 16 across 34 classrooms in 3 junior high schools in Taiwan, with data collected from May to June 2019. The sociometric network nomination method assessed peer relationships, such as unpopularity, unsociability, and alienation. Multilevel models were applied to explore the extent to which the class-level prevalence of overweight and obesity and peer support moderate the relationship between student-level obesity and peer relationships. RESULTS: Overall, students with obesity were more likely to experience unpopularity, unsociability, and alienation from their peers in classroom settings (adjusted odds ratio [AOR] = 1.904, 2.208, 2.777, p < .05). Regardless of their obesity status, students in high classroom peer support were less likely to report unsociability (AOR = 0.124, p < .05). No cross-level interactions were observed, indicating that students with obesity did not experience a reduction of peer rejection in high peer support classrooms. Neither did obese students in classrooms with higher rates of overweight and obesity. CONCLUSIONS: Students with obesity were more likely to experience interpersonal problems. Classroom peer support can increase peer acceptance for typical students but has no beneficial influence on adolescents with weight problems. Classroom peer support needs to be directed to become adequate support for students with obesity.

Validation of the short falls efficacy scale-international for Taiwanese community-dwelling older adults: Associations with fall history, physical frailty, and quality of life.

The FES-I is widely used to measure the fear of falling. However, studies linking the Chinese version of the FES-I to frailty and quality of life among older adults are still limited. Thus, this study examined the association of the full 16-item FES-I and the 7-item short FES-I with fall history, physical frailty, and quality of life among older Taiwanese adults. A total of 751 community-dwelling older adults in Taipei City participated in this study. Data analyses included logistic and linear regression models. The 16-item and the short FES-I were strongly correlated (Spearman rho = 0.963), and both scales are reliable. The 7-item FES-I was positively associated with fall history and physical frailty and negatively associated with the physical (b = -0.65, p < 0.001) and mental (b = -0.59, p < 0.001) components of health-related quality of life, independent of physical frailty. Thus, the short FES-I can be used to increase the feasibility of health screenings of older adults in Chinese-speaking contexts.

Reduction of healthcare costs by implementing palliative family conference with the decision to withdraw life-sustaining treatments.

BACKGROUND: Evidence regarding the impact of early palliative family conferences (PFCs) and decision to withdraw life-sustaining treatment (DTW) on healthcare costs in an intensive care unit (ICU) setting is inconsistent. METHODS: We retrospectively analyzed patients who died in an ICU from 2013 to 2016. PFCs held within 7 days after ICU admission and DTWs were verified by reviewing medical records and claims data. Comparisons were first made between patients with and without DTWs, and secondly, between DTW patients with and without PFCs within 7 days. Propensity score matching methods were used to examine the difference in costs between patients with and without DTWs and PFCs within 7 days. RESULTS: Of the 579 patients included, those with DTWs (n = 73) had a longer ICU stay than those without (n = 506) (12.9 ± 7.1 vs. 8.4 ± 9.6 days, p < 0.001). The DTW patients were more likely to have a "do-not-resuscitate" order (p < 0.001) and PFCs within 7 days (p < 0.001) and had lower healthcare costs (USD 7358 ± 4116 vs. 8669 ± 9,535, p = 0.038). After matching, healthcare cost reduction for patients with DTWs, compared with those without DTWs, was USD 3467 [95% CI, 915-6019] (p < 0.001). Compared with DTW patients without PFCs within 7 days, the costs for DTW patients with PFCs within 7 days further reduced to USD 3042 [95%CI, 1358-4725] (p < 0.001). CONCLUSION: Palliative family conferences held within 7 days after ICU admission with decisions to withdraw life-sustaining treatments significantly lowered healthcare costs.

Second victim: Malpractice disputes and quality of life among primary care physicians.

PURPOSE: The health of physicians can have a strong impact on the quality and safety of the health care they provide. Studies have shown a link between work stress, burnout, and depression. The aim of this study was to examine the association between malpractice dispute experiences and the well-being of physicians. METHODS: We conducted a cross-sectional survey to collect information about the malpractice experiences of primary care physicians in 2004. Data on sociodemographic and clinical characteristics and SF-36 measures were also collected. We used propensity score matching to estimate the association of medical malpractice experience with the general health, mental health, and vitality of physicians. RESULTS: Among the 1206 primary care physicians who completed the survey (response rate of 13.4%), 25.2% reported having ever experienced a malpractice dispute. After adjustment for baseline variables, physicians who had experienced a malpractice dispute had significantly worse health-related quality of life with regard to general health [-4.85; 95% confidence interval (CI), -7.61 to -1.80; P = 0.0016], mental health (-2.68; 95% CI, -5.03 to -0.34; P = 0.0252), and vitality (-3.28; 95% CI, -6.10 to -0.47; P = 0.0224). The effects were particularly strong among physicians specializing in surgery or obstetrics and gynecology. CONCLUSION: The results reveal that a malpractice dispute can have a long-term negative effect on the health of physicians. Harm reduction programs for physicians involved in malpractice disputes should be implemented.

Double disadvantage: income inequality, spatial polarization and mortality rates in Taiwan.

Background: Previous studies have suggested that social and economic spatial polarization is associated with various health outcomes. However, few studies have examined the joint effect of income inequality and spatial polarization on health. Methods: Data on mortality in 2008-12 were from the Ministry of Health and Welfare. We constructed economic spatial polarization using the Index of Concentration at the Extremes (ICE) by tax data from the Ministry of Finance. The Gini coefficient was from the Family Income and Expenditure Survey. Using multilevel datasets of 352 townships nested within 20 cities in Taiwan, we examined the association between township-level ICE and mortality, and further examined whether city-level income inequality moderate this association. Results: In 2008-12, the average age-standardized mortality in Taiwan was 470.5 per 100 000 populations. As compared to the highest income-based ICE quintile, the lowest ICE quintile was associated with an excess 171.7 deaths per 100 000 people (95% CI = 116.1, 227.3) after controlling for income inequality and population size. One unit rise in the Gini coefficient further increased 29.9 deaths (95% CI = 12.4, 47.5) for the lowest ICE quintile, as compared to the highest. Conclusion: The joint effect of income inequality and small-scale economic polarization may shed light on how inequalities increase mortality.

Trajectories of Older Adults' Leisure Time Activity and Functional Disability: a 12-Year Follow-Up.

PURPOSE: This study explored how changes in leisure time activities interplayed with changes in functional disability among Taiwanese older adults. METHOD: A parallel process and multiple-indicator latent growth curve modeling was adopted for analysis of the data. Longitudinal data from four waves of the Taiwan Longitudinal Study on Aging, collected between 1996 and 2007, were used for analysis. Data included responses of 5451 older adults with a mean age of 67.16 years (SD = 2.51) in 1996. RESULTS: Compared to baseline level of leisure time activities, increasing the rate of change in leisure time activities has more than three times the effect on slowing down the progression of functional disabilities. The baseline functional disabilities did not significantly predict the changes in leisure time activity participation. CONCLUSION: Engagement in leisure time activity in later life is associated with a slower speed of progression toward functional disability. Early functional disability may not inhibit leisure time activity participation in later life.

Forecasting the Incidence of Dementia and Dementia-Related Outpatient Visits With Google Trends: Evidence From Taiwan.

BACKGROUND: Google Trends has demonstrated the capability to both monitor and predict epidemic outbreaks. The connection between Internet searches for dementia information and dementia incidence and dementia-related outpatient visits remains unknown. OBJECTIVE: This study aimed to determine whether Google Trends could provide insight into trends in dementia incidence and related outpatient visits in Taiwan. We investigated and validated the local search terms that would be the best predictors of new dementia cases and outpatient visits. We further evaluated the nowcasting (ie, forecasting the present) and forecasting effects of Google Trends search trends for new dementia cases and outpatient visits. The long-term goal is to develop a surveillance system to help early detection and interventions for dementia in Taiwan. METHODS: This study collected (1) dementia data from Taiwan's National Health Insurance Research Database and (2) local Internet search data from Google Trends, both from January 2009 to December 2011. We investigated and validated search terms that would be the best predictors of new dementia cases and outpatient visits. We then evaluated both the nowcasting and the forecasting effects of Google Trends search trends through cross-correlation analysis of the dementia incidence and outpatient visit data with the Google Trends data. RESULTS: The search term "dementia + Alzheimer's disease" demonstrated a 3-month lead effect for new dementia cases and a 6-month lead effect for outpatient visits (r=.503, P=.002; r=.431, P=.009, respectively). When gender was included in the analysis, the search term "dementia" showed 6-month predictive power for new female dementia cases (r=.520, P=.001), but only a nowcasting effect for male cases (r=.430, P=.009). The search term "neurology" demonstrated a 3-month leading effect for new dementia cases (r=.433, P=.008), for new male dementia cases (r=.434, P=.008), and for outpatient visits (r=.613, P<.001). CONCLUSIONS: Google Trends established a plausible relationship between search terms and new dementia cases and dementia-related outpatient visits in Taiwan. This data may allow the health care system in Taiwan to prepare for upcoming outpatient and dementia screening visits. In addition, the validated search term results can be used to provide caregivers with caregiving-related health, skills, and social welfare information by embedding dementia-related search keywords in relevant online articles.

Gender, sleep problems, and obesity in Taiwan: a propensity-score-matching approach.

Obesity has become a major health risk in industrialized countries, with disturbed sleep identified as a correlate. This study used data drawn from Taiwan's 2005 Social Development Trend Survey on Health and Safety and the propensity-score-matching method to shed light on gender-specific associations between sleep problems and obesity among 24,113 adults aged 20-64 years. The average increase in obesity prevalence among respondents with disrupted sleep was 1.85%, as compared to those who did not report disrupted sleep, with similar psycho-social attributes. Similarly, the prevalence of obesity among those who reported restless sleep was increased by an average of 1.40% compared to those who did not report restless sleep with similar psycho-social attributes. We also found gender-specific vulnerability to different types of sleep problems. Among men who reported disrupted sleep, we found a 3.12% increase in the prevalence of obesity. Among women exposed to restless sleep, the increase in obesity prevalence was 1.84%. The observed gender difference in the prevalence of increases in obesity may be attributed to gender-specific behavioral responses to poor sleep. With poor sleep, men may respond to hunger by overeating; women may respond by physical inactivity. Both can contribute to an elevated risk of obesity.

Is a diabetes pay-for-performance program cost-effective under the National Health Insurance in Taiwan?

PURPOSE: In October 2001, a pay-for-performance (P4P) program for diabetes was implemented by the National Health Insurance (NHI), a single-payer program, in Taiwan. However, only limited information is available regarding the influence of this program on the patient's health-related quality of life. The aim of this study was to estimate the costs and consequences of enrolling patients in the P4P program from a single-payer perspective. METHODS: A retrospective observational study of 529 diabetic patients was conducted between 2004 and 2005. The data used in the study were obtained from the National Health Interview Survey (NHIS) in Taiwan. Direct cost data were obtained from NHI claims data, which were linked to respondents in the NHIS using scrambled individual identification. The generic SF36 health instrument was employed to measure the quality-of-life-related health status and transformed into a utility index. Patients enrolled in the P4P program for at least 3 months were categorized as the P4P group. Following propensity score matching, 260 patients were included in the study. Outcomes included life-years, quality-adjusted life-years (QALYs), diabetes-related medical costs, overall medical costs, and incremental cost-effectiveness ratios (ICERs). A single-payer perspective was assumed, and costs were expressed in US dollars. Nonparametric bootstrapping was conducted to estimate confidence intervals for cost-effectiveness ratios. RESULTS: Following matching, no significant difference was noted between two groups with regard to the patients' age, gender, education, family income, smoking status, BMI, or whether insulin was used. The P4P group had an increase of 0.08 (95 % CI 0.077-0.080) in QALYs, and the additional diabetes-related medical cost was US$422.74 (95 % CI US$413.58-US$435.05), yielding an ICER of US$5413.93 (95 % CI US$5226.83-US$5562.97) per QALY gained. CONCLUSIONS: Our results provides decision makers with valuable information regarding the impact of the P4P program of diabetes care through a direct comparison of equivalent groups of patients receiving regular care. Under the single-payer NHI system, the use of financial incentives under the DM-P4P program may be an effective means to ensure the quality of follow-up treatment.

Effectiveness of a menstrual health education program on psychological well-being and behavioral change among adolescent girls in rural Uganda.

Objectives. Menstrual hygiene management is one of the main barriers to girls' education attainment in low-and middle-income countries. Poor access to sanitary products and lack of menstrual knowledge affect students' performance at school compared to the opposite sex. Limited evidence is available to provide solutions for schoolgirls. This study examines the effectiveness of menstrual health education programs on well-being and behavioral change among adolescent girls in rural Uganda. Methods. A cluster randomized controlled trial was conducted across 3 schools, including 66 girls aged 13-17 years, in a rural village in Mukono District, Uganda. Schools were randomly allocated to 2 groups: i) health education program intervention and ii) control group (no intervention). Results. After 5 weeks of the Health Education Program, the schoolgirls in experiment groups showed significantly less fear of sharing the menstruation-related concern with parents and pupils [Mean Difference (MD)=0.87, P=0.029) (MD=2.02, P=0.000), and the sense of shameful feelings during menstruation (MD=1.65, P= 0.004); conversely, the fear to go to school during menstruation did not differ between experiment and control groups (MD=-0.04, P=0.94). However, the changes in feeling comfortable having a period at school were significantly different between the experiment and control groups (P=0.001). Conclusions. The study demonstrated promising results of a low-cost intervention for enhancing girls' menstrual health education in a low-income context. Puberty education and reusable pad sewing provision were strongly associated with improving schoolgirls' psychosocial wellbeing related to menstrual management.

Differential pathways to disordered eating for immigrant and native adolescents in Taiwan.

BACKGROUND: Few studies have investigated disparities in disordered eating between new immigrant and native adolescents in Taiwan. This study examines the differential pathways to disordered eating in these two populations. METHODS: This cross-sectional study analyzed data collected from March to June 2019. In total, 729 adolescents aged between 13 and 16 years recruited from 37 classes in 3 middle schools in New Taipei City were included in the final analysis. Standardized assessment tools measured disordered eating (EAT-26) and psychological distress (BSRS-5). Generalized structural equation modeling was used to conduct the path analysis. RESULTS: The prevalence of disordered eating was significantly higher in immigrant adolescents than in their native counterparts. Multipath models indicated that weight-teasing driven by overweight and obese status and weight overestimation could lead to disordered eating through psychological distress; however, the pathways differed for the two groups studied. Family weigh-teasing indirectly leads to disordered eating through psychological distress for native adolescents; by contrast, for immigrant adolescents, friend weigh-teasing indirectly leads to disordered eating through psychological distress. Additionally, weight overestimation directly leads to disordered eating and indirectly through psychological distress to disordered eating for immigrant adolescents. CONCLUSION: This study offers a plausible explanation of the differences in the paths to disordered eating between immigrant and native adolescents in Taiwan, which was not reported previously. The study urges the need for school-based prevention programs to improve immigrant students' mental health.

This study fills the gap in the literature on disparities in disordered eating and factors associated with disordered eating among immigrant adolescents in Taiwan. To our knowledge, this is the first study focusing on disordered eating among immigrant adolescents in Taiwan. The unique contribution of this research is to elucidate the different pathways leading to disordered eating for native and immigrant adolescents. In native adolescents, weight-teasing by family members but not by friends was indirectly related to disordered eating through psychological distress. In adolescents with an immigrant background, weight-teasing by friends was indirectly associated with disordering eating through psychological distress. Additionally, weight overestimation is a unique risk factor directly and indirectly through psychological distress related to disordered eating for immigrant adolescents. As a highly Westernized country, the Taiwanese's mainstream ideal body shape is "thinness." Substantial social discrimination against obese adolescents regarding peer acceptance and sexual attraction may put immigrant adolescents at an increased risk of experiencing body dissatisfaction, psychological stress, and eating disorder symptoms due to their minority status, struggling to adapt to a social environment different from their parents, and wanting peer acceptance. The study urges the need for school-based prevention programs to improve immigrant students' mental health.