The Contribution of Genetic Risk and Lifestyle Factors in the Development of Adult-Onset Inflammatory Bowel Disease: A Prospective Cohort Study.

INTRODUCTION: The joint associations across genetic risk, modifiable lifestyle factors, and inflammatory bowel disease (IBD) remains unclear. METHODS: Genetic susceptibility to Crohn's disease (CD) and ulcerative colitis (UC) was estimated by polygenic risk scores and further categorized into high, intermediate, and low genetic risk categories. Weighted healthy lifestyle scores were constructed based on 5 common lifestyle factors and categorized into favorable (4 or 5 healthy lifestyle factors), intermediate (3 healthy lifestyle factors), and unfavorable (0-2 healthy lifestyle factors) groups. Cox proportional hazards regression model was used to estimate the hazard ratios (HR) and 95% confidence interval (CI) for their associations. RESULTS: During the 12-year follow-up, 707 cases with CD and 1576 cases with UC were diagnosed in the UK Biobank cohort. Genetic risk and unhealthy lifestyle categories were monotonically associated with CD and UC risk with no multiplicative interaction between them. The HR of CD and UC were 2.24 (95% CI 1.75-2.86) and 2.15 (95% CI 1.82-2.53) for those with a high genetic risk, respectively. The HR of CD and UC for individuals with an unfavorable lifestyle were 1.94 (95% CI 1.61-2.33) and 1.98 (95% CI 1.73-2.27), respectively. The HR of individuals with a high genetic risk but a favorable lifestyle (2.33, 95% CI 1.58-3.44 for CD, and 2.05, 95% CI 1.58-2.66 for UC) were reduced nearly by half, compared with those with a high genetic risk but an unfavorable lifestyle (4.40, 95% CI 2.91-6.66 for CD and 4.44, 95% CI 3.34-5.91 for UC). DISCUSSION: Genetic and lifestyle factors were independently associated with susceptibility to incident CD and UC. Adherence to a favorable lifestyle was associated with a nearly 50% lower risk of CD and UC among participants at a high genetic risk.

Sales of antibiotics without a prescription in pharmacies, 2017 and 2021, China.

Objective: To measure sales of antibiotics without a prescription in pharmacies in China in 2017 and 2021, before and during the coronavirus disease 2019 (COVID-19) pandemic, and determine the factors associated with such sales. Methods: We conducted cross-sectional surveys using the simulated patient method in retail pharmacies in 13 provinces in eastern, central and western China in 2017 and 2021. At the pharmacies, the simulated patients (trained medical students) reported that they had mild respiratory tract symptoms and asked for treatment, using a three-stage process: (i) request some treatment; (ii) request antibiotics; (iii) request specific antibiotics. We used multivariable logistic regression analysis to determine factors associated with sale of antibiotics without a prescription. Findings: Of the pharmacies visited in 2017, 83.6% (925/1106) sold antibiotics without a prescription; this figure was 78.3% (853/1090) in 2021 (P-value: 0.002). After excluding pharmacies prohibited from selling antibiotics because of COVID-19, this difference was not significant (83.6% versus 80.9%; 853/1054; P-value: 0.11). Factors significantly associated with selling antibiotics without a prescription in both 2017 and 2019 were: location in central and western China compared with eastern China; being in a township or village compared with in a city; and presence of a counter where antibiotics were dispensed. Conclusion: Although laws became stricter between 2017 and 2021, antibiotic sales without a prescription were still common in pharmacies across China. Existing regulations need to be more strictly enforced, and pharmacy staff and the public should be made more aware of the risks of antibiotic misuse and dangers of antimicrobial resistance.

Nonlinear Association between Serum 25-Hydroxyvitamin D and All-Cause Mortality in Adults with Inflammatory Bowel Disease in a Prospective Cohort Study.

BACKGROUND: Nonlinear association between serum 25-hydroxyvitamin D [25(OH)D] concentration and all-cause mortality has been widely reported for the general population, but this association has not been quantified for individuals with inflammatory bowel disease (IBD). OBJECTIVES: The aim was to explore the association between serum 25(OH)D and all-cause mortality in individuals with IBD. METHODS: We identified 2690 females and 2532 males aged 40-69 y with diagnosed IBD at baseline in the UK Biobank. Serum 25(OH)D concentration was measured by direct competitive chemiluminescent immunoassay. The outcome was all-cause mortality, ascertained via the death registry. Cox proportional hazard regression was used to evaluate associations between serum 25(OH)D in quintiles and all-cause mortality among individuals with IBD [Crohn disease (CD; n = 1760) and ulcerative colitis (UC; n = 3462)]. Restricted cubic splines were used to investigate potential nonlinearity. RESULTS: During the mean follow-up period of 11.9 y, 529 deaths (198 in CD and 331 in UC) were documented among 5222 individuals with IBD. Compared with the lowest quintile of serum 25(OH)D, HRs for the second to the highest quintiles were 0.82 (95% CI: 0.63, 1.06), 0.63 (95% CI: 0.47, 0.83), 0.64 (95% CI: 0.48, 0.85), and 0.74 (95% CI: 0.55, 0.99), respectively. Nonlinearity was detected in the dose-response association between serum 25(OH)D concentration and all-cause mortality (P-nonlinearity < 0.001), and 25(OH)D concentrations of 44-78 nmol/L were associated with a 50% lower risk of all-cause mortality (than 10 nmol/L). Subgroup analyses showed that the nonlinear association mostly applied to females (P-nonlinearity < 0.001 compared with 0.080 in males). CONCLUSIONS: We observed a nonlinear association, mostly applicable to females, between serum 25(OH)D concentrations and all-cause mortality among individuals with IBD. A 25(OH)D concentration range of 44-78 nmol/L can serve as a starting point for future research to confirm recommended 25(OH)D concentrations for individuals with IBD.

Effectiveness of integrating primary healthcare in aftercare for older patients after discharge from tertiary hospitals-a systematic review and meta-analysis.

BACKGROUND: Quality of aftercare can crucially impact health status of older patients and reduce the extra burden of unplanned healthcare resource utilisation. However, evidence of effectiveness of primary healthcare in supporting aftercare, especially for older patients after discharge are limited. METHODS: We searched for English articles of randomised controlled trials published between January 2000 and March 2022. All-cause hospital readmission rate and length of hospital stay were pooled using a random-effects model. Subgroup analyses were conducted to identify the relationship between intervention characteristics and the effectiveness on all-cause hospital readmission rate. RESULTS: A total of 30 studies with 11,693 older patients were included in the review. Compared with patients in the control group, patients in the intervention group had 32% less risk of hospital readmission within 30 days (RR = 0.68, P < 0.001, 95%CI: 0.56-0.84), and 17% within 6 months (RR = 0.83, P < 0.001, 95%CI: 0.75-0.92). According to the subgroup analysis, continuity of involvement of primary healthcare in aftercare had significant effect with hospital readmission rates (P < 0.001). Economic evaluations from included studies suggested that aftercare intervention was cost-effective due to the reduction in hospital readmission rate and risk of further complications. CONCLUSION: Integrating primary healthcare into aftercare was designed not only to improve the immediate transition that older patients faced but also to provide them with knowledge and skills to manage future health problems. There is a pressing need to introduce interventions at the primary healthcare level to support long-term care.

Effectiveness of Computerized Cognitive Training in Delaying Cognitive Function Decline in People With Mild Cognitive Impairment: Systematic Review and Meta-analysis.

BACKGROUND: With no current cure for mild cognitive impairment (MCI), delaying its progression could significantly reduce the disease burden and improve the quality of life for patients with MCI. Computerized cognitive training (CCT) has recently become a potential instrument for improvement of cognition. However, the evidence for its effectiveness remains limited. OBJECTIVE: This systematic review aims to (1) analyze the efficacy of CCT on cognitive impairment or cognitive decline in patients with MCI and (2) analyze the relationship between the characteristics of CCT interventions and cognition-related health outcomes. METHODS: A systematic search was performed using MEDLINE, Cochrane, Embase, Web of Science, and Google Scholar. Full texts of randomized controlled trials of CCT interventions in adults with MCI and published in English language journals between 2010 and 2021 were included. Overall global cognitive function and domain-specific cognition were pooled using a random-effects model. Sensitivity analyses were performed to determine the reasons for heterogeneity and to test the robustness of the results. Subgroup analyses were performed to identify the relationship between the characteristics of CCT interventions and cognition-related effectiveness. RESULTS: A total of 18 studies with 1059 participants were included in this review. According to the meta-analysis, CCT intervention provided a significant but small increase in global cognitive function compared to that in the global cognitive function of the control groups (standardized mean difference=0.54, 95% CI 0.35-0.73; I2=38%). CCT intervention also resulted in a marginal improvement in domain-specific cognition compared to that in the control groups, with moderate heterogeneity. Subgroup analyses showed consistent improvement in global cognitive behavior in the CCT intervention groups. CONCLUSIONS: This systematic review suggests that CCT interventions could improve global cognitive function in patients with MCI. Considering the relatively small sample size and the short treatment duration in all the included studies, more comprehensive trials are needed to quantify both the impact of CCT on cognitive decline, especially in the longer term, and to establish whether CCT should be recommended for use in clinical practice. TRIAL REGISTRATION: PROSPERO International Prospective Register of Systematic Reviews CRD42021278884; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=278884.

P003 Meat Consumption and All-Cause Mortality in 5763 Inflammatory Bowel Disease Patients: A Prospective Cohort Study.

BACKGROUND: Meat consumption was found to be associated with the incidence and developmental course of inflammatory bowel diseases (IBD), but its roles in the risk of all-cause mortality in IBD patients remained unknown. The aim of this study (UK Biobank Resource under application number 73595) was to assess the associations between meat consumption and all-cause mortality among IBD patients. METHODS: We leveraged data of 5763 IBD patients in the UK Biobank recruited from 2007 to 2010 and followed up to March 13, 2021. Dietary information was collected using a simplified food frequency questionnaire (FFQ) in the touchscreen questionnaire at baseline recruitment. Death events were ascertained from the death registry. Cox proportional hazards models were used to estimate potential associations of each meat consumption with mortality in IBD patients, 0.1-0.9 time per week was seen as the reference, and hazard ratios (HRs) and 95% confidence interval (CIs) were reported. Moreover, we conducted a series of subgroup and sensitivity analyses. RESULTS: During an average follow-up of 11.7 years, we documented 590 deaths over 67,095 person-years. Of the 5763 IBD patients with a mean (SD) age of 57.3 (7.9) years, 3028 (52.5%) were female and 2735 (47.5%) were male, 1834 were with Crohn's diseases (CD) and 3929 were with ulcerative colitis (UC). Consuming processed meat more than 4 times per week (>4 times/week) was associated with an increased risk of mortality in IBD patients (HR 1.53, 95%CI 1.06-2.23, P = 0.025) compared with consumption of less than once per week (0.1-0.9 time/week), while consumptions of fish, unprocessed poultry, or unprocessed red meat were not found to be related to mortality. The association of processed meat with mortality was also observed in CD patients (HR 2.01, 95%CI 1.12-3.62, P = 0.020), but not significantly in UC patients (HR 1.27, 95% CI 0.77-2.09, P = 0.346). In subgroup analyses, we also observed the associations in IBD patients with diseases duration more than 10 years (HR 1.67, 95%CI 1.03-2.69) or patients who had high physical activities (HR 2.21, 95%CI 1.13-4.33), but was not significant in other subgroup analyses, also, the associations manifested robust in sensitivity analyses. CONCLUSION: In this study, more frequent consumption of processed meat was found to be associated with the increased risk of mortality in IBD patients, while no such associations were observed in IBD patients who consuming fish, unprocessed poultry meat or unprocessed red meat. Therefore, based on the results above, we recommend a remodified diet with restricting processed meat as well as supplying an additional healthy diet for IBD patients, using alone or in combination with pharmacotherapy.

The physiological and psychological effects of cognitive behavior therapy on patients with inflammatory bowel disease before COVID-19: a systematic review.

OBJECTIVE: Cognitive behavioral therapy (CBT) is now included in the treatment of patients with inflammatory bowel disease (IBD) in many settings. However, different clinical trials report different outcomes without consensus. This study aims to evaluate the impact of CBT on the mental state, quality of life and disease activity of patients with IBD. DESIGN: Systematic review. METHODS: This systematic review searched eligible studies from 1946 to December 8, 2019, in MEDLINE, EMBASE, CINAHL, Cochrane library, ClinicalTrials.gov, PsycINFO, Web of Science for eligible randomized controlled trials (RCT). RESULTS: Among the initial identified 1807 references, 11 studies met inclusion criteria. CBT was shown to improve patient's quality of life and reduce the level of depression and anxiety post-intervention but was not sustained. Evidence is not enough for the effect of CBT on disease activity, or C-reactive protein level. CONCLUSIONS: CBT has shown short-term positive psychological effects on IBD patients, but there is insufficient evidence for sustained physical and psychological improvements of IBD patients. PROSPERO registration: CRD42019152330.

Health impacts of parental migration on left-behind children and adolescents: a systematic review and meta-analysis.

BACKGROUND: Globally, a growing number of children and adolescents are left behind when parents migrate. We investigated the effect of parental migration on the health of left behind-children and adolescents in low-income and middle-income countries (LMICs). METHODS: For this systematic review and meta-analysis we searched MEDLINE, Embase, CINAHL, the Cochrane Library, Web of Science, PsychINFO, Global Index Medicus, Scopus, and Popline from inception to April 27, 2017, without language restrictions, for observational studies investigating the effects of parental migration on nutrition, mental health, unintentional injuries, infectious disease, substance use, unprotected sex, early pregnancy, and abuse in left-behind children (aged 0-19 years) in LMICs. We excluded studies in which less than 50% of participants were aged 0-19 years, the mean or median age of participants was more than 19 years, fewer than 50% of parents had migrated for more than 6 months, or the mean or median duration of migration was less than 6 months. We screened studies using systematic review software and extracted summary estimates from published reports independently. The main outcomes were risk and prevalence of health outcomes, including nutrition (stunting, wasting, underweight, overweight and obesity, low birthweight, and anaemia), mental health (depressive disorder, anxiety disorder, conduct disorders, self-harm, and suicide), unintentional injuries, substance use, abuse, and infectious disease. We calculated pooled risk ratios (RRs) and standardised mean differences (SMDs) using random-effects models. This study is registered with PROSPERO, number CRD42017064871. FINDINGS: Our search identified 10 284 records, of which 111 studies were included for analysis, including a total of 264 967 children (n=106 167 left-behind children and adolescents; n=158 800 children and adolescents of non-migrant parents). 91 studies were done in China and focused on effects of internal labour migration. Compared with children of non-migrants, left-behind children had increased risk of depression and higher depression scores (RR 1·52 [95% CI 1·27-1·82]; SMD 0·16 [0·10-0·21]), anxiety (RR 1·85 [1·36-2·53]; SMD 0·18 [0·11-0·26]), suicidal ideation (RR 1·70 [1·28-2·26]), conduct disorder (SMD 0·16 [0·04-0·28]), substance use (RR 1·24 [1·00-1·52]), wasting (RR 1·13 [1·02-1·24]) and stunting (RR 1·12 [1·00-1·26]). No differences were identified between left-behind children and children of non-migrants for other nutrition outcomes, unintentional injury, abuse, or diarrhoea. No studies reported outcomes for other infectious diseases, self-harm, unprotected sex, or early pregnancy. Study quality varied across the included studies, with 43% of studies at high or unclear risk of bias across five or more domains. INTERPRETATION: Parental migration is detrimental to the health of left-behind children and adolescents, with no evidence of any benefit. Policy makers and health-care professionals need to take action to improve the health of these young people. FUNDING: Wellcome Trust.

Survival, disabilities in activities of daily living, and physical and cognitive functioning among the oldest-old in China: a cohort study.

BACKGROUND: The oldest-old (those aged ≥80 years) are the most rapidly growing age group globally, and are most in need of health care and assistance. We aimed to assess changes in mortality, disability in activities of daily living, and physical and cognitive functioning among oldest-old individuals between 1998 and 2008. METHODS: We used data from the Chinese Longitudinal Healthy Longevity Study. Three pairs of cohorts aged 80-89 years, 90-99 years, and 100-105 years (in total, 19 528 oldest-old participants) were examined; the two cohorts in each pair were born 10 years apart, with the same age at the time of the assessment in the 1998 and 2008 surveys. Four health outcomes were investigated: annual death rate, Activities of Daily Living (ADL), physical performance in three tests and cognitive function measured by Mini-Mental State Examination (MMSE). We used different tests and multivariate regression analyses to examine the cohort differences. FINDINGS: Controlling for various confounding factors, we noted that annual mortality among oldest-old individuals was substantially reduced between 0·2% and 1·3% in 1998-2008 compared with individuals of the same age born 10 years previously, and that disability according to activities of daily living had significantly reduced annually between 0·8% and 2·8%. However, cognitive impairment in the later cohorts increased annually between 0·7% and 2·2% and objective physical performance capacity (standing up from a chair, picking up a book from the floor, and turning around 360°) decreased anually between 0·4% and 3·8%. We also noted that female mortality was substantially lower than male mortality among the oldest-old, but that women's functional capacities in activities of daily living, cognition, and physical performance were worse than their male counterparts. INTERPRETATION: Advances in medications, lifestyle, and socioeconomics might compress activities of daily living disability, that is, benefits of success, but lifespan extension might expand disability of physical and cognitive functioning as more frail, elderly individuals survive with health problems, that is, costs of success. FUNDING: National Natural Science Foundation of China, National Institute on Aging/National Institutes of Health, United Nations Funds for Population Activities.

Impact of parental migration on psychosocial well-being of children left behind: a qualitative study in rural China.

BACKGROUND: Tens of millions of rural "left-behind children (LBC)" in China grow up experiencing prolonged separation from their migrant worker parents. This study aimed to explore how children are affected by parental migration, from the perspectives of children, parents, and grandparents, focusing on the experiences of prolonged parent-child separation and relationship dynamics in the extended family. METHODS: Qualitative in-depth interviews were conducted in a migrant-sending rural area of eastern China. Participants included 25 children (aged 7 to 14), 17 parents, and 13 grandparents, from 30 families, as well as 24 key informants from the communities. Data analysis followed a grounded theory approach. RESULTS: The results showed that despite the original purpose of benefiting children, parental migration resulted in challenges in child psychosocial well-being, due to the emotional impacts from prolonged parent-child separation. Parental absence also led to inadequate care and support for left-behind children. The negative effects of parental migration may be exacerbated by other vulnerabilities such as parents' divorce, poverty and grandparent caregivers' frailty. Concerns about child well-being made some migrants decide to return home permanently, because of the altered trade-offs of migration. CONCLUSION: Prolonged separation following migration often disrupts parent-child relationships and results in psychosocial difficulties in LBC, especially among those who live with multiple adversities in the family. Community-based interventions may help migrant parents and co-resident caregivers to better engage children and promote their resilience.

Exploring women's decisions about childbearing after the lifting of the one-child policy.

In 2016, China officially ended the 'one-child' policy permitting all couples to have two children for the first time since 1979. While the policy was relaxed due to demographic concerns, it simultaneously provided many women with a new reproductive opportunity. The goal of this study was to qualitatively understand the childbearing decision process in the new era of the two-child policy. We conducted in-depth, semi-structured interviews with 45 postpartum women at two hospitals in Zhejiang Province, China. The interviews explored women's views on the two-child policy and reproductive decisions and how they decided to have their first or second child. Most women approved of the lifting of the one-child policy; however, many were hesitant or uncertain about their own decisions to have second children. Many felt pressured to have two children for the good of, or as an obligation to, the family. However, they also felt that caring for two children was burdensome, and that they would have to sacrifice a lot in terms of freedom, energy and money. Their responses to the new reproductive opportunity highlight the complexity of childbearing decision-making in modern Chinese society, against a background of persisting traditional values.

The effects of China's universal two-child policy.

In October, 2015, China's one-child policy was replaced by a universal two-child policy. The effects of the new policy are inevitably speculative, but predictions can be made based on recent trends. The population increase will be relatively small, peaking at 1·45 billion in 2029 (compared with a peak of 1·4 billion in 2023 if the one-child policy continued). The new policy will allow almost all Chinese people to have their preferred number of children. The benefits of the new policy include: a large reduction in abortions of unapproved pregnancies, virtual elimination of the problem of unregistered children, and a more normal sex ratio. All of these effects should improve health outcomes. Effects of the new policy on the shrinking workforce and rapid population ageing will not be evident for two decades. In the meantime, more sound policy actions are needed to meet the social, health, and care needs of the elderly population.

Massive misuse of antibiotics by university students in China: a cross-sectional survey.

BACKGROUND: Antimicrobial resistance is one of the greatest threats to global population health this century, and is a major contributor to rising healthcare costs worldwide. The primary cause of this resistance is antibiotic misuse, especially routine inappropriate use of antibiotics for self-limiting illnesses. In China, over prescribing of antibiotics is pervasive leading to very high and increasing rates of antimicrobial resistance in both hospital-acquired and community-acquired infections. The aim of this study was to explore the knowledge and behaviours of university students in relation to antibiotic use in six Chinese provinces. METHODS: A stratified, cluster-random sampling method was used to select students across six universities in six provinces (Zhejiang, Wuhan, NanKai, Jilin, Guizhou, and Lanzhou Universities). An anonymous online survey tool, Wen Juan Xing, was used to collect data. Students completed the survey using a smartphone application. χ2 test and logistic regression model were used to assess associations between knowledge and behaviour. Patient consent and ethical approval were obtained for this study. FINDINGS: 11 192/11 459 (98%) students completed the questionnaire. Knowledge of antibiotics and their appropriate use was poor: only 236/11 192 (2%) answered all 13 questions correctly. In terms of healthcare-seeking behaviour, of 3337/11 192 (30%) students who were ill in the preceding month, 913/3337 (27%) went to see a doctor and 600/913 (66%) of these students were prescribed antibiotics; 1711/3337 (51%) treated themselves, 507/1711 (30%) of these with antibiotics. 7057/11 192 (63%) of students keep antibiotics at home. Of 6269/11 192 (56%) students who tried to buy antibiotics from a drugstore in the preceding year, 4133/6269 (66%) tried to do so without prescription and 3964/4133 (96%) succeeded. Students who keep antibiotics at home are almost 5 times more likely to self-treat with antibiotics (OR=4·90, 95% CI 3·48-6·90). INTERPRETATION: Demand for antibiotics has an important role in the excess use of antibiotics among university students in China. An education campaign about proper use of antibiotics is an urgent priority and should involve both health professionals and the general public. Existing regulations prohibiting pharmacists to sell antibiotics over-the-counter must be enforced. FUNDING: None.

Malaria epidemiology in central Myanmar: identification of a multi-species asymptomatic reservoir of infection.

BACKGROUND: The spread of artemisinin-resistant Plasmodium falciparum is a global health concern. Myanmar stands at the frontier of artemisinin-resistant P. falciparum. Myanmar also has the highest reported malaria burden in Southeast Asia; it is integral in the World Health Organization's plan to eliminate malaria in Southeast Asia, yet few epidemiological data exist for the general population in Myanmar. METHODS: This cross-sectional, probability household survey was conducted in Phyu township, Bago Region (central Myanmar), during the wet season of 2013. Interviewers collected clinical and behavioural data, recorded tympanic temperature and obtained dried blood spots for malaria PCR and serology. Plasmodium falciparum positive samples were tested for genetic mutations in the K13 region that may confer artemisinin resistance. Estimated type-specific malaria PCR prevalence and seroprevalence were calculated, with regression analysis to identify risk factors for seropositivity to P. falciparum. Data were weighted to account for unequal selection probabilities. RESULTS: 1638 participants were sampled (500 households). Weighted PCR prevalence was low (n = 41, 2.5%) and most cases were afebrile (93%). Plasmodium falciparum was the most common species (n = 19. 1.1%) and five (26%) P. falciparum samples harboured K13 mutations. Plasmodium knowlesi was detected in 1.0% (n = 16) and Plasmodium vivax was detected in 0.4% (n = 7). Seroprevalence was 9.4% for P. falciparum and 3.1% for P. vivax. Seroconversion to P. falciparum was 0.003/year in the whole population, but 16-fold higher in men over 23 years old (LR test p = 0.016). DISCUSSION: This is the first population-based seroprevalence study from central Myanmar. Low overall prevalence was discovered. However, these data suggest endemic transmission continues, probably associated with behavioural risk factors amongst working-age men. Genetic mutations associated with P. falciparum artemisinin resistance, the presence of P. knowlesi and discrete demographic risk groups present opportunities and challenges for malaria control. Responses targeted to working-age men, capable of detecting sub-clinical infections, and considering all species will facilitate malaria elimination in this setting.

Large reductions in cesarean delivery rates in China: a qualitative study on delivery decision-making in the era of the two-child policy.

BACKGROUND: In 2010, China's cesarean delivery (CD) rates increased to one of the highest in the world, a significant proportion of which were without medical indication. However, recent studies have indicated some declines, coinciding with national and local efforts to promote vaginal birth, as well as the relaxation of the one-child policy. Considering these trends, we aimed to qualitatively explore attitudes towards childbirth and experiences of delivery decision-making among women and physicians. METHODS: Semi-structured interviews were conducted with 45 postpartum women and 7 healthcare providers at one county-level and one provincial-level maternity hospital in Zhejiang Province. We also collected routine data from 2007 to 2016 and observed doctor-patient interactions and hospital facilities as context for the interviews. Interviews were recorded, translated and transcribed into English, and then analyzed using a framework approach. RESULTS: From 2007 to 2016, cesarean delivery rates at the county-level and provincial-level hospital decreased from 46% to 32% and 68% to 44%, respectively. For low-risk women, vaginal birth was the primary choice of delivery method, encouraged by doctors and nurse-midwives. Elective CD was not as widely accepted, in contrast to previous years. Women were aware of and took into consideration the consequences of CD for future pregnancies. Among those who delivered vaginally, women viewed the existing pain relief methods, epidurals and transcutaneous electrical nerve stimulation, with caution or uncertainty. Even when requested, epidurals were only given under certain circumstances. For multiparas with previous CD, repeat CD remains the norm. Both women and professionals were cautious about vaginal birth after cesarean delivery (VBAC) given the associated risks. CONCLUSION: In China, changes in family planning policy and efforts to promote vaginal birth have greatly changed the culture of delivery decision-making, leading to decreased CD rates. This demonstrates the powerful role social factors and public policy can play, and provides a model for other countries with high CD rates. Further research should explore changes in other reproductive decisions during this new multiparous era, particularly across provinces.

Long-term impacts of parental migration on Chinese children's psychosocial well-being: mitigating and exacerbating factors.

PURPOSE: Prolonged separation from migrant parents raises concerns for the well-being of 60 million left behind children (LBC) in rural China. This study aimed to investigate the impact of current and previous parental migration on child psychosocial well-being, with a focus on emotional and behavioral outcomes, while considering factors in family care and support. METHODS: Children were recruited from schools in migrant-sending rural areas in Zhejiang and Guizhou provinces by random stratified sampling. A self-administered questionnaire measured children's psychosocial well-being, demographics, household characteristics, and social support. Multiple linear regression models examined the effects of parental migration and other factors on psychosocial difficulties. RESULTS: Data from 1930 current, 907 previous, and 701 never LBC were included (mean age 12.4, SD 2.1). Adjusted models showed both previous and current parental migration was associated with significantly higher overall psychosocial difficulties, involving aspects of emotion, conduct, peer relationships, hyperactivity, and pro-social behaviors. Parental divorce and lack of available support demonstrated a strong association with greater total difficulties. While children in Guizhou had much worse psychosocial outcomes than those in Zhejiang, adjusted subgroup analysis showed similar magnitude of between-province disparities regardless of parental migration status. However, having divorced parents and lack of support were greater psychosocial risk factors for current and previous-LBC than for never LBC. CONCLUSIONS: Parental migration has an independent, long-lasting adverse effect on children. Psychosocial well-being of LBC depends more on the relationship bonds between nuclear family members and the availability of support, rather than socioeconomic status.

Sociosexuality in mainland China.

The construct of sociosexuality or sociosexual orientation describes the extent to which people will have casual, uncommitted sexual relationships. The Sociosexual Orientation Inventory (SOI) has been used to measure sociosexuality in many countries, but not in China. The aims of this study were to explore sociosexuality in a cross-section of the Chinese adult population, to quantify sex differences in sociosexuality, and to examine the sociodemographic correlates and the impact of the high sex ratio. The study consisted of a cross-sectional survey using a self-completion questionnaire. It was administered to adults of reproductive age in three provinces: Zhejiang, Guizhou, and Yunnan. While questionnaires were received from 7,424 participants, total SOI scores could be computed only for the 4,645 (63 %) who completed all seven items of the SOI. The mean score for men and women combined was 21.0, very low compared with most other countries, indicating restricted sociosexuality. The men (n = 2,048) had a mean of 27, showing more restricted sociosexuality than in all other countries where the SOI has been used. Wealth was the strongest independent correlate of high (unrestricted) sociosexuality in men and women. The effect size for the difference between the sexes was moderate (Cohen's d = .64), and comparable to more developed countries, perhaps reflecting relative gender equality in contemporary China. Despite the very high sex ratio, which is theorized to lead to restricted sexuality, its influence was difficult to determine, since differences in sociosexuality between high and low sex ratio areas within this population were inconsistent.

A social emotional learning intervention to reduce psychosocial difficulties among rural children in central China.

Programmes based on social emotional learning (SEL) have been effective in reducing psychosocial difficulties in a number of countries. In Mainland China, there has been no empirical research on the prevention of children's psychosocial difficulties using the SEL approach. This study aimed to assess whether an adapted version of the SEL programme can reduce psychosocial difficulties of primary school children in rural China. The intervention consisted of 16 weekly 90-min class sessions, conducted among 206 children aged 8-12 years (with 290 controls) in a poor rural area of Central China. Self-report questionnaires were administered at baseline, post-intervention and 5-month follow-up. The results suggested that the programme (1) can reduce children's total difficulties (measured using the Strength and Difficulties Questionnaire) at post-intervention (d = -0.18) and 5-month follow-up (d = -0.19), (2) was more effective among children experiencing verbal abuse (d = -0.21) or physical abuse (d = -0.24) from caregivers and (3) was popular among more than 90% of the participants. The programme is cheap, easy to implement and can be delivered in school hours. Therefore, it has clear potential for replicability and sustainability.