Environmental hazards increase the fall risk among residents of long-term care facilities: a prospective study in Shanghai, China.

BACKGROUND: Falls are one of the most common safety concerns in long-term care facilities (LTCFs). OBJECTIVE: To evaluate the associations between the environmental hazards and the fall risk in LTCF residents. DESIGN: Prospective study with 12-month follow-up. SETTING: Twenty-five LTCFs in a central district of Shanghai. SUBJECTS: A total of 739 older people participated and 605 were followed up for 1 year. METHODS: Environmental hazards were measured using a 75-item Environment Assessment Checklist, and the associations between environmental hazards and falls were analysed using univariate and multilevel logistic regressions. RESULTS: The incidence of falls was 0.291 per person with 11 items/LTCF of hazards on average. The most common hazard items were inadequate/inappropriate handrails (96% LTCFs; odds ratio (OR) for falls: 1.88 [95% confidence interval: 1.13-3.13]), unsafe floors (92% LTCFs; 2.50 [1.11-5.61]) and poor lighting (84% LTCFs; 2.01 [1.10-3.66]). Environmental hazards were most frequently distributed in bedrooms (96% LTCFs), shared toilets/showers (80% LTCFs) and individual toilets/showers (68%LTCFs) and accounted for 20% of the differences in falls occurrence among the LTCFs. After adjusting for individual intrinsic and fall-related behavioural factors, it is found that having more than eight environmental hazard items increased the fall risk among older residents (adjusted OR = 4.01 [1.37-11.73]). Environmental hazards and toilet visits at night showed significant associations with falls (adjusted OR = 5.97 [1.10-32.29]). CONCLUSIONS: The high prevalence of environmental hazards associated with falls highlights the urgency of improving environmental safety in LTCFs and the need of environmental safety policies, resource allocation and interventions in falls prevention.

Falls and Fall-Related Consequences among Older People Living in Long-Term Care Facilities in a Megacity of China.

INTRODUCTION: Falls are currently the top safety problem in long-term care facilities (LTCFs) in China. Due to the increasing number of residents living in LTCFs, more evidence is needed to give a foundation for fall prevention. OBJECTIVE: This study aimed to explore the epidemiological characteristics of falls in LTCFs in central Shanghai. METHODS: The study was conducted in 21 LTCFs in a central district in Shanghai, with a capacity of 3,065 residents. A two-stage sampling method was applied in participant recruitment. Falls were recorded by LTCF staff over a 12-month period. Details of falls were obtained by face-to-face interviews. The χ2 test was used in data analyses. RESULTS: The incidence of falls was 13.5%; 64.0% falls resulted in injuries, with 32.0% involving fractures. Women had a significantly higher incidence of injurious falls than men (χ2 = 4.066, p = 0.044). Residents aged 80-89 years or in level 1 care had the highest incidence of falls with severe consequences. The incidence of falls was significantly higher at small- or medium-sized LTCFs, public LTCFs, and LTCFs with higher environmental risk levels compared to their counterparts. Most falls occurred when walking on a flat floor (28.9%) and rising up or sitting down (24.0%); 40.9% occurred during the night. Of those injured, 54.8% were treated in hospitals, and only 53.7% completely recovered. CONCLUSIONS: Though the average incidence of falls in LTCFs in Shanghai was relatively low, great variation was observed between LTCFs, and severe consequences occurred frequently. Fall prevention programmes should be evidence-based with applicable devices and individualized care services and supports. The roles of personal and institutional factors on falls warrant further study.

Drug resistance characteristics and cluster analysis of M. tuberculosis in Chinese patients with multiple episodes of anti-tuberculosis treatment.

BACKGROUND: Tuberculosis (TB) patients with multiple episodes of anti-TB treatment represent an important source of TB transmission, as well as a serious threat to the control of drug resistant TB, due to the high risk of multidrug and extensively drug resistance (MDR/XDR) and elongating infectiousness of this patient group. In this study we analyzed the possible risk of development and transmission of MDR and XDR in TB patients with multiple episodes of previous treatment history. METHODS: The study subjects were pulmonary TB patients who had at least two episodes of previous anti-TB treatment. A total of 166 eligible patients were identified from 10 counties/districts distributed in east, west, north, south and central China. Drug susceptibility test (DST) was performed by proportion method on LJ-media for the 1st line anti-TB drugs and a line probe assay was used to detect mutations related to resistance of the key 2nd-line drugs. Genotyping of M. tuberculosis (Mtb) was performed with MIRU-VNTR and Spoligotyping. RESULTS: Resistances to 1st-line drugs was observed in 122 (73.5%) of the 166 Mtb isolates with 97 (58.4%) being MDR-TB. Mutations relevant to 2nd-line drug resistance was seen in 63 isolates, including 35 MDR-TB isolates (30 pre-XDR, 5 XDR-TB). The Spoligotyping revealed 83.1% Mtb isolates belonged to the Beijing family. The MIRU-VNTR based genotyping revealed 32 (19.3%) of patients were infected with more than one strain. The number of previous TB treatment episode was found being significantly associated with the risk of MDR-TB and XDR-TB. Among the remaining 134 patients infected with a single Mtb strain, MIRU-VNTR revealed a high homogeneity of strain especially within Beijing family despite the polymorphic variations along with geographic locations. CONCLUSIONS: The high genetic relatedness and risk of MDR-TB and subsequent pre-XDR and XDR-TB among repeatedly treated patients suggest the establishment of M/XDR Mtb in this specific patient population. It highlights the urgent needs of providing DST of both 1st- and 2nd-line drugs before and during the medication in China's MDR-TB control program. Furthermore, the possibility of infection with multiple strains should also be considered to be associated with the drug resistance, which calls for the modification of treatment regimen.

A cost-effectiveness analysis of three components of a syndromic surveillance system for the early warning of epidemics in rural China.

BACKGROUND: Syndromic surveillance systems (SSSs) collect non-specific syndromes in early stages of disease outbreaks. This makes an SSS a promising tool for the early detection of epidemics. An Integrated Surveillance System in rural China (ISSC project), which added an SSS to the existing Chinese surveillance system for the early warning of epidemics, was implemented from April 2012 to March 2014 in Jiangxi and Hubei Provinces. This study aims to measure the costs and effectiveness of the three components of the SSS in the ISSC project. METHODS: The central measures of the cost-effectiveness analysis of the three components of the syndromic surveillance system were: 1) the costs per reported event, respectively, at the health facilities, the primary schools and the pharmacies; and 2) the operating costs per surveillance unit per year, respectively, at the health facilities, the primary schools and the pharmacies. Effectiveness was expressed by reporting outputs which were numbers of reported events, numbers of raw signals, and numbers of verified signals. The reported events were tracked through an internal data base. Signal verification forms and epidemiological investigation reports were collected from local country centers for disease control and prevention. We adopted project managers' perspective for the cost analysis. Total costs included set-up costs (system development and training) and operating costs (data collection, quality control and signal verification). We used self-designed questionnaires to collect cost data and received, respectively, 369 and 477 facility and staff questionnaires through a cross-sectional survey with a purposive sampling following the ISSC project. All data were entered into Epidata 3.02 and exported to Stata for descriptive analysis. RESULTS: The number of daily reported events per unit was the highest at pharmacies, followed by health facilities and finally primary schools. Variances existed within the three groups and also between Jiangxi and Hubei. During a 15-month surveillance period, the number of raw signals for early warning in Jiangxi province (n = 36) was nine times of that in Hubei. Health facilities and primary schools had equal numbers of raw signals (n = 19), which was 9.5 times of that from pharmacies. Five signals were confirmed as outbreaks, of which two were influenza, two were chicken pox and one was mumps. The cost per reported event was the highest at primary schools, followed by health facilities and then pharmacies. The annual operating cost per surveillance unit was the highest at pharmacies, followed by health facilities and finally primary schools. Both the cost per reported event and the annual operating cost per surveillance unit in Jiangxi in each of the three groups were higher than their counterparts in Hubei. CONCLUSIONS: Health facilities and primary schools are better sources of syndromic surveillance data in the early warning of outbreaks. The annual operating costs of all the three components of the syndromic surveillance system in the ISSC Project were low compared to general government expenditures on health and average individual income in rural China.

Measuring costs of data collection at village clinics by village doctors for a syndromic surveillance system-a cross sectional survey from China.

BACKGROUND: Studies into the costs of syndromic surveillance systems are rare, especially for estimating the direct costs involved in implementing and maintaining these systems. An Integrated Surveillance System in rural China (ISSC project), with the aim of providing an early warning system for outbreaks, was implemented; village clinics were the main surveillance units. Village doctors expressed their willingness to join in the surveillance if a proper subsidy was provided. This study aims to measure the costs of data collection by village clinics to provide a reference regarding the subsidy level required for village clinics to participate in data collection. METHODS: We conducted a cross-sectional survey with a village clinic questionnaire and a staff questionnaire using a purposive sampling strategy. We tracked reported events using the ISSC internal database. Cost data included staff time, and the annual depreciation and opportunity costs of computers. We measured the village doctors' time costs for data collection by multiplying the number of full time employment equivalents devoted to the surveillance by the village doctors' annual salaries and benefits, which equaled their net incomes. We estimated the depreciation and opportunity costs of computers by calculating the equivalent annual computer cost and then allocating this to the surveillance based on the percentage usage. RESULTS: The estimated total annual cost of collecting data was 1,423 Chinese Renminbi (RMB) in 2012 (P25 = 857, P75 = 3284), including 1,250 RMB (P25 = 656, P75 = 3000) staff time costs and 134 RMB (P25 = 101, P75 = 335) depreciation and opportunity costs of computers. CONCLUSIONS: The total costs of collecting data from the village clinics for the syndromic surveillance system was calculated to be low compared with the individual net income in County A.

Factors influencing the provision of public health services by village doctors in Hubei and Jiangxi provinces, China.

PROBLEM: The Chinese central government launched the Health System Reform Plan in 2009 to strengthen disease control and health promotion and provide a package of basic public health services. Village doctors receive a modest subsidy for providing public health services associated with the package. Their beliefs about this subsidy and providing public health services could influence the quality and effectiveness of preventive health services and disease surveillance. APPROACH: To understand village doctors' perspectives on the subsidy and their experiences of delivering public health services, we performed 10 focus group discussions with village doctors, 12 in-depth interviews with directors of township health centres and 4 in-depth interviews with directors of county-level Centers for Disease Control and Prevention. LOCAL SETTING: The study was conducted in four counties in central China, two in Hubei province and two in Jiangxi province. RELEVANT CHANGES: Village doctors prioritize medical services but they do their best to manage their time to include public health services. The willingness of township health centre directors and village doctors to provide public health services has improved since the introduction of the package and a minimum subsidy, but village doctors do not find the subsidy to be sufficient remuneration for their efforts. LESSONS LEARNT: Improving the delivery of public health services by village doctors is likely to require an increase in the subsidy, improvement in the supervisory relationship between village clinics and township health centres and the creation of a government pension for village doctors.

Résumé PROBLÈME: Le gouvernement central chinois a lancé le plan de réforme du système de santé en 2009 pour renforcer la lutte contre les maladies et l'amélioration de la santé, et pour fournir un paquet de services de base en termes de santé publique. Les médecins de village reçoivent une subvention modeste pour offrir des services de santé publique liés à ce paquet. Leurs opinions sur cette subvention et la fourniture de services de santé publique pourraient avoir une influence sur la qualité et l'efficacité des services de santé préventive et sur la surveillance des maladies. APPROCHE: Pour comprendre les perspectives des médecins de village sur la subvention et leur expérience dans le domaine de la fourniture de services de santé publique, nous avons organisé 10 discussions de groupe cible avec des médecins de village, 12 entrevues approfondies avec des directeurs de centres de santé cantonaux et 4 entrevues approfondies avec des directeurs départementaux de centres pour la lutte et la prévention des maladies. ENVIRONNEMENT LOCAL: L'étude a été effectuée dans quatre comtés du centre de la Chine, deux dans la province de Hubei et deux dans la province du Jiangxi. CHANGEMENTS SIGNIFICATIFS: Les médecins de village donnent la priorité aux services médicaux, mais ils font de leur mieux pour gérer leur temps de manière à inclure les services de santé publique. La volonté des directeurs de centres de santé cantonaux et des médecins de village d'offrir des services de santé publique s'est accrue depuis l'introduction du paquet et d'une subvention minimale, mais les médecins de village ne considèrent pas que cette subvention constitue une rémunération suffisante pour leurs efforts. LEÇONS TIRÉES: Il est possible que l'amélioration de la fourniture de services de santé publique par les médecins de village nécessite une augmentation de la subvention, l'amélioration de la relation de supervision entre cliniques de village et centres de santé cantonaux et la création d'une pension gouvernementale pour les médecins de village.

Resumen SITUACIÓN: En el año 2009, el gobierno central chino puso en marcha el plan de reforma del sistema sanitario con el objetivo de reforzar el control de las enfermedades y fomentar la salud, así como proporcionar un paquete de servicios básicos de salud pública. Los médicos rurales perciben una modesta subvención por la prestación de los servicios de salud pública relacionados con dicho paquete. Sus opiniones acerca de dicha subvención y la prestación de los servicios de salud pública podrían influir en la calidad y la eficacia de los servicios sanitarios preventivos y de la vigilancia de las enfermedades. ENFOQUE: Con objeto de comprender los puntos de vista de los médicos rurales acerca de la subvención y sus experiencias en la prestación de servicios sanitarios, hemos llevado a cabo 10 debates con grupos focales de médicos rurales, 12 entrevistas en detalle con directores de centros de salud municipales y 4 entrevistas en detalle con directores de Centros para el Control y Prevención de las Enfermedades provinciales. MARCO REGIONAL: El estudio se llevó a cabo en cuatro condados del centro de China, dos de ellos en la provincia de Hubei y otros dos en la de Jiangxi. CAMBIOS IMPORTANTES: Los médicos rurales dan prioridad a los servicios médicos, pero hacen todo lo posible por gestionar su tiempo a fin de incluir los servicios de salud pública. La disposición de los directores de los centros sanitarios municipales y de los médicos rurales para prestar los servicios de salud pública ha aumentado desde la introducción del paquete y de la subvención mínima, si bien los médicos rurales no consideran que sea una retribución suficiente por sus esfuerzos. LECCIONES APRENDIDAS: Es probable que, para mejorar la prestación de servicios de salud pública por parte de los médicos rurales, sea necesario un aumento de la subvención, una mejora en la relación de supervisión entre las clínicas rurales y los centros de salud municipales, así como la creación de una pensión gubernamental para los médicos rurales.

Establishing a web-based integrated surveillance system for early detection of infectious disease epidemic in rural China: a field experimental study.

BACKGROUND: A crucial goal of infectious disease surveillance is the early detection of epidemics, which is essential for disease control. In China, the current surveillance system is based on confirmed case reports. In rural China, it is not practical for health units to perform laboratory tests to confirm disease and people are more likely to get 'old' and emerging infectious diseases due to poor living conditions and closer contacts with wild animals and poultry. Syndromic surveillance, which collects non-specific syndromes before diagnosis, has great advantages in promoting the early detection of epidemics and reducing the necessities of disease confirmation. It will be especially effective for surveillance in resource poor settings. METHODS/DESIGN: This is a field experimental study. The experimental tool is an innovative electronic surveillance system, combining syndromic surveillance with the existing case report surveillance in four selected counties in China. In the added syndromic surveillance, three types of data are collected including patients' major symptoms from health clinics, pharmaceutical sales from pharmacies and absenteeism information from primary school. In order to evaluate the early warning capability of the new added syndromic surveillance, the timelines and validity of the alert signals will be analyzed in comparison with the traditional case reporting system. The acceptability, feasibility and economic evaluation of the whole integrated surveillance system will be conducted in a before and after study design. DISCUSSIONS: Although syndromic surveillance system has mostly been established in developed areas, there are opportunities and advantages of developing it in rural China. The project will contribute to knowledge, experience and evidence on the establishment of an integrated surveillance system, which aims to provide early warning of disease epidemics in developing countries.

Mapping private pharmacies and their characteristics in Ujjain district, Central India.

BACKGROUND: In India, private pharmacies are ubiquitous yet critical establishments that facilitate community access to medicines. These are often the first points of treatment seeking in parts of India and other low income settings around the world. The characteristics of these pharmacies including their location, drug availability, human resources and infrastructure have not been studied before. Given the ubiquity and popularity of private pharmacies in India, such information would be useful to harness the potential of these pharmacies to deliver desirable public health outcomes, to facilitate regulation and to involve in initiatives pertaining to rational drug use. This study was a cross sectional survey that mapped private pharmacies in one district on a geographic information system and described relevant characteristics of these units. METHODS: This study of pharmacies was a part of larger cross sectional survey carried out to map all the health care providers in Ujjain district (population 1.9 million), Central India, on a geographic information system. Their location vis-à-vis formal providers of health services were studied. Other characteristics like human resources, infrastructure, clients and availability of tracer drugs were also surveyed. RESULTS: A total 475 private pharmacies were identified in the district. Three-quarter were in urban areas, where they were concentrated around physician practices. In rural areas, pharmacies were located along the main roads. A majority of pharmacies simultaneously retailed medicines from multiple systems of medicine. Tracer parenteral antibiotics and injectable steroids were available in 83.7% and 88.7% pharmacies respectively. The proportion of clients without prescription was 39.04%. Only 11.58% of staff had formal pharmacist qualifications. Power outages were a significant challenge. CONCLUSION: This is the first mapping of pharmacies & their characteristics in India. It provides evidence of the urban dominance and close relationship between healthcare provider location and pharmacy location. The implications of this relationship are discussed. The study reports a lack of qualified staff in the presence of a high proportion of clients attending without a prescription. The study highlights the need for the better implementation of regulation. Besides facilitating regulation & partnerships, the data also provides a sampling frame for future interventional studies on these pharmacies.

Design of a randomized trial to evaluate the influence of mobile phone reminders on adherence to first line antiretroviral treatment in South India--the HIVIND study protocol.

BACKGROUND: Poor adherence to antiretroviral treatment has been a public health challenge associated with the treatment of HIV. Although different adherence-supporting interventions have been reported, their long term feasibility in low income settings remains uncertain. Thus, there is a need to explore sustainable contextual adherence aids in such settings, and to test these using rigorous scientific designs. The current ubiquity of mobile phones in many resource-constrained settings, make it a contextually appropriate and relatively low cost means of supporting adherence. In India, mobile phones have wide usage and acceptability and are potentially feasible tools for enhancing adherence to medications. This paper presents the study protocol for a trial, to evaluate the influence of mobile phone reminders on adherence to first-line antiretroviral treatment in South India. METHODS/DESIGN: 600 treatment naïve patients eligible for first-line treatment as per the national antiretroviral treatment guidelines will be recruited into the trial at two clinics in South India. Patients will be randomized into control and intervention arms. The control arm will receive the standard of care; the intervention arm will receive the standard of care plus mobile phone reminders. Each reminder will take the form of an automated call and a picture message. Reminders will be delivered once a week, at a time chosen by the patient. Patients will be followed up for 24 months or till the primary outcome i.e. virological failure, is reached, whichever is earlier. Self-reported adherence is a secondary outcome. Analysis is by intention-to-treat. A cost-effectiveness study of the intervention will also be carried out. DISCUSSION: Stepping up telecommunications technology in resource-limited healthcare settings is a priority of the World Health Organization. The trial will evaluate if the use of mobile phone reminders can influence adherence to first-line antiretrovirals in an Indian context.

Treatment quality and outcome for multidrug-resistant tuberculosis patients in four regions of China: a cohort study.

BACKGROUND: China incurs an extremely low treatment coverage of multidrug-resistant tuberculosis (MDR-TB). This study aimed to understand the experience of MDR-TB patients on quality of health care, and the clinical impact through an up to six-year follow-up. METHODS: Cohorts of MDR-TB patients were built in TB/MDR-TB designated hospitals in four regions of China from 2014 to 2015. Patients were followed up during treatment course, and yearly confirmation afterward until 2019. Delay in MDR-TB diagnosis and treatment was calculated upon bacteriological confirmation and treatment initiation. Risk factors for unfavourable outcomes were identified by multivariate logistic regression. RESULTS: Among 1168 bacteriological-positive TB patients identified from a 12-million population, 58 (5.0%) MDR-TB cases were detected. The median delay for MDR-TB diagnosis was 90.0 days, with 13.8% having a delay above 180.0 days. MDR-TB treatment was only recommended to 19 (32.8%) participants, while the rest continued with regimen for drug-susceptible TB. In MDR-TB treatment group, 36.8% achieved treatment success, while the others had incomplete treatment (21.1%), loss to follow-up (36.8%) and TB relapse (5.3%). For non-MDR-TB treatment group, 33.3% succeeded, 25.6% relapsed, 2.6% failed, 23.1% died, and 15.4% were lost to follow-up. Overall, only 35.7% (20/56) of detected MDR-TB patients had favourable outcomes and higher education level was positively associated with it (adjusted odds ratio [aOR]: 3.60, 95% confidence interval [CI]: 1.04-12.5). CONCLUSIONS: A large proportion of patients did not receive MDR-TB treatment and had unfavourable outcomes. Delayed MDR-TB diagnosis resulted in poor quality of MDR-TB care. Rapid diagnosis, regulated patient management and high-quality MDR-TB treatment should be enhanced in China.

Improved treatment outcome of multidrug-resistant tuberculosis with the use of a rapid molecular test to detect drug resistance in China.

OBJECTIVES: Numerous studies investigate the advantages of rapid molecular drug susceptibility testing (DST) in comparison to phenotypic DST, but the clinical impact on treating multi/extensively drug resistant TB(M/XDR-TB) is less studied. Therefore, we examined how molecular DST testing may improve MDR-TB treatment management and outcome in Chinese settings. METHODS: We performed a comparative study of patient cohorts before and after the implementation of molecular DST diagnosis with Genotype MTBDRsl/MTBDRplus assay in two Chinese hospitals. We collected clinical information including time to sputum culture conversion and final treatment outcome. RESULTS: In total, 242 MDR-TB patients were studied including 114 before (pre-implementation group) and 128 after the implementation (post-implementation group) of molecular DST. Time to MDR-TB diagnosis was significantly reduced for patients in the post-implementation group, as compared to the pre-implementation group (median,16 vs 62 days; P < 0.001). Patients with early available molecular DST results had a more rapid culture conversion (aHR1.94 95% CI: 1.37-2.73; median,12 vs 24 months, respectively; P < 0.001) and higher rate of treatment success (68% vs 47%, P < 0.01). CONCLUSIONS: The use of molecular DST in routine care for MDR-TB diagnosis as compared to phenotypic DST was associated with a decreased time to culture conversion and improved treatment outcome, highlighting its important clinical value.

Rising challenge of multidrug-resistant tuberculosis in China: a predictive study using Markov modeling.

BACKGROUND: Multidrug-resistant tuberculosis (MDR-TB) is on the rise in China. This study used a dynamic Markov model to predict the longitudinal trends of MDR-TB in China by 2050 and to assess the effects of alternative control measures. METHODS: Eight states of tuberculosis transmission were set up in the Markov model using a hypothetical cohort of 100 000 people. The prevalence of MDR-TB and bacteriologically confirmed drug-susceptible tuberculosis (DS-TB+) were simulated and MDR-TB was stratified into whether the disease was treated with the recommended regimen or not. RESULTS: Without any intervention changes to current conditions, the prevalence of DS-TB+ was projected to decline 67.7% by 2050, decreasing to 20 per 100 000 people, whereas that of MDR-TB was expected to triple to 58/100 000. Furthermore, 86.2% of the MDR-TB cases would be left untreated by the year of 2050. In the case where MDR-TB detection rate reaches 50% or 70% at 5% per year, the decline in prevalence of MDR-TB would be 25.9 and 36.2% respectively. In the case where treatment coverage was improved to 70% or 100% at 5% per year, MDR-TB prevalence in 2050 would decrease by 13.8 and 24.1%, respectively. If both detection rate and treatment coverage reach 70%, the prevalence of MDR-TB by 2050 would be reduced to 28/100 000 by a 51.7% reduction. CONCLUSIONS: MDR-TB, especially untreated MDR-TB, would rise rapidly under China's current MDR-TB control strategies. Interventions designed to promote effective detection and treatment of MDR-TB are imperative in the fights against MDR-TB epidemics.

Where are healthcare providers? Exploring relationships between context and human resources for health Madhya Pradesh province, India.

OBJECTIVE: In India, heterogeneous healthcare providers in the public and dominant private sectors serve a diverse population, including those from vulnerable groups, the scheduled castes and tribes. We explored relationships between the distribution of different categories of healthcare providers (public and private); and contextual socioeconomic and demographic variables. Access to healthcare providers for scheduled castes and tribes was specifically studied. METHOD: Set in Madhya Pradesh province (60.4 million), India. Dependent variables included district-wise densities of physicians and paramedics (public and private separately); and unqualified providers (private). Contextual variables included infrastructure, urbanization, economy, female literacy and proportion of scheduled castes and tribes. RESULTS: Urbanization was strongly correlated with private physician density; and negatively with paramedical density (public and private). Private paramedical density variation was partially explained by economy. Public physician and paramedical density were positively correlated to district proportions of scheduled tribes. All provider densities (public and private) were negatively related to proportions of scheduled castes. CONCLUSIONS: Overall density of qualified providers was low. Qualified physicians tended to be more densely situated in the relatively more urban districts. Access to healthcare providers for scheduled castes and tribes is different. More targeted approaches are necessary for improving access for scheduled castes.

Insomnia, Benzodiazepine Use, and Falls among Residents in Long-term Care Facilities.

Background: Falls are leading cause of injury among older people, especially for those living in long-term care facilities (LTCFs). Very few studies have assessed the effect of sleep quality and hypnotics use on falls, especially in Chinese LTCFs. The study aimed to examine the association between sleep quality, hypnotics use, and falls in institutionalized older people. Methods: We recruited 605 residents from 25 LTCFs in central Shanghai and conducted a baseline survey for sleep quality and hypnotics use, as well as a one-year follow-up survey for falls and injurious falls. Logistic regression models were applied in univariate and multivariate analysis. Results: Among the 605 participants (70.41% women, mean age 84.33 ± 6.90 years), the one-year incidence of falls and injurious falls was 21.82% and 15.21%, respectively. Insomnia (19.83%) and hypnotics use (14.21%) were prevalent. After adjusting for potential confounders, we found that insomnia was significantly associated with an increased risk of falls (adjusted risk ratio (RR): 1.787, 95% CI, 1.106-2.877) and the use of benzodiazepines significantly increased the risk of injurious falls (RR: 3.128, 95% CI, 1.541-6.350). Conclusion: In elderly LTCF residents, both insomnia and benzodiazepine use are associated with an increased risk of falls and injuries. Adopting non-pharmacological approaches to improve sleep quality, taking safer hypnotics, or strengthening supervision on benzodiazepine users may be useful in fall prevention.

Tuberculosis suspicion and knowledge among private and public general practitioners: Questionnaire Based Study in Oman.

BACKGROUND: Early detection of smear positive TB cases by smear microscopy requires high level of suspicion of TB among primary care physicians. The objective of this study is to measure TB suspicion and knowledge among private and public sector general practitioners using clinical vignette-based survey and structured questionnaire. METHODS: Two questionnaires were distributed to both private and public GPs in Muscat Governorate. One questionnaire assessed demographic information of the respondent and had 10 short clinical vignettes of TB and non-TB cases. The second questionnaire had questions on knowledge of TB, its diagnosis, treatment, follow up and contact screening based on Ministry of Health policy. TB suspicion score and TB Knowledge score were computed and analyzed. RESULTS: A total of 257 GPs participated in the study of which 154 were private GPs. There was a significant difference between private and public GPs in terms of age, sex, duration of practice and nationality. Among all GPs, 37.7% considered TB as one of the three most likely diagnoses in all 5 TB clinical vignettes. Private GPs had statistically significantly lower TB suspicion and TB knowledge scores than public GPs. CONCLUSION: In Oman, GPs appear to have low suspicion and poor knowledge of TB, particularly private GPs. To strengthen TB control program, there is a need to train GPs on TB identification and adopt a Private Public Mix (PPM) strategy for TB control.

Barriers of mistrust: public and private health sectors' perceptions of each other in Madhya Pradesh, India.

India has one of the most highly privatized health care systems in the world. The dominant private health sector functions alongside a traditional tiered public health sector. There has been an overall lack of collaboration between the two sectors despite international policy recommendations and local initiatives. It has been postulated that "conflicting perceptions" might contribute to the uncooperative attitude between the two sectors. But there has been little empirical exploration of the existing perceptions that the private and public health sectors have of each other. We explored these perceptions among key stakeholders (who influence the direction of health policy) in the public and private health sectors in the province of Madhya Pradesh, India. The barriers of mistrust, which hinder true dialogue, are complex, and have social, moral, and economic bases. They can be best addressed by necessary structural change before any significant long-term partnership between the two sectors is possible.

High-risk screening and detection of multidrug-resistant tuberculosis in two prefectures of China: a drug susceptibility surveillance-based secondary data analysis.

BACKGROUND: In China, less than one-fifth of multidrug-resistant tuberculosis (MDR-TB) cases are detected. MDR-TB screening is conducted amongst the following five high-risk groups of TB patients: chronic cases, close contacts of MDR-TB patients, patients with treatment failure, relapsed and returned patients, and smear-positive patients at the end of the third month of initial treatment. OBJECTIVE: To estimate the possibility of detecting MDR-TB cases if only the high-risk screening strategy is applied in China. METHODS: A secondary analysis was applied to the surveillance-based longitudinal data of all sputum smear-positive TB patients in Prefecture E and Prefecture W of China from 2013 to 2015. The population attributable risk (PAR) was estimated using odds ratios for five risk factors/predictors and exposure proportions amongst all MDR-TB cases. RESULTS: A total of 3513 TB patients (2807 from Prefecture E and 706 from Prefecture W) were included. Males accounted for 77.91% (2737/3513) of the patients. The average age was 52.5 ± 20.0 years old. Overall, 40.34% (71/176) of MDR-TB patients were from the five high-risk groups during the three-year study period. The detected proportion of MDR-TB cases using the high-risk screening strategy was significantly higher in Prefecture E than in Prefecture W. The PAR% for all five risk factors/predictors was 43.4% (95% CI: 24.6-61.7%), 49.9% (95% CI: 31.3-67.0%), and 30.3% (95% CI: 12.9-50.1%) in Prefecture E and 36.6% (95% CI: 10.4-64.5%), 13.3% (95% CI: -1.7-39.7%), and -82.5% (95% CI: -117.5--11.2%) in Prefecture W in 2013, 2014, and 2015, respectively. The PAR% for the five specific risk factors/predictors ranged from 0.4% (95% CI: -0.2-4.8%) to 21.0% (95% CI: 13.1-30.0%) in these two prefectures. CONCLUSION: In general, a high-risk screening strategy would miss more than half of the MDR-TB patients because they do not belong to the five high-risk groups.

Use and Adaptation of Open Source Software for Capacity Building to Strengthen Health Research in Low- and Middle-Income Countries.

Health research capacity strengthening is of importance to reach health goals. The ARCADE projects' aim was to strengthen health research across Africa and Asia using innovative educational technologies. In the four years of the EU funded projects, challenges also of technical nature were identified. This article reports on a study conducted within the ARCADE projects. The study focused on addressing challenges of video conferencing in resource constrained settings and was conducted using action research. As a result, a plugin for the open source video conferencing system minisip was implemented and evaluated. The study showed that both the audio and video streams could be improved by the introduced plugin, which addressed one technical challenge.

Barriers to prompt TB diagnosis-a comparative study between northern Malawi and eastern rural China.

Background: Tuberculosis (TB) case detection in China has improved remarkably, partly benefiting from the reducing delay to TB care, whereas the timeliness of TB care in Malawi remains problematic. Methods: This study investigates barriers hindering timely TB diagnosis in Malawi and China, and attempts to share the experience in high burden countries. A cross-sectional study on TB diagnostic delay was conducted among 254 Malawian and 146 Chinese TB patients. Results: The medians of patient's delays were 22 and 20 days (p>0.05), and provider delays were 12 and 11.5 days (p>0.05) in Malawi and China, respectively. Malawian patients had a higher proportion (72.05% vs 67.12%) of patient's delay longer than 14 days (p=0.042), which was significantly associated with initial visits to lower-level health providers in the villages (aOR=1.989, 95% CI: 1.075-3.682), and patients conducting casual/piece work (aOR=3.318, 95% CI: 1.228-8.964). Initial healthcare visits at village level also led to longer provider delay in both Malawi (aOR=2.055, 1.211-3.487) and China (aOR=5.627, 2.218-14.276). Conclusion: Establishing a good communication and referral mechanism between different levels of health facilities is crucial to timely TB diagnosis. China's experience on pro-poor interventions could be useful to its Malawian counterpart and other similar settings with high TB burden.

Difference in symptoms suggesting pulmonary tuberculosis among men and women.

Longer delays in diagnosis and lower case-detection of tuberculosis (TB) among women remain a problem in many countries. This study describes reported symptoms of new smear-positive pulmonary TB among men and women, and their association with TB diagnostic delays. All 1,027 new smear-positive pulmonary TB cases aged 15 years or over (757 men and 270 women) diagnosed by 23 district TB units of four provinces in Vietnam during 1996 were interviewed at the time of diagnosis. Among these, 540 patients diagnosed during January-June 1996 were followed up during treatment course. Pattern of symptoms was similar between the sexes. However, symptoms of cough (90.7% women, 94.7% men, P = .021), sputum expectoration (83.6% women, 89.9% men, P = .006), and hemoptysis (27.8% women, 34.9% men, P = .033) were less common among women than among men. Absence of cough and sputum expectoration was significantly associated with increased doctor's delays. Two months after treatment, cough and sputum expectoration recovered significantly more quickly among women compared to men.