Table of Content

05 November 2022, Volume 25 Issue 31

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Editorial

Enhancing Access to Health Workers in Remote Areas Using the Modified Monash Model: Australia's Experience and Implications for China

GAN Yingying, WANG Shuping, WU Xiaofan, YAN Lina

2022, 25(31):  3843-3850.  DOI: 10.12114/j.issn.1007-9572.2022.0385

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In Australia, 28% of the population live in remote and rural areas, where they face many health service utilization challenges due to geographical conditions, and generally have lower health status than those living in coastal metropolitan areas. To address the challenges of accessing health services in remote and rural areas, the Australian Government Department of Health and Aged Care has introduced a geographical classification system to help healthcare providers to improve healthcare services since 1994, and regularly updated the system to adapt to the latest sociodemographic and healthcare status, as well as formulated a range of complementary health policies to support rural and remote areas. From 2018, Australian Government Department of Health and Aged Care has adopted a new classification standard, the Modified Monash Model. We reviewed Australia's practices and concluded that, to better deliver high-quality and accessible healthcare services to areas with weak healthcare resources in China, Australia's experience could be used for reference, during taking actions to promote and refine the geographic classification system for healthcare services in a timely manner, formulating policies supporting the enhancement of access to health workers systematically, and taking advantage of modern, high and new technologies.

Comparative Study of Payment Systems for General Practitioners in Four Countries

ZHAO Minjie, Ayan MAO, WANG Kun, MENG Yueli, YAN Xiaoling, QIU Wuqi

2022, 25(31):  3850-3856.  DOI: 10.12114/j.issn.1007-9572.2022.0158

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As main health service providers in primary care, general practitioners (GPs) undertake the responsibility of gatekeepers for residents' health. Vigorously training GPs will contribute to the transformation of the healthcare delivery model, and the addressing of the issue related to difficult and high cost of getting medical treatment in China. However, the number of qualified GPs is insufficient in China, and low income is a major factor associated with the willingness of medical students to work as a GP. How to take actions to recruit, retain and appropriately employ GPs in primary care is a problem that needs to be addressed urgently in the development of China's primary care workforce. To provide evidence for the improvement of China's payment system for GPs, we collected the information related to the payment for GPs in the United Kingdom, the United States, Australia, and China by reviewing relevant studies and relevant official websites of the four countries, and performed an inter-county comparative analysis of the information in terms of income source, income level, payment methods, payment composition, and performance appraisal. We found that the four countries have the following aspects in common: all of them own a payment system for GPs and an assessment system for service quality and effectiveness of GPs, adopt a mixed payment method for GPs, and use financial incentives to promote GPs to improve the quality of their performance. In addition, the United States and China have explored methods to decentralize the management of medical insurance funds, so that the primary healthcare institutions can independently redistribute the surplus funds which has improved the proactivity of GPs at work. And Australia has set up the "coefficient of difference" and scholarships/subsidies for GPs, and carried out free trainings for improving the service capacities of GPs working in remote areas, to increase the attractiveness of working as a GP.

Article·Focus on Cognitive Impairment

Machine Learning-based Gait Analysis for Recognition of Amnestic Mild Cognitive Impairment and Alzheimer's Disease

TAO Shuai, HAN Xing, KONG Liwen, WANG Zumin, XIE Haiqun

2022, 25(31):  3857-3865.  DOI: 10.12114/j.issn.1007-9572.2022.0437

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Background

The prevalence of age-related cognitive impairment, including dementia, has significantly increased with population aging. It has been shown that cognitive function is associated with gait status. Previously, researchers used statistical analysis methods instead of machine learning methods to study the gait of amnestic mild cognitive impairment (aMCI) and Alzheimer's disease (AD) .

Objective

To develop a model to identify aMCI and AD based on gait status using machine learning methods, explore gait markers differentiating between aMCI and AD, and to assess their possible values as aided tools in diagnosing aMCI and AD.

Methods

We recruited 102 cases from the Rehabilitation Hospital Affiliated to National Research Center for Rehabilitation Technical Aids, the First People's Hospital of Foshan, and Affiliated Zhongshan Hospital of Dalian University from December 2018 to December 2020, and included 98 of them according to the screening criteria, including 55 patients with aMCI, 10 patients with AD, and 33 healthy controls (HC) . The gait parameters of the participants were collected during performing single-task (free walking) , dual-task (counting backwards in sevens) and another dual-task (counting backwards from 100) using a wearable device. Random forest (RF) algorithm and gradient boosting decision tree (GBDT) algorithm were separately used to establish a model to compare the effect of two algorithms in recognizing three groups, with 10 gait parameters as predictive variables and the physical status (healthy, aMCI, AD) as response variables. Then important features were chosen using a machine learning algorithm combined with recursive feature elimination (RFE) .

Results

No statistically significant differences were found among the three groups in terms of sex ratio, average age, height, body weight or shoe size (P>0.05) , while the differences in terms of average MMSE score and MoCA score were statistically significant (P<0.05) . In the free walking test, aMCI group and AD group had shorter average stride length and smaller average heel-to-ground angle (HtA) than HC group (P<0.05) . AD group had slower average gait speed and smaller average toe-off angle (ToA) than both HC group and aMCI group (P<0.05) . In performing the dual-task of counting backwards in sevens, compared with HC group, aMCI group and AD group had slower average gait speed and smaller average ToA and HtA (P<0.05) . AD group had longer average stance phase than HC group (P<0.05) . AD group had average smaller ToA than aMCI group (P<0.05) .In performing the dual-task of counting backwards from 100, AD group had slower average gait speed and smaller average HtA and ToA than both HC group and aMCI group (P<0.05) . Moreover, AD group had shorter average stride length than HC group (P<0.05) . The average HtA in aMCI group was smaller than that in HC group (P<0.05) . Using the GBDT-RFE method, we found important gait features in distinguishing between aMCI and AD to be the stride length, ToA and HtA, and the model using the RF algorithm performed better in identifying aMCI and AD, with an accuracy as high as 87.69%.

Conclusion

Stride length, ToA and HtA are important gait markers to identify aMCI and AD. These findings could help clinicians diagnose aMCI and AD in the future.

Comparison of the Brief CSI-D and MMSE Scales in Screening for Dementia in Middle-aged and Elderly Chinese People

WEI Xiaxia, HAO Zhimei, CHEN Ling, WANG Fenglan, JING Liwei, XING Fengmei

2022, 25(31):  3866-3871.  DOI: 10.12114/j.issn.1007-9572.2022.0272

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Background

The number of dementia patients is increasing along with the aging of the population. Dementia greatly impairs health and quality of life of patients, so early prevention and identification are particularly important.

Objective

To compare the results of the brief Community Screening Interview for Dementia (CSI-D) and the Mini-Mental State Examination (MMSE) in dementia screening, and to assess the examination consistency of the two scales.

Methods

In November 2021, we collected data of a sample of 2 668 middle-aged and elderly people with complete data (including assessment results of CSI-D and MMSE, sex, age, place of residence, education level and marital status) of the CHARLS 2018. The brief CSI-D and MMSE were used to screen the risk of dementia. Pearson correlation analysis was used to analyze the correlation of the scores of the brief CSI-D with those of MMSE. The consistencies of the two scales in the screening of dementia in all cases and subgroups divided by personal characteristics were calculated, the overall consistency was assessed using Kappa statistic.

Results

The average CSI-D score and average MMSE score for all participants were (5.84±2.26) and (24.93±3.24) , respectively. Pearson correlation analysis showed that the brief CSI-D score was positively correlated with the MMSE score (r=0.394, P<0.001) . The overall prevalence of dementia was 27.36% (730/2 668) screened by the brief CSI-D, and was 22.11% (590/2 668) by the MMSE, showing statistically significant difference (χ²=40.167, P<0.001) . The consistency of the two scales in screening dementia in all cases was 20.22%, and ranged from 12.50% to 30.43% in screening dementia in subgroups divided by personal characteristics. Kappa statistic showed that the kappa value between the two scales was 0.121 (P<0.001) , suggesting a weak level of consistency.

Conclusion

In general, there are differences and weak consistency in the screening results of dementia between CSI-D and MMSE in general household population. Therefore, the use of the scales should be analyzed according to the actual situation. The in-depth comparison and discussion on the screening accuracy of the two scales could be further performed in combination with the gold standard for diagnosing dementia.

Feasibility Analysis of the Computer-aided Language Assessment System in Measuring Cognitive-linguistic Impairment

ZHOU Yu, LI Gangwei, LI Wanyue, CHEN Yan, LING Weixin, SHAN Sharui, CHEN Zhuoming, SHANG Yaru

2022, 25(31):  3872-3876,3890.  DOI: 10.12114/j.issn.1007-9572.2022.0474

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Background

Cognitive impairment prevalence is increasing as aging population grows in China, which greatly affects the quality of life of the sufferers. Currently, the screening forcognitive-linguistic impairment still relies on traditional neuropsychological scales, which are technically demanding, time-consuming, and poorly tolerant.

Objective

To explore the feasibility of the Computer-aided Language Assessment System (CLAS) in the measurement of cognitive-linguistic impairment.

Methods

Random sampling method was used to recruit 73 participants, among them 55 (75.3%) were stroke/brain injury patients〔with a baseline score of 10-20 on the Mini-Mental State Examination (MMSE) 〕hospitalized in Department of Rehabilitation Medicine, the First Hospital of Jinan University from March 2018 to March 2020, and the other 18 (24.7%) were healthy volunteers (consisting of undergraduate medicalinterns from Jinan University, family members and accompanying caregivers of the patients) . The CLAS, Montreal Cognitive Assessment Scale (MoCA) , MMSE and Aphasia Battery of Chinese (ABC) were used to evaluate the linguistic and cognition functions of the participants. The Spearman correlation was used to assess the correlation of the score of CLAS with that of MoCA and MMSE. A receiver operating characteristic curve (ROC) of CLAS was plotted to estimate its diagnostic value for cognitive-linguistic impairment, with sensitivity, specificity and accuracy being calculated as well. A satisfaction survey was conducted in 18 healthy volunteers to understand their satisfaction with the use of the CLAS.

Results

The total CLAS score was positively correlated with that of MMSE, and MoCA (r_s=0.910, 0.884, P<0.05) .Compared with MoCA (total MoCA score <26) in combination with ABC in diagnosing cognitive impairment, the CLAS had an AUC of 0.733〔95%CI (0.632, 0.834) , P<0.001〕in identifying cognitive-linguistic impairment when the optimal cut-off value was set as 85 points, and the maximum Youden index was obtained, with 1.000 sensitivity, 0.703 specificity, and 0.931 (68/73) accuracy. The average satisfaction score of 18 healthy volunteers was (4.07±0.48) , indicating an overall satisfaction level of "satisfactory".

Conclusion

High participant satisfaction with the CLAS was obtained in this study. And as the CLAS has proven to have good validity and diagnostic accuracy, as well as good performance in identifying cognitive-linguistic impairment, it could be applied to the screening and identification of cognitive-linguistic impairment.

Risk Factors of Cognitive Frailty in Hospitalized Older Patients with Comorbidities and Its Implication for Patient Outcomes

YAN Xuedan, CHEN Shanping, ZHOU Lihua, WANG Lingxiao, YANG Yongxue, REN Yan

2022, 25(31):  3877-3883.  DOI: 10.12114/j.issn.1007-9572.2022.0154

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Background

Cognitive frailty is a cognitive impairment state between normal aging and dementia. Cognitive frailty is associated with higher possibility of negative clinical events than simple frailty or cognitive impairment in older people. As cognitive frailty could be reversible toa certain degree, early identification of high-risk groups and timely intervention are particularly important in reducing adverse prognoses and improving the quality of life of elderly patients in their later years.

Objective

To investigate the prevalence and influencing factors of cognitive frailty, and its relationship with two-year post-discharge mortality in hospitalized elderly patients with comorbidities.

Methods

The data were collected from part of the project "Research and Demonstration of Clinical Management and Community-based Continuing Care Models for Older People with Comorbidities", involving a cluster sample of older inpatients with comorbidity aged≥60 years recruited from Department of Gerontology, Chengdu Fifth People's Hospital from November 2015 to January 2018. Demographics, chronic disease prevalence, and comprehensive geriatric assessment results were collected. Cognitive frailty was assessed by the FRAIL scale and Mini-Mental State Examination. Binary Logistic regression was used to analyze the influencing factors of cognitive frailty. The survival status was investigated at the end of a two-year follow-up after discharge. Cox regression was used to analyze the relationship of cognitive frailty with two-year post-discharge mortality.

Results

A total of 554 cases were included, and 15.9% (88/554) of them had cognitive frailty. Compared with non-cognitive frailty group, cognitive frailty group had older average age, lower prevalence of high school education or above, lower average family care score, higher prevalence of malnutrition, depression, dependence in activities of daily living and balance dysfunction (P<0.05) . Binary Logistic regression analysis showed that malnutrition, balance dysfunction, and family care disorder were independent factors of cognitive frailty. During the follow-up period, 456 patients (82.3%) survived, 81 (14.6%) died, and 17 (3.1%) were lost to follow-up. After controlling for confounding factors, Cox regression analysis indicated that, the risk of two-year post-discharge mortality in cognitive frailty group was 2.039〔95%CI (1.060, 3.922) 〕times higher than that of those with normal cognitive function and non-frailty, and was 5.266〔95%CI (3.159, 8.778) 〕times higher than that of those with simple cognitive frailty (P<0.05) .

Conclusion

Cognitive frailty is common among elderly inpatients with comorbid conditions, and it can increase the relative risk of two-year post-discharge mortality. Clinical medical workers should pay more attention to this group to identify high-risk individuals of cognitive frailty as soon as possible and give them preventive interventionsin time.

Article·Focus on Population Health

The Relationship between Sleeping Time and Falls in Middle-aged and Elderly Residents over 45 Years in China

HE Xiangyang, LIU Zheng, XU Ying, MA Yan, ZHAO Rencheng, SUN Panpan, GUO Yanfang

2022, 25(31):  3884-3890.  DOI: 10.12114/j.issn.1007-9572.2022.0305

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Background

There are few studies on the relationship between sleep time and falls at present, and the research results are inconsistent.

Objective

To explore the relationship between sleeping time and falls in middle-aged and elderly residents in China, and to provide reference for preventing falls in this population.

Methods

The study based on the data from China Health and Retirement Longitudinal Survey (CHARLS) data in 2015. 18 181 subjects aged ≥45 years with complete key data were included. Collect the indicators of the middle-aged and old people in the past two years, such as falls and medical treatment, sleep time, demographic characteristics, behavior and lifestyle, health status, self-life satisfaction and self-rated health. The subjects were divided into 5 groups according to the sleep time per night: <5 h (2 945 cases) , 5-<6 h (2 755 cases) , 6-<7 h (reference group, 3 824 cases) , 7 to <8 hours (3 257 cases) and ≥8 hours (5 400 cases) . Logistic regression model was used to adjust different variables to gradually evaluate the relationship between sleep time and the occurrence of falls and medical treatment for falls in the past two years.

Results

The average sleeping time of middle-aged and elderly people was (6.4±1.9) hours, the incidence of falls in the past two years was 17.01% (3 092/18 181) , and the rate of medical treatment for falls was 6.95% (1 264/18 181) . The incidence of falls in subjects with sleep time <5 h, 5-<6 h, 6-<7 h, 7-<8 h and≥8 h were 25.26% (744/2 945) , 19.82% (546/2 755) , 15.51% (593/3 824) , 14.03% (457/3 257) , 13.93% (752/5 400) , the incidence of falling to hospital was 10.97% (323/2 945) , 8.09% (223/2 755) , 6.04% (231/3 824) , 5.43% (177/3 257) and 5.74% (310/5 400) , which were significant differences demonstrated by the trend chi-square test, and the difference was statistically significant (P<0.05) . Compared with 6-<7 hours after adjusting factors such as age, gender, those with sleeping time ≥8 hours had a significantly lower risk of falling〔OR (95%CI) =0.88 (0.78, 0.99) 〕, and those with sleeping time <5 h and 5-<6 h had a significantly higher risk of falling〔OR (95%CI) _{<5 h}=1.31 (1.16, 1.49) , OR (95%CI) _{5-<6 h}=1.14 (1.00, 1.30) 〕. The middle-aged and old people who slept less than 5 hours per night had a higher risk of falling and seeking medical treatment〔OR (95%CI) =1.30 (1.08, 1.56) 〕.

Conclusion

The incidence of falls in middle-aged and elderly people in China is relatively high, sleep time <6 hours per night will increase the risk of falls, and sleeping≥8 hours may reduce the risk of falls. Adjusting sleeping time of middle-aged and elderly people and strengthening lifestyle intervention can effectively reduce the incidence of falls in the middle-aged and elderly people.

Mediator Role of Future Time Perspective in the Longitudinal Effects of Cumulative Ecological Risk on Healthy Lifestyle of Left-behind and Non-left-behind Adolescents in Rural Areas

JIN Ming, JI Huajuan, LI Yachen, ZHANG Tengyu, SU Lulu

2022, 25(31):  3891-3898,3913.  DOI: 10.12114/j.issn.1007-9572.2022.0365

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Background

Exploring the factors influencing healthy lifestyle in adolescents is beneficial to promoting the physical and mental health of adolescents, which is an important initiative to promote the achievement of the goals of Healthy China. Moreover, it is also an important means to achieve the goals of health poverty alleviation and targeted poverty alleviation projects in both left-behind and non-left-behind rural adolescents.

Objective

To investigate the longitudinal effect of cumulative ecological risk on healthy lifestyle and the mediating effect of future time perspective between them in rural left-behind and non-left-behind adolescents.

Methods

Rural left-behind and non-left-behind adolescents from 24 classes in 12 schools in Shijiazhuang, Hebei Province were selected from October 2020 to October 2021. Three surveys (the first, second and third were on cumulative ecological risk, future time perspective and healthy lifestyle, respectively) were conducted with them, and had 1 135, 1 102 and 1 053 responders, respectively. Person correlation analysis was used to analyze the correlation between cumulative ecological risk, future time perspective and healthy lifestyle. Structural equation model was used for mediation analysis, and Bootstrap sampling method was used to further assess the mediating effect of future time perspective.

Results

Finally, 1 053 cases who effectively responded to each of the three surveys were included for analysis, including 335 left-behind adolescents (31.81%) and 718 non-left-behind adolescents (68.19%) . The scores of annual cumulative ecological risk (October 2020) , future time perspective (April 2021) and healthy lifestyle (October 2021) were (2.78±1.45) , (53.40±13.80) and (150.72±24.67) , respectively for left-behind responders, and were (2.34±1.24) , (59.21±8.46) and (159.07±14.43) , respectively for non-left-behind responders. Correlation analysis showed that cumulative ecological risk was negatively correlated with both future time perspective and healthy lifestyle (P<0.05) , and future time perspective was negatively correlated with healthy lifestyle (P<0.05) . Forced regression indicated that the healthy lifestyle was inversely and longitudinally influenced by cumulative ecological risk in rural left-behind adolescents (β=-0.31, P<0.01) , showing a trend of sharp and positively accelerated decline. The healthy lifestyle was also inversely and longitudinally influenced by cumulative ecological risk in non-left-behind adolescents (β=-0.22, P<0.01) , demonstrating a relatively liner trend of mild decline. Mediating analysis using Bootstrap sampling revealed that future time perspective played a mediating role in the longitudinal effect produced by cumulative ecological risk on the healthy lifestyle in both rural left-behind and non-left-behind adolescents (P<0.01) .

Conclusion

The cumulative ecological risk may be a longitudinal predictor of the healthy lifestyle in left-behind and non-left-behind adolescents, and its predictive value was higher in the latter. Future time perspective was a mediator in the relationship between cumulative ecological risk and healthy lifestyle in both left-behind and non-left-behind adolescents.

Consistency and Discrepancy between Parents- and Teachers-assessed Behavioral Problems in Preschoolers

WANG Li, WANG Nianrong, TU Mingshu, CHEN Qun, YE Yuan, LI Daiqin, HE Huanrong, ZHANG Li

2022, 25(31):  3899-3903.  DOI: 10.12114/j.issn.1007-9572.2022.0218

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Background

Pediatricians often receive inconsistent reports from parents and teachers on children's behavior, but there are few available studies on comparing parents and teachers' evaluation of preschool children's behavior problems.

Objective

To investigate the prevalence of behavioral problems in preschoolers from Chongqing's main urban areas, and to explore the consistency and discrepancy between parents- and teachers-assessed behavioral problems in these children.

Methods

In June 2018, 2 698 preschoolers were sampled by cluster sampling from kindergartens in the main urban area of Chongqing. For understanding the prevalence of behavioral problems in them, their behaviors were rated by their parents using the Conners Parent Symptom Questionnaire (PSQ) , and by their teachers using the Conners Teacher Rating Scale (TRS) . And parents- and teachers-assessed results were compared.

Results

The survey obtained a response rate of 98.59%, involving 2 660 children that were finally included. In accordance with parents' assessment, the prevalence of behavioral problems was 14.47% in preschool children (385/2 660) , and that in boys was higher than in girls〔17.91% (245/1 368) vs 10.84% (140/1 292) , P<0.001〕. According to teachers' assessment, the prevalence of behavioral problems was 4.44% in preschool children (118/2 660) , and that in boys was also higher than in girls〔6.29% (86/1 368) vs 2.48% (32/1 292) , P<0.001〕. Parents' assessment showed that boys had higher prevalence of learning problem, psychosomatic problems, and higher hyperactivity index, while teachers' assessment showed that boys had higher prevalence of conduct problems and higher hyperactivity index. In comparison with girls, boys had higher prevalence of behavior problems in in four factors of PSQ, namely learning problem, conduct problems, impulsivity-hyperactivity and hyperactivity index, and higher prevalence of behavior problems in all four factors of TRS. Spearman correlation analysis indicated that scores rated for boys by teachers in terms of conduct problems, inattention-passivity, and hyperactivity index in TRS were positively correlated with scores rated for them by parents in terms of conduct problems, learning problems, impulse-hyperactivity, and hyperactivity index in PSQ; that scores rated for boys by teachers in terms of hyperactivity problems in TRS were positively correlated with scores rated for them by parents in terms of conduct problems, impulse-hyperactivity, and hyperactivity index in PSQ (r_s ranged from 0.056 to 0.113, P<0.05) ; that scores rated for boys by teachers in terms of hyperactivity problems in TRS were negative correlated with scores rated for them by parents in terms of anxiety problems (r_s=-0.059, P<0.05) . In girls, the scores of each factor in TRS were not correlated with those in PSQ (P>0.05) .

Conclusion

The prevalence of behavior problems in preschoolers assessed by parents was higher than that assessed by teachers. Although there are some differences between the assessment by parents and teachers, there is a good consistency in their assessment of conduct problems and hyperactivity.

Latent Class Analysis and Influencing Factors of Medication Adherence in Multiple Chronic Conditions Patients

ZHANG Zhenxiang, HE Fupei, ZHANG Chunhui, LIN Beilei, PING Zhiguang, GUO Huijuan

2022, 25(31):  3904-3913.  DOI: 10.12114/j.issn.1007-9572.2022.0340

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Background

The cases of multiple chronic conditions are increasing yearly, yet their medication adherence is unsatisfactory though taking medication as prescribed is recognized as the most effective measure to manage chronic diseases. To improve the prevention and control of chronic diseases, it is crucial to identify the causes and influencing factors of non-compliance in multiple chronic conditions patients.

Objective

To classify the medication adherence and to identify the associated factors of each class of medication adherence in multiple chronic conditions patients.

Methods

This investigation was conducted between July and September 2021 with a convenience sample of 267 inpatients from two tertiary A general hospitals of Henan Province using the Chinese version of Beliefs about Medicines (BMQ-C) , the Chinese version of 8-item Morisky Medication Adherence Scale (MMAS-8-C) , and the Medication Knowledge Scale (MKS) . Latent class analysis was used to classify the medication adherence. Demographic characteristics, medication use, medication knowledge and medication beliefs were compared by the class of medication adherence. Multiple Logistic regression was used to explore the associated factors of each class of medication adherence.

Results

The medication adherence of the participants was divided into three latent classes, namely subjective poor medication adherence, overall poor medication adherence, and overall good medication adherence, and the prevalence of the three classes was 18.0%, 34.4% and 47.6%, respectively. The education level, occupational status after an illness, living situation, household monthly income per person, financial resources, prevalence of having pharmacist guidance, number of medications, frequency of taking medication, years of taking medication, the BMQ-C score, and MKS score in the participants differed significantly by the class of medication adherence (P<0.05) . By multiple Logistic regression analysis, compared with patients with subjective poor medication adherence, those with overall good medication adherence had higher prevalence of having pharmacist guidance, and higher average scores of BMQ-C and MKS, and lower prevalence of retirement due to illness and offspring's support as the only financial resource (P<0.05) . Compared with those with overall poor medication adherence, those with overall good medication adherence had higher prevalence of retirees, taking medication once a day, and having pharmacist guidance, as well as higher average scores of BMQ-C and MKS (P<0.05) .

Conclusion

The medication adherence in these multiple chronic conditions patients could be classified into three latent classes. More attention should be given to those who were retired due to illness or financially supported by their children, because they were prone to having poor medication adherence. Those who had lower frequency of medication use, medication guidance from a pharmacist, and higher levels of medication knowledge and beliefs were prone to having good medication adherence.

Factors Influencing the Annual Number of Hospitalizations in Mountain Residents from Southern Ningxia: an Analysis Based on Zero-inflation Concept and Zero-inflated Models

GAO Baokai, HU Zhaoyan, WANG Wenlong, QIAO Hui

2022, 25(31):  3914-3922.  DOI: 10.12114/j.issn.1007-9572.2022.0322

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Background

An era of expanded information capacity poses new challenges to data utilization capabilities of all practitioners. The true relationship between variables can only be revealed by identifying the type and characteristics of the data, then analyzed using the appropriate statistical analysis methods. Most available studies focuson the analysis of the rate of due/non-hospitalization, and there are few articles analyzing the factors influencing the number of hospitalizations using the countdata.

Objective

To fit an optimal model suitable for the annual number of hospitalizations of residents, and to analyze its influencing factors.

Methods

Data came from the health service survey database of the project "innovating payment system toimprove health benefits" carried out from July to August 2019. A total of 27 196 residents from four mountainous counties (Yanchi, Haiyuan, Pengyang and Xiji) in southern Ningxia were selected to attend a questionnaire survey by use of multistage stratified random sampling, and 22 427 (82.46%) of them with complete and clear key information who returned responsive questionnaires were included for analysis. Four models (Possion regression, negative binomial regression, zero-inflated Poisson regression and zero-inflated negative binomial regression) were established with annual number of hospitalizations as the dependent variable, and demographic factors (sex, age, marital status, education level and occupation) , household characteristics (household size, annual household income per capita, prevalence of poverty-stricken household/household living on minimum subsistence allowances) , social feature (distance to the nearest township health center) as independent variables, then the model with the best fitting performance was selected to explore the factors associated with the annual number of hospitalizations.

Results

The percentage of residents with zero annual hospitalizations was 88.30% (19 802/22 427) . The negative binomial regression model was examined to have better fitting performance than the Possion regression model by discrete choice experiments (O=87.665, P<0.01) . The statistic value of Vuong's test was greater than 1.96, indicating that the data were zero-inflated. The zero-inflated negative binomial regression model had the smallest goodness of fit (18 331.87) measured by the Akaike information criterion. And the analysis using this model revealed that sex, education level, occupation, household size, annual household income per capita, an prevalence of poverty-stricken household/household living on minimum subsistence allowances were associated with annual number of hospitalizations (P<0.05) . And age, marital status, education level and occupation were associated with the zero-inflation in annual number of hospitalizations (P<0.05) .

Conclusion

The zero-inflated negative binomial regression model fitted the data of annual hospitalizations of the participants best. Being female, unemployed, or poverty-stricken household/household living on minimum subsistence allowances was associated with higher possibility of seeking hospitalization care, while higher education level, or a larger household size was associated with lower possibility of seeking hospitalization care. A higher potential demand for hospitalization care was found in 40-59-year-olds and the married, which could be partially lowered by improving education level and reducing physical labor intensity level.

Article·Focus on Proactive Health

Proactive Care in China: Implementation Status and Recommendation Strategies for Various Undertaking Bodies

ZHANG Qianqian, JIN Hua, SHI Xiaoxiao, YU Dehua

2022, 25(31):  3923-3927,3932.  DOI: 10.12114/j.issn.1007-9572.2022.0419

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The model of proactive care delivery is becoming a hot research topic. In China, the implementation of proactive care has revealed some problems, which may be due to unclear definition and connotation of proactive care, and unclear division of labor in various undertaking bodies. We combed the definition and connotation of proactive care, then analyzed and summarized the implementation status of proactive care in China. After that, we put forward implementation strategies for various undertaking bodies in accordance with the actual domestic conditions to improve the implementation effectiveness of proactive care to achieve universal health, and to move forward to the future of proactive care in China. The government should formulate a national proactive care plan, establish a proactive care promotion organization, regulate the cooperation between relevant departments, and optimize the community environment. Medical institutions should develop and implement health plans, prevent and treat diseases, and help the public to improve health literacy and develop healthy behavior and habits. Residents should develop healthy living habits according to the features of themselves and their families in a proactively and self-disciplined way. Relevant departments should take actions to promote stakeholders of proactive care resources to be engaged in proactive care implementation.

Implementation Strategies of Community-based Proactive Care Management

LI Wanyu, JIN Hua, YU Dehua

2022, 25(31):  3928-3932.  DOI: 10.12114/j.issn.1007-9572.2022.0280

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To improve people's health via meeting their growing health needs, the "Healthy China 2030" Planning Outline highlights the concept of protective care, and actively promotes the transformation from disease-centered care to human-centered care. There is still no a standard proactive care system. We summarized the essence, development status and significance of proactive care, then based on this, explored implementation strategies and assessment system regarding proactive care management conducted by community health institutions and community medical workers. We believe that community health institutions and community medical workers play an important role in the implementation of proactive care, and improving people's awareness of proactive care and self-health management ability via integrating proactive care into health management is of great significance to improve the national health level.

Research Status of Health Literacy Assessment Tools from the Perspective of Active Health and Its Enlightenment to China

FU Qiangqiang, JIN Hua, LI Li, MA Yu, YU Dehua

2022, 25(31):  3933-3943.  DOI: 10.12114/j.issn.1007-9572.2022.0101

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Background

The Outline of the "Healthy China 2030" Plan points out improve the health literacy and lifestyle monitoring system covering the whole country, strengthen personal health responsibility, improve residents' self-health management ability and health level, in order to greatly improve the level of national health literacy. Scientific health literacy assessment tools can systematically understand the health literacy level of residents and provide targeted interventions. The health literacy assessment started late in China. The content of existing health literacy assessment tool should been improved, which is called Chinese Citizens' Health Literacy-Trial Implementation of Basic Knowledge and Skills (to try out), because it is definitely important to create an effective and reliable health literacy assessment tool.

Objective

Based on the perspective of active health, this paper reviews the relevant literature on health literacy assessment tools at home and abroad.

Methods

Chinese and foreign databases of PubMed, Web of Science, CNKI, Wanfang and VIP were systematically retrieved using keywords including "Health literacy" "Tool""Evaluation" "Assessment" "Questionnaire" "Scale". The related literature of health literacy assessment tools was obtained with the retrieval time from 1990-01-01 to 2021-06-30, and the current situation and contents of health literacy assessment tools were reviewed.

Results

A total of 47 health literacy assessment tools were screened, including 27 objective assessment tools and 20 subjective assessment tools. The most of research and development (R&D) and application is in the United States (22) , followed by Europe (13) . The number of English tools is the largest (25) , followed by Portuguese (5) , Italian (3) and Spanish (2) . The evaluation time of REALM-SF, SILS is the shortest (1 minute) , and the longest for MHLS (25 minutes) . The least item is in SILS (1 item) , and REALM (125 items) has the most evaluated items. The most widely used evaluation tools are the REALM series scale and TOFHLA series scale in objective evaluation tools, and the HLS-EU-Q series scale in subjective evaluation tools. The evaluation mainly content involves vocabulary recognition, information acquisition, computing ability, reading comprehension, information exchange, information application and so on.

Conclusion

The development and application of health literacy assessment tools are dominated by European and American countries, and the number of objective health literacy assessment tools is in the majority. As the change of the connotation of health literacy from a single personal assessment to a comprehensive assessment of individuals and external environment, the R&D of health literacy assessment tools in China should be based on the establishment of unified standards across the country on the premise of deepening the connotation of health literacy and the concept of active health, the indicators should mainly be quantitative or semi quantitative indicators. A health literacy assessment tool suitable for China's national conditions covering the whole life cycle should be developed to provide scientific and effective support for improving the health literacy level of residents.

Effect of Health Literacy on Colonoscopy Screening Compliance in an At-risk Population Identified by the First Colorectal Cancer Screening

MUZAIPAIER· Muhetaer, JIN Hua, YU Dehua

2022, 25(31):  3944-3948.  DOI: 10.12114/j.issn.1007-9572.2022.0142

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Background

The prevention and treatment of colorectal cancer has become a societal concern. One key to colorectal cancer prevention and treatment is to improve the detection rate of colonoscopy screening, an essential tool for early diagnosis of colorectal cancer, in populations at high risk of colorectal cancer. Some research results show that the ability of individuals to make healthy choices and decisions is closely associated with their ability to acquire and understand information.

Objective

To investigate the association of health literacy level with colonoscopy screening compliance in an at-risk population identified by the first colorectal cancer screening.

Methods

Participants were individuals at risk of colorectal cancer selected from January to March 2020 who were identified by the general colorectal cancer screeningconducted by a community health center in Shanghai's Yangpu District during 2017—2018. General Demographic Information Questionnaire and the Chinese version of Health Literacy Management Scale (HeLMS-C) were used to conduct a questionnaire survey.

Results

Altogether, 337 cases attended the survey, and 329 of them (97.6%) who handed in responsive questionnaires were finally included. Among the respondents, 252 had never received a colonoscopy, and only 77 had received that, with a colonoscopy screening compliance of 23.4%. The total average HeLMS-C score for the respondents was (103.77±3.78) . And the average scores of four domains of the scale, namely accessing GP healthcare services, communication with health professionals, patient attitudes towards their health, and social support were (44.50±1.70) , (36.34±2.10) , (15.83±2.01) and (7.09±1.37) , respectively. The distribution of marital status, type of risk for colorectal cancer identified by the first colorectal cancer screening, total score of the HeLMS-C, scores of accessing GP healthcare services, communication with health professionals and patient attitudes towards their health differed significantly between respondents who received a colonoscopy and those who did not (P<0.05) . Logistic regression analysis results showed that the type of marriage status, patient attitudes towards their health and communication with health professionals were associated with colonoscopy screening compliance (P<0.05) .

Conclusion

Having a spouse, higher patient attitudes towards their health, and higher level of communication with health professionals were associated with higher colonoscopy screening compliance in individuals at risk of colorectal cancer identified by the first colorectal cancer screening. In view of this, to improve the colonoscopy screening compliance of these people, attention should be paid to the improvement of the level of their health literacy.

Article·Focus on General Practice Education

Relationships between Perceived Workplace Violence by Patients, Psychological Capital, and Professional Identity among General Practitioners in China

YU Minyi, FENG Jing, ZHENG Yanling, LEI Zihui, SHEN Xin, LI Xinyan, QU Ge, GAN Yong

2022, 25(31):  3949-3954.  DOI: 10.12114/j.issn.1007-9572.2022.0394

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Background

Social environment and psychological factors have a notable impact on professional identity. Currently, there are no available studies on relationships between perception of workplace violence (WPV) by patients, psychological capital (PsyCap) , and professional identity among general practitioners (GPs) in China.

Objective

To investigate the relationships between perceived WPV by patients, PsyCap, and professional identity among GPs in China.

Methods

A self-administered electronic questionnaire survey was conducted with 4 632 GPs selected by use of stratified multistage random sampling from eastern, central, and western China between March and May 2021. The survey was used for collecting data mainly consisting of GPs' basic demographics, perceived WPV by patients, PsyCap, and professional identity. Spearman's correlation was used to analyze relationships between perceived WPV by patients, PsyCap, and professional identity. Hierarchical multiple regression analysis was used to analyze the effects of perceived WPV by patients and PsyCap on professional identity.

Results

Altogether, 94.47% of the GPs (4 376/4 632) who handed in responsive questionnaires were included for analysis. Six hundred and twenty-four (14.26%) GPs had experienced WPV by patients in the past year. The average total scores of PsyCap and professional identity were (102.89±16.94) and (33.93±8.95) , respectively. The increase in the score of perceived WPV by patients was correlated with a decrease in the scores of PsyCap and its dimensions, and in the score of professional identity (P<0.01) . The increase in the scores of PsyCap and its dimensions was correlated with increased score of professional identity (P<0.01) . Hierarchical multiple regression analysis showed that the frequency of WPV by patients had a negative predictive effect on professional identity (low frequency, b=-0.071; intermediate frequency, b=-0.054; high frequency, b=-0.042; P<0.001) . PsyCap had a positively predicted effect on professional identity (b=0.330, P<0.001) , and it played a partial mediating role between perceived WPV by patients and professional identity.

Conclusion

The GPs' perceived WPV by patients, PsyCap, and professional identity are interrelated, and PsyCap plays a partial mediating role between perceived WPV by patients and professional identity. Great importance should be attached to the professional work environment, occupational status, and mental health among Chinese GPs.

Development of the Onion Model-based Competency Assessment System for Community General Practitioners

LIAN Guohua, CHEN Liang, ZHANG Xiangjie, ZHANG Chen, CHENG Ju

2022, 25(31):  3955-3959.  DOI: 10.12114/j.issn.1007-9572.2022.0646

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Background

As healthcare gatekeepers, the competency of community general practitioners (GPs) will directly determine the quality of their services. However, the requirements for the competency of community GPs are still unclear and relevant applied research is scarce.

Objective

To construct a competency assessment system for community GPs.

Methods

An item pool of the first draft of the Onion Model-based Competency Assessment System for Community General Practitioners (OMCASCGP) was created by use of literature review in January 2021, then items in which were screened and improved in accordance with the results of two rounds of email-based expert consultation conducted with a purposive sample of 52 experts in general medicine and general medical management from February to March 2021. The weight of each index was determined by using the Analytic Hierarchy Process.

Results

The response rate, authority coefficient, judgment coefficient and the degree of familiarity with the index for both rounds of consultation were 100.0% (52/52) , 0.91, 0.904, and 0.916, respectively. The formal system is composed of 6 first-level indices, 15 second-level indices and 48 third-level indices. The 6 first-level indices with corresponding weights are basic information (0.085 7) , clinical capability (0.436 1) , public health capability (0.244 5) , humanistic literacy (0.110 4) , career development (0.082 7) , and other aspects (0.040 6) . The Kendall's W measuring inter-expert agreement on the first-, second- and third-level indices was 0.254, 0.302, and 0.341, respectively (P<0.001) .

Conclusion

The OMCASCGP developed by us has been validated to be scientific and reliable, which could be appropriately promoted as a tool for assessing the comprehensive competencies of GPs.

Review

Recent Developments in Capacity Evaluation of Community Emergency Preparedness and Response for Public Health Emergencies

WEI Jili, BAI Wenhui, LU Ying, LI Jiake, ZHANG Hongmei

2022, 25(31):  3960-3964.  DOI: 10.12114/j.issn.1007-9572.2022.0308

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The human health damage and social stability caused by public health emergencies have attracted worldwide attention. But there is a lack of research on capacity evaluation of China's community emergency preparedness and response for public health emergencies. We summarized the latest advances in theoretical frameworks and capacity evaluation of community emergency preparedness and response for public health emergencies based on a systematic review and textual analysis of relevant studies, and proposed that future research should pay attention to the building of the capacity of community emergency preparedness and response for public health emergencies and the development of corresponding assessment tools applicable to communities in China. This study will contribute to the assessment, normalization and improvement of the capacity of community emergency preparedness and response for public health emergencies.

Research Progress on Assessment Tools of Intimate Partner Violence

YANG Shuang, HU Aiping, XIANG Mingfang

2022, 25(31):  3965-3970.  DOI: 10.12114/j.issn.1007-9572.2022.0350

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Intimate partner violence (IPV) refers to the occurrence of threatening or abusive behaviors between intimate partners; the specific forms of which include physical, mental, or sexual injuries. Existing studies have shown that IPV can bring a series of physical and psychological injuries to victims, which seriously affect the victims' quality of life. Accurate assessment of IPV is a prerequisite and fundamental to the formulation of targeted preventive measures. However, domestic research on IPV is still in its infancy, and assessment tools for IPV are lacking. In this paper, we divided eight IPV assessment tools commonly used abroad into research tools and screening tools, reviewed the main contents, applications and characteristics of each tool, and compared the advantages and disadvantages of these eight assessment tools, aiming to provide reference for IPV related research practices in China and a basis for accurately assessing and identifying IPV victims.