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2017 Vol. 33, No. 11

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Application of evidence-based chronic diseases prevention and control in four countries:a comparison study
WANG Zhao-xin, YU De-hua, XIAO Yue.et al
2017, 33(11): 1583-1586. doi: 10.11847/zgggws2017-33-11-11
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Objective To reveal current status and obstruction of the application of evidence-based concepts or methods in chronic disease prevention in United States,Australia,China,and Brazil.Methods Fifty qualitative semi-structured interviews were conducted in public health institutions in the four countries between February and July 2016;the contents of the interviews involved the current status of application of evidence-based chronic disease prevention and obstructive factors for the implementation and promotion of the application.Results The United States and Australia are committed to promote the evidence-based countermeasures against chronic diseases;while,China and Brazil are still in the stage of evidence accumulation.Deficit of governmental investment and stable source of funding and lack of efficient mechanisms are main hindering factors for the application of of evidence-based process in chronic disease prevention for the four countries.Conclusion Policy is a common influencing factor for evidence-based chronic diseases prevention practice but the affect of the factor is different due to various backgrounds in the four countries.The experiences of the developed countries can provide certain references for evidence-based chronic diseases prevention in developing countries.
Prevalence of non-communicable chronic diseases (NCDs) in eastern coastal China and its implication for NCDs prevention and treatment
WANG Zhao-xin, WANG Xia-wei, YU De-hua.et al
2017, 33(11): 1563-1566. doi: 10.11847/zgggws2017-33-11-06
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Objective To examine the epidemic trend of non-communicable chronic diseases (NCDs) in Southeast China and to provide evidences for prevention and treatment of the diseases.Methods We collected 1 907 484 medical records of NCDs patients admitted to 12 tertiary general hospitals located in 5 provinces of Southeast China between 2003 through 2014.Distribution of and changing trend in NCDs spectrum among the inpatients were analyzed.Results The proportion of digestive diseases decreased significantly (Z=-4.28,P<0.0001),and that of mental and behavioural disorders were not changed significantly (Z=-1.43,P=0.077) among the male inpatients; while among the female inpatients,the proportion of digestive diseases did not changed significantly (Z=-0.270,P=0.394),but that of mental and behavioural disorders increased significantly (Z=5.130,P<0.001).Moreover,the proportion of the inpatients aged 21-50 years with diabetes,blood diseases or endocrine diseases skyrocketed over this period (all P<0.001).However,the proportion of inpatients with cancer decreased sharply with the increment of age (all P<0.05).Conclusion The prevalence of NCDs showed specific characteristics with the economic development in Southeast China,particularly among women and younger people,suggesting that the burden of NCDs needs to be concerned.
Cognition and practice of evidence-based medicine among practitioners engaged in chronic disease prevention and control in Shanghai municipality
SHI Jian-wei, XIAO Yue, LIU Rui.et al
2017, 33(11): 1575-1577. doi: 10.11847/zgggws2017-33-11-09
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Objective To analyze current status of cognition about evidence-based chronic disease prevention and control (CDPC) and its influencing factors among medical practitioners and to provide information for implementing evidence-based chronic disease prevention and control in China.Methods Based on Brownson's theoretical model,we collected relevant information from 84 personnel in medical institutions at different administrative levels in Shanghai municipality between July and September 2016 with a questionnaire survey.The cognition on evidence-based CDPC and its personal,institutional,social and cultural,as well as political influencing factors were analyzed.Results Of the participants,78.58% did not know evidence-based CDPC method at all;25% never practiced evidence-based CDPC method.The participant-reported main individual-related obstructive factors for cognition and practice of evidence-based CDPC included the lack of relative knowledge (reported by 57.14% of the participants) and working time (42.86%); the major institutional-related factor was the shortage of resources (73.81%);the main social-related hinder factor was the limitation in precious evidences for specific populations (50.00%);and the policy-related major problem was the insufficiency of supporting funds (53.57%).Conclusion Effectively combining the evidence-based concept and daily practice and medical service and population demand,together with institutional induction and multiple support at political level,could promote the implementation of evidence-based chronic disease prevention and control.
Analysis on bottlenecks of chronic disease prevalence prediction and establishment of optimized model in China
LIU Rui, SHI Jian-wei, YU De-hua.et al
2017, 33(11): 1552-1555. doi: 10.11847/zgggws2017-33-11-03
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Objective To analyze the development,methodology,and bottleneck of research on prediction of chronic disease prevalence trend in China and to provide a theoretical basis by optimizing prevalence prediction model for prevention and control of chronic diseases.Methods We conducted a meta-analysis of relevant literatures,systemically reviewed development status and bottlenecks of chronic disease prevalence prediction in China,and optimized models for chronic disease prevalence prediction.Results There is a lack in concerns to the prediction for chronic disease prevalence trend and there are a few studies on prediction of chronic disease incidence.The application of methodology is still restricted to linear or multiple regression.We screened out influential variants in scopes of population,economy,and society and then constructed a state space model with those variants.The established model demonstrated a higher fitness than other time series autoregressive models.Conclusion The use of state space model in conducting prevalence prediction of chronic disease for a specific region could improve the precision and sensitivity of long term prediction and to provide strong evidences for evidence-based decision-making.
Evidence-based public health:analysis on international experiences and its development in China under new scenario of public health
XIAO Yue, SHI Jian-wei, CAO Hui.et al
2017, 33(11): 1556-1559. doi: 10.11847/zgggws2017-33-11-04
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With the coming of new public health,which changes its mission from disease treatment to disease prevention,how to scientifically carry out public health decision-making and practice has become an important subject.This study analyzes the history and experience of the development of evidence-based public health in developed countries by literature review.By comparing with the situation in developed countries,we found that the public health evidence-based decision-making is still in its early stage in China and there are some problems to be solved urgently although some progresses have been achieved.Based on the experiences of developed countries,we put forward some suggestions on the establishment of theories on evidence-based public health,the accumulation of evidence and the establishment of database,in order to promote the development of evidence-based public health in China.
Analysis on theoretical framework of evidence-based chronic disease prevention (EBCDP) and establishment of EBCDP framework in China
SHI Jian-wei, XIAO Yue, GENG Jin-song.et al
2017, 33(11): 1548-1551. doi: 10.11847/zgggws2017-33-11-02
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Objective To establish a theoretical framework for evidence-based chronic disease prevention (EBCDP) for promoting EBCDP practice in public health practitioners in China.Methods We conducted literature review to systematically tease apart theoretical models proposed by international researches.Results All the models,including reach,effectiveness,adoption,implementation,and maintenance (RE-AIM) framework,diffusion of innovation theory,practical,robust implementation and sustainability model (PRISM),as well as Brownson's model,focus on the process and impact factors of the establishment of EBCDP framework.However,Brownson's model,as a forefront model,focuses on the process and impact factors of EBCDP from practitioners' point of view.Conclusion The theoretical framework of EBCDP plays an important role in promoting EBCDP practice and could be adopted to guide analyses on application and potential impact factors of evidence-based disease control projects.
Conditions for implementation of evidence-based chronic disease control and prevention in four countries:evaluation from individual and organizational perspective
WU Zhi-gui, TAN Xin-yu, TAN Du-xun.et al
2017, 33(11): 1560-1562. doi: 10.11847/zgggws2017-33-11-05
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Objective To compare the application of evidence-based chronic disease prevention and control in the United States,Australia,China,and Brazil,as well as the similarities and differences in its obstruction factors from individual and institutional aspects.Methods A total of 50 qualitative and semi-structured interviews were conducted in public health institutions of the four countries from February to July 2015,focusing on the status of evidence-based chronic disease prevention and control,individual and institutional resistance factors for practice and promotion of the evidence-based practices.Results The relevant databases were not well utilized in evidence-based practices in all the four countries studied.In developed countries,practitioners were subject to arduous work;while in developing countries,individuals were lack of evidence-based skills.On the institutional level,the lack of leadership and institutional support were the major constraints.In addition,the individuals' capacity and the institutions' ability to acquire aid were found to be important factors in promoting the implementation of evidence-based interventions.Conclusion More efforts should be made to provide diversified routes for acquiring evidence-based measures,to explore more individual and organizational resources,and to promote the implementation of organizational systems and cultures for promoting evidence-based chronic disease prevention and control in China.
Current situation and problems for evidence-based chronic disease prevention and control practice in China
SHI Jian-wei, GENG Jin-song, XIAO Yue.et al
2017, 33(11): 1545-1547. doi: 10.11847/zgggws2017-33-11-01
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Objective To examine successful experiences of evidence-based chronic disease prevention and control(EBCDP)in western countries for promoting EBCDP in China.Methods Published studies on the implementation of EBCDP in foreign countries and in China were systematically reviewed and analyzed comparatively.Results In the developed countries,much more evidences for efficient prevention and control of chronic diseases have been accumulated and the theoretical and empirical studies are focusing on practices and applications of EBCDP currently.While in China,the researches on practice and promotion of EBCDP are still lagging behind due to lacking theoretical guidance and intervention measure development.Conclusion Qualitative and quantitative exploration studies are warranted to analyze the status and influencing factors of EBCDP for promoting researches and implementations of EBCDP in China.
Status and prospect of utilization of mobile health applications in patients with chronic disease
ZHANG Hai-yu, ZOU Hai-ou
2017, 33(11): 1587-1590. doi: 10.11847/zgggws2017-33-11-12
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Objective With the advent of aging society,the number of patients with chronic diseases increased year by year.Chronic disease not only reduces the quality of life of the patients,leading to high mortality,but also brings greater economic burden to the society.Patients with chronic diseases need to reduce complications and improve health outcomes through long-term self-management,good treatment adherence,and positive change of bad habits.Mobile health applications (APP) can help patients improve self-management and adherence,and is gradually favored by medical personnel and patients.This paper summarizes the researches on four aspects:the application of mobile health APP,the implementation effects,deficiencies,and prospects of APP.
Sleep quality,depressive symptoms and their relationship among middle school students in Shenzhen city
ZHANG Sheng, LI Peng-sheng, PAN Si-yuan.et al
2017, 33(11): 1643-1646. doi: 10.11847/zgggws2017-33-11-26
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Objective To examine the status of sleep quality and the prevalence of depressive symptoms and to explore the correlation between sleep quality and depressive symptoms among middle school students in Shenzhen city.Methods Totally 3 168 students were randomly selected from 12 middle schools in Shenzhen city using a two-stage stratified cluster sampling and were surveyed anonymously with Pittsburgh Sleep Quality Index (PSQI) and Depression Self-Rating Scale for Children (DSRSC) between October 2015 and January 2016.Results The average total PSQI score of the students was 5.41±2.93 and 22.0% of the students were identified with poor sleep quality.The mean DSRSC score of the students was 8.39±6.09 and 17.0% of the students reported depressive symptoms.A positive correlation between total PSQI score and DSRSC score (r=0.443,P<0.001) was observed among the students.Conclusion Poor sleep quality and depressive symptoms are prevalent,to some degree,and the two disorders are positively correlated among middle school students in Shenzhen city.
Influence factors of hand,foot and mouth disease incidents among kindergarten children in Shenzhen city
HOU Wan-li, ZHAO Zhi-guang, FU Xia.et al
2017, 33(11): 1615-1619. doi: 10.11847/zgggws2017-33-11-19
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Objective To analyze influence factors of hand,foot and mouth disease (HFMD) among kindergarten children and to provide references for HFMD control and prevention.Methods A hand hygiene intervention was conducted in 18 kindergartens selected with stratefied random cluster sampling in Shenzhen city in 2015.The basic information of all the 8 275 children in the kindergartens were collected with a questionnaire survey and the HFMD incidents in the children were monitored from April to October in 2015.Results Among the kindergarten children,totally 122 HFMD cases were diagnosed,of which 9 children were recurrent cases,during the monitoring period.Single factor analysis showed that the HFMD incidence in the kindergarten children of intervention group was significantly lower than that in those of the control group (0.9% vs.2.5%,χ2=33.154; P<0.001); the incidence of HFMD showed a reverse correlation with the age among the children; and the children living in residential communities had a higher HFMD incidence than those in urban villages (1.7% vs.0.5%,χ2=14.019; P<0.001).Multivariate analysis showed that hand hygiene intervention could significantly reduce the HFMD incidence in the kindergarten children (odds ratio[OR]=0.404,95% confidence interval[95% CI]:0.272-0.601); the children at younger ages,with lower familial income,living in residential communities,and with guardians received higher education were more likely to have HFMD incidence.Conclusion The hand hygiene intervention could reduce HFMD risk in kindergarten children and HFMD incidence is manily influenced by age,family income,living area and guardian's education background in the children.
Effect of Ganoderma lucidum polysaccharide sulfate on scopolamine-induced learning and memory impairment in mice
LI Ya-wei, JIN Ying, LIANG Cheng-wu.et al
2017, 33(11): 1595-1598. doi: 10.11847/zgggws2017-33-11-14
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Objective To explore the effect of Ganoderma lucidum polysaccharides sulfate (GLPS) on learning and memory abilities of the mice with scopolamine-induced memory impairment and its mechanism.Methods Ganoderma lucidum polysaccharide (GLP) was modified by sulfation to obtain the GLPS.Fifty male Kunming mice were randomly divided into 5 groups:blank control,model control,positive control group (laci staw 100 mg/kg·d),GLP group (100 mg/kg·d),and GLPS group (100 mg/kg·d).The memory impairment mouse model was established with scopolamine.Learning ability of the mice was determined with step-down passive avoidance test.Acetylcholinesterase (AchE) was detected with kit method; the expression of nuclear factor-κB (NF-κB) p65 and cleaved caspase-3 in the hippocampus of the mice were measured with Western blot.Results Compared with those of the control group,the incubation period for jumping down from the platform was shortened and the number of error reaction decreased significantly for the model group.Compared with the model group,the GLP and GLPS showed significantly prolonged incubation period for jumping down from the platform and decreased number of error reaction (both P<0.05).The AChE activity of the model group (18.9±1.1 nmol/L) was obviously higher than that of the control group and the AChE activity of the GLP and GLPS group (17.1±0.8 and 15.0±0.6 nmol/L) decreased significantly compared with that of the model group (both P<0.05),with an obviously lower level in the GLPS group than that in the GLP group (P<0.05).Compared with those of the control group,the expressions of NF-κB p65 (0.83±0.04)and cleaved caspase-3 protein (0.55±0.04)in the hippocampus of the model group mice increased significantly (P<0.05); the expressions of NF-κB p65 (0.68±0.02)and cleaved caspase-3 protein (0.41±0.05)in the hippocampus of the GLPS group mice reduced significantly in comparison to those in the model mice (both P<0.05).Conclusion Ganoderma lucidum polysaccharides sulfate could significantly improve learning and memory ability of the mice with memory impairment and the mechanism of the effect may relate to the regulation of NF-kB signal transduction pathway.
Protectional effect of lutein on myocardial fibrosis in rats
ZHAO Li-jing, LI He, ZHAO Zong-ren.et al
2017, 33(11): 1603-1606. doi: 10.11847/zgggws2017-33-11-16
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Objective To explore the protective effect and mechanism of lutein on myocardial fibrosis induced by isopropyl adrenaline in rats.Methods Sixty Wistar rats (half male and half female) were divided into six groups randomly.All the rats were subcutaneously injected with isoproterenol (Iso) at the dose of 5 mg/kg/d for 7 consecutive days to establish myocardial fibrosis model,except for those of the normal control group.At the second day of Iso treatment,the rats of low-,moderate-,and high-lutein groups were gavaged with lutein at the dosages of 20,40,and 80 mg/kg/d and the rats of positive control group were gavaged with captopril (10 mg/kg/d);the rats of model and normal control group were given distilled water of same quantity for 28 consecutive days.By the end of last treatment,the heart weight index of the rats were calculated;Bl-420E+ biological function experiment system was adopted to detect the heart function,electrocardiogram,and exercise endurance of the rats;hydroxyproline (HYP),glutathione (GSH),and malondialdehyde (MDA) in myocardial tissues and serum superoxide dismutase (SOD) were measured;and myocardial pathological changes of the rats were observed with hematoxylin-eosin (HE) staining.Results Compared with the normal control rats,the model rats showed decreased exercise tolerance,significantly increased heart weight index (HWI) (3.73±0.58 mg/g) and left ventricular mass index (LVMI) (2.57±0.43 mg/g) (both P<0.01) and obviously increased heart rate.Significantly increased HYP (0.48±0.07 g/mg),MDA (2.37±0.84 nmol/mgpr),and GSH (55.19±2.08 U/mg)(P<0.05 for all) in myocardial tissues and significantly decreased serum SOD (512.17±26.48 U/ml) (P<0.01) were detected in the model rats.The increase of stroma components,distance enlargement between cell nucleus,large number of inflammatory cells,and fibrous hyperplasia complicated with myocardial hypotrophy were observed in myocardial tissues of the model rats.Compared with the model rats,the rats with high-dose lutein treatment exhibited increased exercise tolerance,significantly decreased HWI (3.02±0.28 mg/g)and LVMI (2.09±0.17 mg/g) (both P<0.01),remarkably decreased myocardial HYP (0.28±0.06 g/mg) and MDA (1.89±0.61 nmol/mgpr) (both P<0.05) and obviously increased myocardial GSH (72.70±0.05 U/mg) and serum SOD (571.19±15.58 U/ml) (both P<0.01).Minor increase of stroma components and fibrous hyperplasia but no inflammatory cell infiltration and hypotrophy were observed in myocardial tissues of the rats with high-dose lutein treatment.Conclusion Lutein presents certain protective effect on isopropyl adrenaline-induced myocardial fibrosis in rats and the mechanism of the effect may be related to the improvement of antioxidant ability.
Health literacy and its influencing factors among middle school students in Guiyang city
WANG Yan, WEN Jian, LIU Xiao-ping.et al
2017, 33(11): 1657-1661. doi: 10.11847/zgggws2017-33-11-30
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Objective To examine the status quo and influencing factors of health literacy among middle school students in Guiyang city.Methods Using multistage stratified cluster sampling,we conducted a survey on health literacy among 3 295 junior and senior high school students in two districts of Guiyang municipality during May 2015 with modified Health Literacy Questionnaire for Chinese Residents-2014 designed by China Health Education Center.SPSS 20.0 was used in data analyses.Results Of the students,only 5.5% showed adequate health literacy.The highest ratio of adequate health literacy was for basic health skills (30.0%) and the lowest was for basic health knowledge and attitude (4.6%) among the students.For the 6 health literacy related items,the highest correct answer ratio was for safety and first aid (47.8%),while the lowest was for chronic disease prevention and control (10.4%).The results of univariate χ2 test showed that residential region,with local registered residence,being only one child,whether having health lectures in school,parental education level,self-rated academic achievement,and the grade were significant impact factors of health literacy (P<0.01 for all); multivariate logistic analysis revealed that the health literacy of the students was influenced by residential region,parental education level,self-rated academic achievement,whether having health lectures in school,and grade.Conclusion The health literacy is at a low level and the level is mainly influenced by parental education level,academic achievement,study grade,and whether having health related lectures in school among middle school students in Guiyang city.
DEHP-induced testicular oxidative stress and down-regulated serum testosterone in rats
YANG Min, WEI Li, LIU Chang-jiang
2017, 33(11): 1599-1602. doi: 10.11847/zgggws2017-33-11-15
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Objective To explore effects and potential mechanisms of di-(2-ethylhexyl) phthalate (DEHP) on testes and sex hormones in pubertal male rats.Methods Twenty-four 18-day-old male Sprague-Dawley rats were randomly divided into 4 groups (control,low-,moderate-,and high-dose groups,6 rats in each group) by weight.The rats of dose groups were gavaged with DEHP at doses of 250,500,750 mg/kg/d for 30 days.All rats were sacrificed by decapitation at the end of the treatments.Serum samples were collected and reproductive organs were removed and weighted.Serum testosterone (T),luteinizing hormone (LH),follicle-stimulating hormone (FSH),gonadotropin releasing hormone (GnRH),and 5α-dihydrotestosterone (5α-DHT) levels and testicular glutathione peroxidase (GSH-Px),superoxide dismutase (SOD),malondialdehyde (MDA),and 5α-reductase 2 (5α-R2) levels were measured.Results In the rats exposed to DEHP,the testis index and epididymis index were decreased.Tubular lumina shrinking,structure collapse,breaks of cell membranes,and disordered cell arrangement of seminiferous tubules were observed in the DEHP-treated rats.Levels of T (115.04±14.21 pg/mL) and LH (23.42±3.12 mIU/mL) in the high-dose group were significantly declined compared with those of the control.In moderate-and high-dose groups,FSH levels (5.49±0.42 and 4.63±0.51 IU/L) were significantly lower (P<0.05) than those of the control.Moreover,significantly decreased GSH-Px (728.3±95.3 U/mg pro) and SOD (835.8±151.2 U/mg pro) activities in rat testis were also detected in the high-dose group;on the contrary,MDA level (79.6±13.9 and 90.6±4.0 nmol/mg pro) and 5α-R2 activity (415.9±112.7 and 415.9±147.8 IU/mg pro) in the moderate-and high-dose groups were significantly higher than those of the control (P<0.05 for all).Conclusion After exposure to DEHP,oxidative stress occurred in the testis and serum testosterone level was down-regulated via inducing decreased activity of 5α-reductase 2.
Safe utilization of food packaging material and its influence factors among consumers in Guangzhou city
YANG Zhen-yuan, WU Pei-cong, YE Wei-yun.et al
2017, 33(11): 1650-1653. doi: 10.11847/zgggws2017-33-11-28
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Objective To investigate behaviors of safe utilization of food packaging material and its influence factors among consumers in Guangzhou city.Methods A anonymous questionnaire survey was conducted among 1 300 consumers recruited in 25 supermarkets located in 5 districts of Guangzhou city.SPSS 19.0 was used in data analysis.Results For the 1 154 participants with valid information,the scores of safe utilization of food packaging material ranged between 4 and 19 on a scale of 21 as the maximum and the scores at 25%,50%,and 75% quantile were 8,10,and 12,with only 19.3% of the participants had the scores of 13 or above.The proportions of the participants with basic or adequate knowledge about using materials specific for food packaging,suitable materials for heating with microwave oven,and reasonable reuse of food packaging materials based on their characteristics were 32.6%,53.9%,and 21.6%,respectively.The scores of the participants significantly differed by gender (Z=-3.279,P=0.001),age (χ2=50.593,P<0.001),education (χ2=42.093,P<0.001),and familial income (χ2=110.864,P<0.001).There were positive correlations between the score and the concern about the safety of food packaging material (r=0.429),the knowledge level about the requirement on the characteristics of material used for food packaging (r=0.358),the knowledge level about food packaging (r=0.190),and the intension to acquire information on food packaging material (r=0.273) (P<0.001 for all).All the variables were of significance when included in the multivariate logistic regression equation (all P<0.05),except for education.Conclusion Discretionary and unsafe utilization of food packaging material are prevalent among consumers in Guangzhou city,suggesting that education on safety utilization of food packaging material in daily life needs to be strengthened in the population.
Impacts of metal elements on oxidative stress and A protein deposition in SH-SY5Y cells
ZHU Jing-li, WU Yue, LU Zhao-shuo.et al
2017, 33(11): 1591-1594. doi: 10.11847/zgggws2017-33-11-13
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Objective To study the effects of copper (Cu),iron (Fe),zinc (Zn),and aluminum (Al) exposure on oxidative stress and beta amyloid (Aβ) protein deposition in human neuroblastoma cell line (SH-SY5Y) and to provide evidences for senile dementia prevention.Methods SH-SY5Y cells were treated with various doses of Cu,Fe,Zn,and Al,respectively.The viability of the cells was determined with 3-[4,5-dimedthylthiazol]-2,5-diphenyltetrazolium bromide (MTT) assay.The activity of superoxide dismutase (SOD) in cultured SH-SY5Y cells was detected with xanthine oxidase method;the activity of glutathione peroxidase (GSH-PX) was measured with colorimetry;the content of malondialdehyde (MDA) in culture supematant fluid was assessed with thiobituric acid reaction (TBA) method.Cellular reactive oxygen species (ROS) level was detected using fluorescent probe of 2',7'-dichlorofluorescein diacetate (DCFH-DA).The content of Aβ1-42 was measured by enzyme-linked immunosorbent assay (ELISA).Results Cu,Fe,Zn,and Al could suppress the viability of SH-SY5Y cells in a concentration-dependent manner.When treated with copper sulfate (CuSO4) at the dosages of 50,200,and 400 μmol/L,the survival rates of the SH-SY5Y cells were 90.47%,74.81%,and 64.97%;at the dosages of 1,2,and 4 mmol/L,the survival rates of the SH-SY5Y cells were 93.08%,78.28%,and 56.10% when exposed to ferrous sulfate (FeSO4) and 2.21%,85.30%,and 62.72% when exposed to aluminum chloride (AlCl3);the survival rates of the the SH-SY5Y cells were 91.76%,76.51%,and 61.27% when treated with zinc sulfate (ZnSO4) at the dosages of 50,100,and 200 μmol/L,respectively.The survival rates of the SH-SY5Y cells exposed to various concentrations of the four metallic compounds were all significantly lower than that of the blank control group (P<0.05 for all).When treated with the four metallic compounds,the intracellular activity of SOD decreased but the intracellular ROS increased significantly;the activity of GSH-PX declined but the content of MDA and Aβ1-42 increased significantly in culture supematant fluid compared to those of the control (all P<0.05).Conclusion Copper,iron,zinc,and aluminum compounds could induce damage in SH-SY5Y cells and result in deposition of Aβ protein by ROS generation and oxidative stress pathway.
Influencing factors of prognosis among HBV-related HCC patients with radical resection:a Cox regression analysis
ZHANG Hao-yang, CAO Yi, XU Yue.et al
2017, 33(11): 1646-1649. doi: 10.11847/zgggws2017-33-11-27
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Objective To explore influencing factors of prognosis for hepatitis B virus (HBV)-related hepatocellular carcinoma (HCC) patients after radical resection and to provide references for improving life quality of the patients.Methods We enrolled 426 HCC patients with radical resection from December 2003 through 2012 and conducted telephone follow-up every 2-4 months to collect relevant information.R 3.1.2 was used in univariate and multivariate Cox regression to analyze the influencing factors of survival among the patients.Results The mean survival time of the patient was 42.06±26.75 months and the 1-,2-,3-,4-,and 5-year survival rate were 86.15%,73.71%,66.67%,61.27%,and 58.92% among the patients,respectively.Multivariate Cox regression analysis showed that the risk factors of the survival of the patients included vascular invasion,with a B Child-Pugh grade,α-fetoprotein (AFP) >400 ng/mL,high expression of topoisomerase Ⅱα (TopoⅡα),and alcohol consumption,while the protective factors included tumor encapsulation and Edmonson grade I.Conclusion Vascular invasion,Child-Pugh grade,AFP,TopoⅡα expression,alcohol consumption,tumor encapsulation,Edmonson grade could affect the prognosis of HBV-related HCC patients after radical resection.
Effects of work-related factors on anorectal diseases in adult residents in China
CHEN Ping, HAN Bao, ZHOU Lu.et al
2017, 33(11): 1628-1631. doi: 10.11847/zgggws2017-33-11-22
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Objective To investigate effects of work-related factors on anorectal diseases and to provide evidences for targeted prevention and treatment of anorectal diseases.Methods Multistage cluster random sampling was adopted to recruit 68 906 urban and rural residents aged ≥ 18 years from all provinces,municipalities,and autonomous regions,except for Hong Kong and Macao Special Administrative Region,in China.We collected relevant data by means of face-to-face questionnaire survey and anorectal examination from March to December 2013,and analyzed the effects of work-related factors on prevalence of anorectal diseases.Results The prevalence of anorectal diseases was 50.10% among the residents and the prevalence of urban residents (51.14%)was higher than that of rural residents (48.39%).The top five prevalent anorectal diseases among the residents were hemorrhoids,anal fissure,anal eczema,anal fistula,and rectal prolapse,with the prevalences of 49.14%,0.18%,0.14%,0.10%,and 0.02%,respectively.Of all identified anorectal disease cases,98.09% were hemorrhoids patients.The residents with the experience of working in hot and humid environment had an obviously higher anorectal disease prevalence compared to those working in normal or comfortable environment and the prevalence was positively related to the intensity of weight bearing in occupational activity.The occupations with top three anorectal disease prevalence were drivers (69.49%),teachers (57.17%),and business/service workers (56.65%) in the urban residents and drivers (62.81%),professional and technical personnel (61.96%),and teachers (55.56%) in the rural residents,respectively.Conclusion The prevalence of anorectal diseases is still at a high level among Chinese residents;the residents with occupations involved hot and humid working environment,weight bearing,and longtime sitting or standing are populations at a high risk of anorectal diseases and specific preventive measures should be promoted among the people.
Life events and suicide risk:mediation role of reasons for life and mindfulness adjustment
YU Hong-su, ZHAO Jiu-bo, ZHANG Xiao-yuan
2017, 33(11): 1624-1627. doi: 10.11847/zgggws2017-33-11-21
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Objective To explore the mediating role of reasons for life on the relationship between life events and suicidal behavior and the mediating effect of mindfulness on the association between reasons for life and suicidal behaviors.Methods Totally 2 494 freshmen were recruited from a college in Guangzhou city with cluster sampling and surveyed with the Adolescent Self-Rating Life Events Check List (ASLEC),Reasons for Living Inventory for Adolescents (RFL-A),Five Facet Mindfulness Questionnaire (FFMQ),and Suicidal Behaviors Questionnaire-Revised (SBQ-R) in December 2013.Results Among the freshmen,the average scores were 33.25±6.58 for life events (ASLEC),4.78±2.10 for suicidal behavior (SBQ-R),162.71±18.72 for reasons for life (RFL-A),and 123.63±12.41 for mindfulness (FFMQ),respectively.The life events score was positively correlated with suicidal behaviors score (r=0.32,P<0.05)and reversely correlated with reasons for living score (r=-0.16,P<0.05);reasons for living score was reversely correlated with suicidal behavior score (r=-0.32,P<0.05).A well-fitted structure equation model including variables of life events,reasons for living,and suicidal behaviors was constructed and the model revealed a significant mediating role of reasons for life on the relationship between life events and suicidal behavior,with the test statistics of χ2=665.54,df=96,root mean square error of approximation (RMSEA)=0.05,comparative fit index (CFI)=0.96,incremental fit index (IFI)=0.96,normed fit index (NFI)=0.95,and relative fitness index (RFI)=0.93,respectively.The product term of the score of standardized reasons for life and the score of mindfulness was positively correlated with suicidal behaviors score (r=0.76),indicating a significant mediating effect of mindfulness on the association between reasons for life and suicidal behavior.Conclusion There are close relationships among life events,reasons for life,mindfulness and suicidal behaviors;the association of suicidal behaviors with life events may be mediated by reasons for life and that with reasons for live may be moderated by mindfulness.
Willingness-to-participate in medical insurance and its influencing factors among residents in Shandong province after integration of urban and rural medical insurance systems
SUN Qian, ZHAO Ming-yue, YIN Ai-tian
2017, 33(11): 1639-1642. doi: 10.11847/zgggws2017-33-11-25
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Objective To investigate the willingness-to-participate in medical insurance and its influencing factors among urban and rural residents.Methods Stratified random sampling was used to recruit 1 160 residents from 5 municipalities in Shandong province for a household face-to-face questionnaire survey on willingness and relevant factors for participating in medical insurance during September 2015.Chi-square test and logistic regression model were applied in data analyses.Results Of the residents,80.7% reported the willingness to participate in urban and rural medical insurance system and 19.3% did not report the willingness; 73.6% expressed their satisfaction about current medical insurance system while 13.7% were not satisfied with the system; 42.4% did not present the understanding to the current medical insurance system and only 26.3% showed the understanding to the system.The results of multivariate logistic regression revealed that main hindering factors for the willingness to participated in the medical insurance system included dissatisfaction to the system (odds ratio[OR]=2.967) and with poor understanding of the system (OR=2.332) and main promoting factors included the education level of high school (OR=0.336) or college and above (OR=0.325),with the annual family income of 10 000-24 999 RMB yuan (OR=0.578),25 000-39 999 (OR=0.473), ≥ 40 000 (OR=0.448),and residing in Zibo city (OR=0.454) or Jining city (OR=0.475) (all P<0.05).Conclusion Special attention should be paid to the need of medical insurance among the residents with various familial income and the systemic rationality of the integration of urban and rural medical insurance to promote the residents' willingness to participate in the medical insurance system.
Awareness rate of core knowledge on leprosy among close contacts of leprosy patients in Guizhou province
YANG Li-li, LI Jin-lan, LIU Jie.et al
2017, 33(11): 1611-1614. doi: 10.11847/zgggws2017-33-11-18
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Objective To examine the awareness of core knowledge about leprosy among close contacts of leprosy patients in Guizhou province and to provide a basis for future development of health education on leprosy in the province.Methods A household survey was carried out among close contacts of surviving leprosy patients registered between January 1st,2005 and December 31st,2013 in Guizhou province with a questionnaire about the awareness of core knowledge for leprosy.Results Among the 5 497 participants,4 275 gave correct answers to 5 or more questions about core knowledge of leprosy,with an awareness rate of 77.77%;the correct rates for answers to every single question relevant to the core knowledge on leprosy ranged between 70.00% and 84.00%.The proportions of the participants acquiring core knowledge of leprosy from promotional materials,family members/friends/colleagues,and consultation with doctors were 47.88%(2 562),46.72%(2 500),and 44.70%(2 392),respectively.Gender,age and educational level had influences on the level of the awareness among the participants,and the female participants,those aged 13-20 years and more than 60 years old,and being illiteracy or with the education of primary school had a lower awareness rate.Conclusion The awareness rate of core knowledge on leprosy is relatively high among close contacts of leprosy patients in Guizhou province and the situation may be concerned in health education on leprosy.
Prevalence and impact factors of disability among elderly people in rural China
ZHOU Xu-feng, MA Ya-na
2017, 33(11): 1665-1668. doi: 10.11847/zgggws2017-33-11-32
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Objective To reveal features of disability and its impact factors among the elderly in rural China.Methods The data of China Health and Retirement Longitudinal Study (CHARLS) collected in 2013 were used and the data on the elderly of 60 years and older in rural China were analyzed.The activity of daily living (ADL) and the disability of the rural elderly were assessed with Katz Index Scale.Logistic regression was applied to analyze the influencing factors of disability.Results Valid information for a total of 7 629 rural elderly were extracted from the datasets of CHARLS and 668 of them were identified as disability and the disability prevalence was 8.8%.The highest observed prevalence rate of disability (5.8%) was for bathing activity and the lowest (1.2%) was for eating activity.The results of logistic regression analysis showed that main risk factors for disability were aged ≥ 80 years (odds ratio[OR]=4.186,95% confidence interval[CI]:3.364-5.210),low income (OR=2.689,95% CI:1.832-3.947),suffering from 3 or more chronic diseases (OR=2.301,95% CI:1.827-2.897),poor sleeping quality (OR=1.727,95% CI:1.384-2.155),and poor mental health (OR=2.511,95% CI:1.962-3.214)and a protective factor was drinking alcohol once or more per month (OR=0.530,95% CI:0,417-0.675) among the elderly.Conclusion The prevalence of disability was high among rural elderly in China and intervention measures should be promoted among the population.
Prevalence and influencing factors of chronic diseases among elderly empty nesters in Nanjing city
HE Ting-ting, CHAO Jian-qian, GU Jia-yi.et al
2017, 33(11): 1571-1575. doi: 10.11847/zgggws2017-33-11-08
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Objective To investigate the prevalence of chronic diseases and its affecting factors among the elderly empty nesters in Nanjing city.Methods From April 2013 to March 2014,a self-designed questionnaire was used to survey 1 121 empty nesters aged ≥ 60 years recruited from communities of Nanjing city with random cluster sampling.Results The self-reported prevalence rate of chronic diseases among the elderly empty nesters was 71.0%,with the top five most prevalent chronic diseases of hypertension (48.3%),diabetes (16.8%),coronary heart (10.3%),cataract (9.2%),and hyperlipaemia (5.6%).At the ages of 70-79 years,living alone,with high frequency of taking high-fat and pickled food per week,overweight and obesity,and with less number of walking steps per week were risk factors of chronic diseases among the elderly empty nesters.The results of the self-health assessment showed that there were statistical differences in body function,daily self-care activity,and emotional personality between the elderly empty nesters with and without chronic diseases (all P<0.05).Conclusion The prevalence of chronic diseases is high and suffering from chronic disease is one of major influence factors of quality of life among the elderly empty nesters in Nanjing city.
Professional knowledge and skills among public health workers in township hospitals in central and western China
FU Qian, HE Zhi-fei, MING Hui.et al
2017, 33(11): 1635-1639. doi: 10.11847/zgggws2017-33-11-24
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Objective To examine current situation of professional knowledge and skills among public health workers in township hospitals in central and western China and to provide references for conducting occupational education.Methods With multistage random cluster sampling,273 public health workers in township hospitals in Chongqing municipality and Guizhou,Hubei and Henan province were enrolled and surveyed with a self-designed questionnaire for assessment of public health knowledge and skill.Results For all the participants,the average overall score for basic knowledge and skills was 7.20±1.38 for a scale of 10 as the maximum; the average degree of key knowledge and skill proficiency was 0.65±0.13.Among the participants,the proportions of answering questions on public health service correctly were high for the items of identifying the constitution of traditional Chinese medicine (100%),principles of on site first aid (100%),measures of omphalitis prevention (98.59%),and management of an epidemic site (97.56%); while the proportions were low for the items of cognitive function screening (7.29%),health guidance for neonates (12.68%),detection of dorsalis pedis artery pulse (13.48%),and motor function checkup (17.05%).Conclusion The professional knowledge and skills are generally poor among the public health workers in township hospitals in central and western China,suggesting that professional training programs for the medical workers should be promoted.
Related factors of high risk sexual behaviors among amphetamine-type stimulant addicts
HAN Hui, WANG Shan-shan, SU Hang.et al
2017, 33(11): 1631-1634. doi: 10.11847/zgggws2017-33-11-23
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Objective To explore related factors of high risk sexual behaviors among amphetamine-type stimulant (ATS) addicts and to provide evidences for future intervention.Methods Totally 1 677 ATS addicts in Shanghai Compulsory Isolated Detoxification Center were recruited and divided into a high risk group (697 with two or more sexual partners during recent one year and never using condom in sexual activity during recent one month)and a non-risk group (980);all the participants were surveyed with a questionnaire on demographic characteristics and drug use history and Barratt Impulsiveness Scale (BIS-Ⅱ) between August 2013 and December 2014.Logistic regression analysis was used to assess discrepant variables between the two groups.Results The participants being male gender (odds ratio[OR]=1.934,95% confidence interval[CI]:1.484-2.521),with multiple drug use (OR=1.773,95% CI:1.302-2.414),having first sexual behavior at early age (OR=1.791,95% CI:1.426-2.250),with long-term ATS use (OR=1.478,95% CI:1.197-2.826),and with a high impulsivity score (OR=1.382,95% CI:1.120-2.707)were more likely to have high risk sexual activity.Conclusion The influence factors of high-risk sexual behavior are relatively complex among amphetamine-type stimulant addicts,suggesting specific intervention strategies should be developed to reduce high-risk sexual activities among the population.
Awareness of key knowledge about tuberculosis and its major influencing factors among general population in Zhejiang province
ZHANG Ming-wu, CEHN Song-hua, ZHONG Jie-ming.et al
2017, 33(11): 1607-1611. doi: 10.11847/zgggws2017-33-11-17
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Objective To explore the awareness status of knowledge about tuberculosis (TB) and its influencing factors among general population in Zhejiang province.Methods We conducted a household questionnaire survey on 5 items of core knowledge about TB among 6 532 urban and rural residents aged 12-65 years selected with stratified random sampling from 11 counties or districts in 11 municipalities in Zhejiang province between May and August 2014.SPSS 13.0 was adopted in data analysis.Results The average score for key knowledge about TB was 2.22±1.54 among all the participants and the scores were 2.41±1.53,2.49±1.45,2.49±1.51,2.33±1.57,2.07±1.52,and 1.95±1.49 for the participants aged 12-19,20-29,30-39,40-49,50-59,60-65 years,respectively,with a significant difference (F=21.820,P<0.001).The score differed among the participants by education level (the lowest[1.54±1.45]among the illiteracy or semi-illiteracy participants and the highest[3.02±1.32]among the participants with college education[F=105.529,P<0.001]) and occupation (the highest[4.02±1.00]for medical workers and the lowest[1.89±1.43]for the unemployed[F=26.950,P<0.001]).The results of multivariate analyses revealed that the knowledge level was positively related to education level of the participants and the knowledge level was also influenced by familial income and occupation of the participants.The awareness rate was impacted by the ways of acquiring TB-related information,including newspaper,leaflet,television,bulletin board,and other active acquirement methods.Conclusion The awareness rate of key knowledge about TB is poor and mainly influenced by education,occupation,and ways of acquiring related information among general population in Zhejiang province.
Cross-level moderate effects of group identification on relationship between personality and sub-health symptoms in teachers
WANG Hao, ZHANG Jian-xin, ZHOU Ming-jie
2017, 33(11): 1619-1623. doi: 10.11847/zgggws2017-33-11-20
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Objective To explore moderate effects of group identification on the relationship between personality and sub-health symptoms in teachers.Methods Totally 2 100 teachers were selected with stratified random cluster sampling from 22 primary and high schools in 15 municipalities of 7 provinces and investigated using Big Five Inventory,Sub-Health State Comprehensive Assessment Questionnaire,and Group Identification Scale.Results The average score of sub-health symptoms was 49.81±9.83 for the teachers;no significant between-gender difference (F=0.23,P>0.05) but significant between-age difference (F=4.104,P<0.01) in the score were observed and age was a positive predictor for sub-health symptoms (β=0.205,P<0.001).Among the teachers,the average conscientiousness score was 3.57±0.54 and it negatively predicted the sub-health symptoms (β=-3.572,P<0.001);the average extraversion score was 3.31±0.57 and it negatively predicted the sub-health symptoms (β=-2.557,P<0.001);the average neuroticism score was 2.66±0.61 and it positively predicted the sub-health symptoms (β=6.867,P<0.001);the teachers' average group identity score was 10.71±2.79.Hierarchical liner model analyses showed that there was an interactive effect between group identity and neuroticism on sub-health symptoms (β=-1.344,P<0.05).Conclusion Age and personality traits may be risk factors of sub-health status and group level identity could alleviate negative effect of neuroticism trait on sub-health symptoms among primary and high school teachers.
Cognition and demand on mobile medical application among urban residents of Lanzhou city
ZHOU Shuang-shuang, MA Li-yang, XING Long.et al
2017, 33(11): 1662-1664. doi: 10.11847/zgggws2017-33-11-31
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Objective To examine the status quo of cognition and demand on mobile medical application (APP) among urban residents in Lanzhou city of Gansu province for the development and improvement of the mobile medical APP.Methods A self-administered questionnaire survey was carried out among 816 adult urban residents selected with stratified random cluster sampling in Lanzhou city between July and August 2015.Results The awareness rate of mobile medical APP was very low among the participants,with the ratios of 16.4% and 13.5% of the participants correctly answering the two questions on the characteristics of mobile medical APP and the items of medical service provided by mobile medical APP.The middle-aged and elderly participants (≥ 45 years old)showed a significantly lower awareness about mobile medical APP and utilization ratios of the three APP items (‘a doctor like a friend in need’,‘asking a doctor in time’,and ‘a good doctor’) than the young participants (<45 years old)(P<0.05 for all).The ratios of the participants reporting the willingness to utilize mobile medical APP for seeking medication,making an appointment with a doctor,and buying pharmaceutical product were of 38.8%,38.9%,and 35.6%,respectively,with the lower ratios among the middle-aged and elderly participants than among the young participants (P<0.05 for all).Conclusion The awareness rate and utilization rate of mobile medical application are low among adult urban residents in Lanzhou city and related education programs need to be promoted with a great effort among the residents.
Birth defects among perinatal infants in Guangdong province,2006-2015
LUO Can, XU Hao-li, CHEN Ting-ting.et al
2017, 33(11): 1669-1672. doi: 10.11847/zgggws2017-33-11-33
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Objective To explore prevalence trend and associated factors of birth defect among perinatal infants in Guangdong province between 2006 and 2015,and to provide evidences for developing and evaluating birth defect intervention program.Methods Surveillance data on birth defect from 2006 through 2015 in Guangdong province were collected for retrospective description and trend analysis.Results The total incidence of birth defects among perinatal infants was 276.80/10 000 (26 040/2 024 583) during the 10-year period;the incidence was higher than that in other provinces and showed an increasing trend (Z=1.99,P=0.04).Significant difference in the incidence was observed between male and female perinatal infants (33 629 males,21 976 females,435 unknown gender,χ2=758.24;P<0.001),among the puerperas of different age (P<0.01),and between puerperas living in urban and rural regions (26 896 in cities or towns,28 981 in villages,χ2=35.30;P<0.001).The top five birth defects with high incidence in Guangdong province were congenital heart disease,glucose-6-phosphate dehydrogenase deficiency,hydrops fetalis syndrome,polydactyly,and club foot,which was replaced by syndactly in 2015.Conclusion The registered birth defect incidence was high and comprehensive prevention measures are warranted in Guangdong province.
Chronic disease management approaches in various countries and design of China's integrated chronic disease management model
LÜ Lan-ting, LIU Fang
2017, 33(11): 1578-1583. doi: 10.11847/zgggws2017-33-11-10
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We summarize five internationally recognized chronic disease management approaches and their typical implementation in five countries,based on a 3-aspects (provider,patient,and insurer) analysis framework.We then propose to construct an "integrated" chronic disease management model in China:specifying explicit targeting population,formulating grassroots-centered care pathways and national management standards,appointing dedicated individual to strengthen the cooperation among required services providers at difference tiers and of various disciplines,improving chronic disease management practice by means of incentives such as additional payment from insurance schemes and financial support,promoting the use of performance management to improve care quality,and exploring systematic supporting methods to drive the implementation of chronic disease management.
Prevalence of common chronic diseases and its influences on health-related quality of life among general population aged 15 years and over in China
JIA Xin-xin, XU Ling, ZHANG Yao-guang.et al
2017, 33(11): 1567-1570. doi: 10.11847/zgggws2017-33-11-07
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Objective To explore the prevalence of common chronic diseases and its influences on health-related quality of life (HRQoL) among general population aged 15 years and over in China,and to provide evidence-based references for chronic disease intervention and prevention and the allocation of health resources.Methods Data were obtained from the Fifth National Health Service Survey (NHSS) organized by Center for Health Statistics and Information of National Health and Family Planning Commission conducted in 2013.The prevalence of chronic disease among Chinese population aged 15 and over was analyzed and 10 common chronic diseases were selected according to the prevalence ranking of the diseases.A cumulated synthetic index derived by Sun for HRQoL was generated using European Quality of Life-5 Dimensions (EQ-5D).The HRQoL of patients with different chronic diseases were compared;the losses of quality of life due to chronic diseases were evaluated and then the quality-adjusted life year (QALY) losses and economic loss were estimated accordingly.Results The overall prevalence of chronic diseases among the population aged 15 years and over was 33.0%(30.9% and 34.9% for the males and the females);the top ten chronic diseases with higher prevalence were hypertension,diabetes,intervertebral disc disease,other skeletal and muscular system diseases,cerebrovascular disease,acute and chronic gastroenteritis,other heart diseases,arthritis,other ischemic heart diseases,and chronic obstructive pulmonary diseases (COPD) and the ten chronic diseases accounted for 79.7% of all of the patients (75 866) identified.The results of multivariate linear regression revealed that chronic disease was associated with HRQoL loss of different degrees among the patients after adjusting for age and gender.The chronic disease-related synthetic index for HRQoL loss in a descending order was 0.122 for cerebrovascular disease,0.102 for other skeletal and muscular system diseases,0.101 for arthritis,0.084 for hypertension,0.084 for intervertebral disc disease,0.048 for COPD,0.043 for acute and chronic gastroenteritis,0.040 for other heart diseases,0.040 for other ischemic heart diseases,and 0.036 for diabetes (P<0.001 for all).The estimated total annual QALY loss due to the prevalence of the top 10 chronic diseases was 16 655 592 years and the estimated total annual economic loss was about 6 980 025 591 Yuan RMB in 2013.Conclusion The prevalence of chronic disease is relatively high and results in the loss of quality of life,heavy disease burden and economic loss among Chinese adult population,suggesting that intervention on major chronic diseases should be promoted in the population.
Prediction of demand for health human resources in rural Gansu province
LIU Yu, LI Xiu-xia, GU Wen-jing.et al
2017, 33(11): 1654-1657. doi: 10.11847/zgggws2017-33-11-29
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Objective To predict the demand for health human resources in rural areas of Gansu province between 2012 and 2020 and to provide a reference for regional health workforce planning.Methods Baseline data on the rural population and the number of medical personnel in Gansu province (Gansu) between 2003 and 2011 were collected and then the demand and deficit of medical personnel during the period between 2012 and 2020 were predicted using manpower/population ratio method.Results The average annual increase rates of licensed practicing (assistant) doctor and registered nurse were 1.74% and 5.27% between 2003 and 2011.The predicted numbers of licensed practicing (assistant) doctor and registered nurse in rural areas of Gansu would be 23 810 and 21 763 in 2020.Compared with the requirements of "The Medium and Long Term Planning for Medical Talent Development in Gansu Province (2011-2020)",the deficits in the numbers of licensed practicing (assistant) doctor and registered nurse are 15 253 and 36 645,respectively.Conclusion The number of medical personnel in rural Gansu will increase yearly between 2012 and 2020 and the deficit in the number required would decrease but remain.