mHealth as a health system strengthening tool in China

Over the past 70 years,there was a rapid epidemiological transition in disease burden in China,from infectious disease to non-communicable diseases(NCDs),which requires long-term prevention and management.Rapid growth in mobile phone use,internet connectivity and digital health technology,presents new opportunities for improvement in NCD healthcare delivery and population-based outcomes.Although there were a growing number of research to evaluate the feasibility and effectiveness of the mobile health(mHealth)interventions for NCD management,the extent to which mHealth contributes towards the health system strengthening in China remains unknown.In this paper,we provided a high-level overview of mHealth in China and its role for Chinese health system strengthening.We conclude with several recommendations for the future of mHealth research in China based on existing evidence identified.

Barriers to nurse-patient communication in primary healthcare centers in Bahrain:Patient perspective

Objectives:Effective and efficient communication is a core element in healthcare systems,especially between healthcare providers and patients.This study aimed to identify communication barriers be-tween nurses and patients in primary healthcare centers in Bahrain.Methods:This is a cross-sectional study conducted across primary healthcare centers in Bahrain.Four hundred and two patients were recruited using convenience sampling.A self-administered question-naire comprising 29 items on communication barriers was used.Results:A total of 402 patients consented to participate.The majority of participants reported the following statements had large effects on communication:“shortage in the number of nurses compared to the large number of patients”(254/401,63.3%),“lack of desire of nurse to communicate with patients”(246/402,61.2%),and“negative attitude of the nurse toward the patient”(238/401,59.4%).Further,“difference in language between nurses and patients,”“lack of self-confidence by nurses,”and“nurses overwhelmed by work”were ranked as top three statements with a significant influence on commu-nication between nurses and patients.Conclusions:Communication between healthcare providers and patients is pivotal for an optimal healthcare service.Based on the findings of this study and the literature,we recommend formal training of health care workers in improving communication skills and including this not only in medical cur-riculum but also in the form of continuing medical education(CMEs)1.

Self-care:A concept analysis

Objectives:There is extensive literature from various disciplines on self-care,an important aspect of nursing intervention via evaluation and education,but its meaning remains unprecise due to the difficulty integrating the diverse definitions developed over time across disciplines.Therefore,it is vital to clarify the meaning of self-care and formulate the defining attributes,antecedents,and consequences to self-care.Methods:Walker and Avant’s concept analysis approach was used to analyze the concept of self-care.A search of the literature was completed using the databases CINAHL,PubMed,and EBSCOhost for years 1975e2020;literature search included peer-review articles,full-text publications,and available in English.A total of 31 articles were reviewed,and saturation was reached.Results:An extensive review of the literature revealed salient characteristics that reflected the most frequently used terms associated with the concept.Guided byWalker and Avant’s method,three defining attributes emerged as common themes:awareness,self-control,and self-reliance.Conclusions:A clarified definition was identified:the ability to care for oneself through awareness,selfcontrol,and self-reliance in order to achieve,maintain,or promote optimal health and well-being.

Perceptions of the effectiveness of Advanced Practice Nurses on a neurosurgery unit in a Canadian Tertiary Care Centre:A pre-and-post implementation design

Objectives:A framework for the advanced practice nurse(APN)role was developed in our Canadian Tertiary Care Centre,delineating five domains of advanced nursing practice:clinical practice,consultation,research,education and leadership.The goal of this study was to evaluate perceptions of the effectiveness of the implementation of an innovative APN role on an in-patient Neurosurgery unit.Methods:A pre-and-post implementation design,incorporating both qualitative and quantitative data,was utilized.An innovative APN role was implemented within the Neurosurgery program focusing on the clinical domain and required the successful candidates to be NP prepared.This APN role was designed to improve patient flow,documentation,communication and patient and staff satisfaction.Three primary outcomes were measured:pre-implementation questionnaire(nurses),post-implementation questionnaire(nurses and residents)and number of pages to the on-call resident.Results:Survey scores by nurses and residents indicated improvement across all aspects studied.Average scores increased from 1.1 to 2.6,reflecting an overall statistically significant increase.The number of pages to the on-call resident also showed a decrease.Conclusion:Perceptions of patient care delivery and professional collaboration improved following implementation of the APN role.Responses indicated that APNs significantly impacted patient care and improved nurses and residents'job satisfaction.

Applying the ADDIE—Analysis, Design, Development, Implementation and Evaluation—Instructional Design Model to Continuing Professional Development for Primary Care Physicians in Saudi Arabia

Background: As professionals, family physicians are obliged to remain current on advances and trends in medicine and health care delivery. This is usually achieved through engagement in continuing professional development. Instructional design is a systematic method of development of education and training programs for improved learner performance. ADDIE is an instructional systems design model for building effective education and training in five phases: analysis, design, development, implementation and evaluation. Purpose: The purpose of this study was to introduce a professional development program for primary care physicians using the ADDIE instructional design model. Methods: Program requirements were defined using a needs assessment questionnaire and consultation observations. Interactive sessions were designed and developed based on the analysis results. The sessions were evaluated with interim and final feedback forms, a final problem-based questionnaire, a self-assessment questionnaire, and focus groups. Results: Scores on the final knowledge assessment were lower than expected. However, at least 50% of participants self-reported their learning improvement as “great” for 16 out of 23 topics. Focus group feedback was generally positive but also identified areas for improvement. Conclusion: Applying a structured instructional design model for creating professional development program for physicians is a fruitful, relevant experience in primary healthcare. 1) Continuing professional development (CPD) is an essential method to help physicians maintain and further develop knowledge and expertise;2) The ADDIE (analysis, design, development, implementation, evaluation) model provides an established and useful structure for creating effective CPD programs;3) The ADDIE process ensures that physicians’ appropriate learning needs are met effectively;4) The evaluation phase of the ADDIE process provides feedback that can lead to improvement in the CPD program’s future iterations.

The men’s health center:Disparities in gender specific health services among the top 50“best hospitals”in America

Objective:Gender-specific integrated health services have long existed in the arena of women’s health care,but men’s health centers(MHCs)have only recently emerged as a novel practice model.Here,we seek to evaluate the prevalence and format of MHCs found in the leading academic medical centers in the United States.Methods:The US News&World Report’s Top 50 Ranked Hospitals for Urology was used as our cohort.Data were gathered on the presence of MHCs and types of providers and conditions treated.An equivalent search was performed for women’s health centers(WHCs).Results:Sixteen of 50(32%)promoted some type of MHC,compared to 49 of 50(98%)offering a WHC.Eight of the top 15 ranked institutions(53%)had an MHC compared to eight of 35(23%)remaining programs.Six of 16 MHCs incorporated providers from a variety of medical disciplines,including urologists,internists,endocrinologists,cardiologists,and psychologists,while another six of 16 MHCs were staffed solely by urologists.Eight of 16 provided services for exclusively urologic issues,four of 16 offered additional services in treatment of other medical conditions,and four of 16 did not specify.

Status of Equities in Prenatal Care Utilization and Changing Patterns among Women in China

Objective To assess the extent and relative changes of the equities in prenatal care utilization among women with different educational attainment in some areas of China. Methods Data were collected in 13 counties/cities covered by Perinatal Health Care Surveillance System established by Institute of Reproductive and Child Health, Peking University. The study population consisted of 103 704 women who delivered single live births in 1994 and 2000. Chi-square and multiple Logistic regression were employed to compare the administrative rates and relative risks. Concentration index was used to assess the relative changes of equities in prenatal care utilization. SPSS 11.5 and Microsoft Excel 2003 were used for analysis. Results The total systematic management rate was 22.1% in 1994 and 57.4% in 2000. The concentration index was -0.046 in 1994 and 0.066 in 2000. In northern areas, the concentration index increased from 0.015 in 1994 to 0.295 in 2000, while it increased from -0.015 in 1994 to 0.062 in 2000 in southern areas. In rural areas, the concentration index increased from O. 002 in 1994 to 0.026 in 2000, while it decreased from 0.042 in 1994 to 0.019 in 2000 in urban areas. Conclusion Inequities in prenatal care utilization in 2000 become more obvious than in 1994, especially in northern areas. More attention should be paid to solve the inequities.

The role of multilateral organizations and governments in advancing social innovation in health care delivery

Background:Despite great medical advances and scientific progress over the past century,one billion people globally still lack access to basic health care services.In the context of the 2030 Agenda for Sustainable Development social innovation models aim to provide effective solutions that bridge the health care delivery gap,address equity and create social value.This commentary highlights the roles of multilateral organizations and governments in creating an enabling environment where social innovations can more effectively integrate into health systems to maximize their impact on beneficiaries.Main text:The integration of social innovations into health systems is essential to ensure their sustainability and the wide dissemination of their impact.Effective partnerships,strong engagement with and endorsement by governments and communities,regulations,trust and sometimes willingness are key factors to enhance system integration,replication and dissemination of the models.Three examples of social innovations selected by the Social Innovation in Health Initiative illustrate the importance of engaging with governments and communities in order to link,integrate and synergize their efforts.Key challenges that they encountered,and lessons learnt are highlighted.Multilateral organizations and governments increasingly engage in promoting and supporting the development,testing and dissemination of social innovations to address the health care delivery gap.They play an important role in creating an enabling environment.This includes promoting the concept of social innovation in health care delivery,spreading social innovation approach and lessons learnt,fostering partnerships and leveraging resources,convening communities,health system actors and various stakeholders to work together across disciplines and sectors,and nurturing capacity in countries.Conclusions:Multilateral organizations and local and national governments have a critical role to play in creating an enabling environment where social innovations can flourish.In supporting and disseminating social innovation approach,multilateral organizations and governments have a great opportunity to accelerate Universal Health Coverage and the achievement of the Sustainable Development Goals.

Gastroenterology in developing countries:Issues and advances

Developing countries shoulder a considerable burden of gastroenterological disease. Infectious diseases in particular cause enormous morbidity and mortality. Diseases which afflict both western and developing countries are often seen in more florid forms in poorer countries. Innovative techniques continuously improve and update gastroenterological practice. However, advances in diagnosis and treatment which are commonplace in the West, have yet to reach many developing countries. Clinical guidelines, based on these advances and collated in resource-rich environments, lose their relevance outside these settings. In this two-part review, we first highlight the global burden of gastroenterological disease in three major areas： diarrhoeal diseases, hepatitis B, and Helicobacter pylori. Recent progress in their management is explored, with consideration of future solutions. The second part of the review focuses on the delivery of clinical services in developing countries. Inadequate numbers of healthcare workers hamper efforts to combat gastroenterological disease. Reasons for this shortage are examined, along with possibilities for increased specialist training. Endoscopy services, the mainstay of gastroenterology in the West, are in their infancy in many developing countries. The challenges faced by those se^ing up a service are illustrated by the example of a Nigerian endoscopy unit. Finally, we highlight the limited scope of many clinical guidelines produced in western countries. Guidelines which take account of resource limitations in the form of ＂cascades＂ are advocated in order to make these guidelines truly global. Recognition of the different working conditions facing practitioners worldwide is an important step towards narrowing the gap between gastroenterology in rich and poor countries.

Patient-centered medical home and integrated care in the United States: An opportunity to maximize delivery of primary care

The reciprocal relationship between mental and physical health is well established.Undiagnosed,untreated,and poorly managed mental health conditions are associated with numerous physical health complications,poor treatment adherence,and decreased quality of life.Despite growing evidence regarding the importance of effectively addressing these conditions in primary care,the rates of identification remain low and follow-up and management by primary care providers has been criticized.The objective of this review was to demonstrate the role of Patient-Centered Medical Home(PCMH)and mental health integration in addressing comprehensive health care needs in primary care patients,and to describe common barriers and facilitators to the implementation of these types of programs.

Association of types of diabetes and insulin dependency on birth outcomes

BACKGROUND Diabetes rates among pregnant women in the United States have been increasing and are associated with adverse pregnancy outcomes.AIM To investigate differences in birth outcomes(preterm birth,macrosomia,and neonatal death)by diabetes status.METHODS Cross-sectional design,using linked Missouri birth and death certificates(singleton births only),2010 to 2012(n=204057).Exposure was diabetes non-diabetic,pre-pregnancy diabetes-insulin dependent(PD-I),pre-pregnancy diabetes-non-insulin dependent(PD-NI),gestational diabetes-insulin dependent(GD-I),and gestational diabetes-non-insulin dependent(GD-NI).Outcomes included preterm birth,macrosomia,and infant mortality.Confounders included demographic characteristics,adequacy of prenatal care,body mass index,smoking,hypertension,and previous preterm birth.Bivariate and multivariate logistic regression assessed differences in outcomes by diabetes status.RESULTS Women with PD-I,PD-NI,and GD-I remained at a significantly increased odds for preterm birth(aOR 2.87,aOR 1.77,and aOR 1.73,respectively)and having a very large baby[macrosomia](aOR 3.01,aOR 2.12,and aOR 1.96,respectively);in reference to non-diabetic women.Women with GDNI were at a significantly increased risk for macrosomia(aOR1.53),decreased risk for their baby to die before their first birthday(aOR 0.41)and no difference in risk for preterm birth in reference to non-diabetic women.CONCLUSION Diabetes is associated with the poor birth outcomes.Clinical management of diabetes during pregnancy and healthy lifestyle behaviors before pregnancy can reduce the risk for diabetes and poor birth outcomes.

Information seeking and anxiety among colonoscopy-na?ve adults: direct-to-colonoscopy vs traditional consult-first pathways

AIM To investigate the effects of direct to colonoscopy pathways on information seeking behaviors and anxiety among colonoscopy-na?ve patients.METHODS Colonoscopy-na?ve patients at two tertiary care hospitals completed a survey immediately prior to their scheduled outpatient procedure and before receiving sedation.Survey items included clinical pathway(direct or consult),procedure indication(cancer screening or symptom investigation),telephone and written contact from the physician endoscopist office,information sources,and pre-procedure anxiety.Participants reported pre-procedure anxiety using a 10 point scale anchored by "very relaxed"(1) and "very nervous"(10).At least three months following the procedure,patient medical records were reviewed to determine sedative dose,procedure indications and any adverse events.The primary comparison was between the direct and consult pathways.Given the very different implications,a secondary analysis considering the patient-reported indication for the procedure(symptoms or screening).Effects of pathway(direct vs consult) were compared both within and between the screening and symptom subgroups.RESULTS Of 409 patients who completed the survey,34% followed a direct pathway.Indications for colonoscopy were similar in each group.The majority of the participants were women(58%),married(61%),and internet users(81%).The most important information source was family physicians(Direct) and specialist physicians(Consult).Use of other information sources,including the internet(20% vs 18%) and Direct family and friends(64% vs 53%),was similar in the Direct and Consult groups,respectively.Only 31% of the 81% who were internet users accessed internet health information.Most sought fundamental information such as what a colonoscopy is or why it is done.Pre-procedure anxiety did not differ between care pathways.Those undergoing colonoscopy for symptoms reported greater anxiety [mean 5.3,95%CI: 5.0-5.7(10 point Likert scale)] than those for screening colonoscopy(4.3,95%CI: 3.9-4.7).CONCLUSION Procedure indication(cancer screening or symptom investigation) was more closely associated with information seeking behaviors and pre-procedure anxiety than care pathway.

A paradigm shift in models of oral health care:An example and a call to action

The consequences of oral disease are wide-ranging and can have a major impact on an indi-vidual’s and that person’s family’s quality of life.A range of factors interact to determine a person’s oral and general health.Such factors can be biological,social,economic,political,cultural,or environmental,in addition to knowledge,attitudes and behaviors.Traditional models of oral health care,however,have generally ignored these factors and instead have focused on the treatment and management of existing pathology(tertiary prevention/downstream approach).This has had no effect on the rate of hospitalization or the inequitable distribution of dental diseases.To reduce the prevalence and severity of oral diseases at the individual and population levels,holistic evidence-informed prevention-based health-promoting models of care that focus on upstream determinants of health are required.The Oral Health Program at North Richmond Community Health in the state of Victoria,Australia,has developed an innovative model of oral health care based on the follow-ing principles:health promotion,disease prevention,risk-based access to care,client-and family-centered care,team-based provision of care,multidisciplinary care,and innovation.Evaluation of this approach is currently being conducted to study the sustainability of such a model under the current public dental service funding model.

What if communities held the solutions for universal health coverage?

This commentary highlights the value of community-engaged social innovations to advance health care delivery in low-and middle-income countries and to accelerate universal health coverage.It emphasizes the importance of research to guide the innovators on what works,what does not work to make their innovations sustainable and to replicate and scale them up as relevant.It also helps to demonstrate impact and to enhance uptake within the health systems.

Chinese Medicine Pattern Differentiation and Its Implications for Clinical Practice

Chinese medicine practitioners apply the differentiation reasoning for decision-making. The wide scope of Chinese medicine intervention provides coverage of methods and techniques with applications to primary, secondary and tertiary levels of prevention. The rapid evolution of mathematical and computational techniques allowed the implementation of several models for pattern differentiation that were tested for several physiologic systems. Concurrently, it is argued that pattern differentiation might improve the efficacy of either traditional or conventional medical interventions. This article reviewed the influence of pattern differentiation into clinical practice organized by medical field： general pattern differentiation; genitourinary （recurrent cystitis）; cardiovascular （coronary heart disease; arterial hypertension; angina pectoris）; neurology （stroke）; surgery; metabolic （diabetes mellitus）; hepatic （cirrhosis）; gastrointestinal （chronic superficial gastritis）; orthopedic （low back pain; rheumatoid arthritis; cervical spondylosis; elbow arthritis）; oncology （gastric mucosal dysplasia; lung cancer）; gynecologic and obstetric manifestations （nausea and vomiting）. The reviewed studies presented achievements that have contributed to the integration of Chinese medicine and evidence-based medicine in the treatment of many mild and severe diseases. Target diseases considered as major public health problems were also investigated and the results are promising regarding the possibility to treat guided by pattern differentiation.

The questionnaire on autonomic regulation： a useful concept for integrative medicine？

The concept of autonomic regulation （aR） reflects the relevance of the function of different autonomic systems for health, aR can be captured by questionnaires. We differentiate between a trait or constitutional aR questionnaire version including 12 （short-version） or 18 items, respectively, with three subscales （orthostatic-circulatory, rest/activity and digestive regulation）, and an 18-item state aR questionnaire on the preceding week with four subscales （rest/activity, orthostatic-circulatory, thermo- and digestive regulation）. The validated questionnaires show satisfying to good reliability and robust validity with clear construct validity. In this article, we summarized the actually available literature on aR and the use of aR questionnaires in clinical and observational studies. We described the relationship of high aR with health and in case of low aR or loss of regulation with disease and functional disorder in the three （four） different subscales and functional systems, such as rest/activity, orthostatic-circulatory or digestive regulation （thermoregulation） with the consecutive therapeutJc need. Finally, we gave perspectives of its further application in clinical research.

Reconsidering the Barefoot Doctor Programme

This paper examines the widely acclaimed Barefoot Doctor campaign in China. The Barefoot Doctor campaign has come to symbolise the success of Chinese health care to the extent that it has become a model for WHO public health strategy. Yet little has been done to understand how or whether it worked on the ground and what difficulties and contradictions emerged in its implementation. Using previously unexplored party archives as well as newly collected oral interviews, this paper moves away from a narrow focus on party politics and policy formulation by examining the reality of health care at the local level and the challenges faced by local authorities and individuals as the campaigns evolved.