Browsing by Author "Yan, Lijing Lily"

Background: Hypertension and related complications are major contributors to deaths and disabilities in Nepal. We aim to explore existing work flows, needs and challenges to hypertension care coordination and assess feasibility of establishing a FCHV-based hypertension management program in Kavre, Nepal.

Design: We conducted 23 in depth-interviews and one focus group discussion that consists of nine patients with hypertension, six health workers, four health officials, and 12 FCHVs in two village development committees of Kavre district, Nepal. Applied thematic analysis was performed using NVivo 12.

Results: Health literacy related to hypertension was low. Delay in treatment initiation and lost to follow up were common patterns despite comply with antihypertensive medication. Underutilization of primary healthcare institutions, communication gap and lack of grass-roots level educational campaigns were identified as major health system-related barriers. Community pharmacies, monthly health camps and increasing governmental attention to NCDs were favorable for hypertension management. This study also showed FCHVs have the potential to promote hypertension educational, screening and referral in their catchments, with adequate training and proper motivation.

Conclusions: Barriers and facilitators identified in this study have implications for future hypertension management intervention design. We recommend grassroot level hypertension education and screening across the Nepal. FCHVs have the potential to take on these responsibilities, once they are empowered with appropriate training and motivated by proper incentives.

Keywords: hypertension management, barriers, facilitators, community health workers, female community health volunteers, Nepal, qualitative research

Arthritis is a chronic condition affecting millions of older adults worldwide and a leading cause of pain and disability. Physical activity is effective and recommended in managing arthritis and promoting overall health in older adults. However, many older adults with arthritis struggle with participation consistent in physical exercises and activity as a result of pain, stiffness, and fatigue. A cross-sectional study design is applied to derive the findings in this study using the National Health and Nutrition Examination Survey (NHANES). We found that 9467(27%) participants reported as Arthritis from 2007 to 2018. Compared with non- arthritis subjects, Arthritis participants tended to be older (62.2 ± 13.8 vs. 45.3 ± 17.0, p<.001), female (59.5% vs. 48.5%, p<.001), lower level of education (3.2 ± 1.3 vs. 3.5 ± 1.3, p<.001). The multivariable logistic regression showed that Osteoarthritis was only negatively correlated with vigorous work activity (OR: 0.75, 95%CI: 0.59-0.95, p=.018). Participants with Osteoarthritis or degenerative were more likely to perform moderate work activity (OR:1.17, 95%CI:1.07-1.28, p<.001) and instead perform less walking or bicycle (OR:0.79, 95%CI: 0.71-0.88, p<.001), and moderate recreational activities (OR:0.84, 95%CI:0.77-0.92, p<.001). Patients with other types of Arthritis were more willing to engage in recreational activities than work activity. Further, we also included the population ≥65 years of age or older with Arthritis causing physical movement difficulties, to find out about the health status of these people and whether they are physically active or how often they are physically active. Compared to arthritis patients (≥65 years older) with non-functional limitations, arthritis patients with functional limitations tended to be female (63% vs. 53%), divorced (48% vs. 39%). In addition, minutes of sedentary activity were associated with having a higher functional limitations risk among arthritis patients with 65 years or older (OR, 1.59 for >480 mins, OR, 1.32 for (360~480) mins compared with ≤240 mins, Fig.2-3). Compared with arthritis patients doing less than 30 minutes of moderate recreational activities on a regular day, those doing above 180 minutes had a higher risk of functional limitations. The findings of this study will provide important insight for developing interventions to foster physical activity among older adults with arthritis and consequently improve their health and well-being.

Background: Metabolic syndrome is a group of risk factors that, if unaddressed, can lead to various non-communicable diseases such as cardiovascular disease and type 2 diabetes. Previous studies have shown that there is an association between diet and metabolic syndrome. As poor diet and obesity are increasingly prevalent in adolescent populations, adolescents become more at risk of developing metabolic syndrome at an earlier age. This study examined the association between diet quality, as measured by healthy eating index (HEI), and metabolic syndrome in US adolescents aged 12 to 18 years.Methods: The analytic sample consisted of 1,178 adolescents aged 12 to 18 years who participated in NNHANES cycles between 2011 and 2016. Healthy eating index was constructed using information from the NHANES 24-hour dietary recalls, as well as the USDA’s Food Patterns Equivalents Database. HEI was scored continuously on a scale from 0-100. I then categorized participants into quintiles by HEI for further analysis. Metabolic syndrome was measured using data from a variety of NHANES databases using standards for diagnosis of metabolic syndrome in adolescents established in previous NHANES studies. I examined the association between HEI and metabolic syndrome using adjusted and unadjusted logistic regression models. The adjusted model included the covariates age, gender, BMI, ethnicity, household size, income-to-poverty ratio, and physical activity. Finally, I performed a sensitivity analysis to investigate whether the definition of metabolic syndrome used for adolescents was appropriate. Results: HEI was not significantly associated with metabolic syndrome in adolescents when treated as a continuous predictor. When treated as a categorical predictor, only those in the highest quintile of HEI had significantly lower odds of metabolic syndrome (odds ratio [OR] = 0.28; 95% confidence interval [CI]: 0.10, 0.81). The frequency of metabolic syndrome in this quintile was 4.68 percent. The sensitivity analysis found that there was no significant difference in results when using the current diagnosis standards for metabolic syndrome versus more relaxed standards (only 2 symptoms present versus 3). Conclusions: This study found preliminary evidence to support the hypothesis that healthy eating index is inversely associated with risk of metabolic syndrome in adolescents aged 12 to 18 years in the United States. This may be because diet is an important risk factor in the development of the 5 indicators of metabolic syndrome. Adolescents with metabolic syndrome are at higher risk for metabolic syndrome, heart disease, and type 2 diabetes as adults. Therefore, prevention and management of this condition in adolescence is important to change the trajectory of adolescents’ health. A healthy diet in alignment with the USDA’s Dietary Guidelines is beneficial for all adolescents to develop healthy lifestyle habits. Future research should investigate the use of nutrition education and counseling as a tool for metabolic syndrome treatment and prevention in this population.

Hypertension is one of the most important global public health problems today, especially among middle-aged and older adults. Numerous studies have been done to explore the risk factors of hypertension, among which sleep duration, has aroused immense attention. However, no consistent conclusion has been drawn and the empirical evidence from China was scarce. This study aims to investigate the association between sleep duration and onset of hypertension among Chinese middle-aged and older adults based on China and Health Retirement Longitudinal Study (CHALRS).The study conducted a survival analysis of participants from CHARLS from 2011 to 2015. A total of 7655 participants were included in this study. Information on self-reported sleep duration, hypertension, quality of sleep, nap, age, sex, smoking, drinking, health insurance, body mass index (BMI), Hukou status, marital status, highest education level, diabetes or high blood sugar and dyslipidemia was collected. Kaplan-Meier estimate and cox proportional hazard models were used to estimate for the onset of hypertension in relation to sleep duration. Subgroup analysis was conducted to evaluate the age difference. There was no significant association between self-reported sleep duration and hypertension in the whole sample, but in the subgroup of older adults aged more than 60, the cox model reported lower hazard ratio (HR) for those with sleep duration 6-7 hours than reference group (7-8 hours) (HR=0.758, 95% CI 0.606-0.948). Although no significant relationship was found between sleep duration and hypertension among middle-aged and older Chinese population, this study revealed that sleep for 6-7 hours was a protective factor of hypertension among older adults.

Background: Hypertension presents a public health challenge globally, both in developing and developed countries such as the Netherlands. Complications of hypertension accounted for a total number of 10.46 million deaths every year in the world, and disability-adjusted life years associated with high blood pressure is 143.0 million in 2015. Among Dutch people aged between 30 and 70, 31.4% suffer from hypertension. Dutch guideline recommendations for treating patients with SBP between 160 and 180 mmHg is unique: low-risk patients are recommended without BP lowering medication, and middle-risk patients should be treated only in the presence of other risk-increasing factors. For these two groups of patients, guidelines from other countries, like United Kingdom and the United States, suggests “lifestyle advice with prompt drug initiation”. This study explores attitudes of health professionals, the target users of the unique Dutch guideline, towards the risk table and two guideline recommendations of commencing antihypertensive drug treatment for low- and middle-risk patients. In addition to health professionals’ attitude, this study also explores their perceived application barriers of the risk table. The risk table and two recommendations are only a small part of the CVRM guideline. This study focused on the risk table and the two recommendations because these are the guidance for treating hypertension patients.

Methods: A cross-sectional, mixed-method study was conducted in the Netherlands, mainly in Amsterdam. A total of 77 online questionnaires in English were conducted among health professionals in the Netherlands, while 13 face-to-face in-depth interviews in English were conducted among participants in Amsterdam. All participants completed the online questionnaire that assessed their knowledge, attitude, and practice of the Dutch General Practitioner’s Society (Nederlands Huisartsen Genootschap NHG) CVRM guideline and the risk table, as well as their attitude towards the two recommendations of antihypertensive drug prescription for low- and middle-risk patients. The in-depth interview aimed to further explore barriers of applying the risk table and the reasons for their attitude towards the two recommendations.

Results: Majority of our survey respondents have positive attitudes towards the NHG CVRM guideline in general and the risk table. Knowledge and attitude are not barriers of applying NHG CVRM guideline. All the respondents reported that they knew the existence of the guideline, and almost all of them (97%) agreed that they knew the guideline content. 92% respondents think that NHG CVRM guidelines are valuable, and 92% report that they believe NHG guidelines are well-supported by scientific evidence. Despite that only 3.9% participants reported they did not apply the risk table to every patient, health professionals perceived lacking important risk factors as an important barrier of applying the risk table.

Regarding attitudes towards pharmacological treatment for low- and middle-risk patents, 66% agreed that middle-risk patients required drug treatment only in the event of risk-increasing factors and SBP > 140mmHg and/or LDL> 2.5 mmol/L, 58% agreed low-risk patients rarely required drug treatment. The most reported reasons to follow the unique recommendations include: follow the guideline, clinical uncertainty of the persistency of the elevated BP, perceived patient attitude and drug adherence, and drug burden. Confusion of guideline interpretation for treatment advice on low-risk patient with SBP over 180 mmHg is detected in this study.

A significant relationship existed between attitudes towards lowering current treatment threshold and sex (p=.011). Female health professionals were more likely to agree with lowering treatment threshold compared to male.

Conclusions: Knowledge is not a barrier of applying NHG CVRM guideline, and attitudes towards the guideline are found to be generally positive. The highest perceived barriers to applying the risk table is lack of important risk factors, for example SES, ethnicity, psychological factors, physical exercise, BMI, family history of CVD, and chronic conditions like chronic kidney diseases and autoimmune disease. Most participants agree that low-risk patients rarely require drug treatment, and middle-risk patients require drug treatment only in the event of risk-increasing factors and SBP> 140mmHg and/or LDL> 2.5 mmol/L. The most reported reasons to follow the unique recommendations include: follow the guideline, clinical uncertainty of the persistency of the elevated BP, perceived patient attitude and drug adherence, and drug burden. Confusion of guideline interpretation for treatment advice on low-risk patient with SBP over 180 mmHg is detected in this study.

Background: Vietnam is in the process of an epidemiological transition, with cardiovascular diseases now ranked as the leading cause of death. This study assessed the commune health centers in selected rural and urban communities in Vietnam in terms of their capacity for prevention and management of cardiovascular diseases by using a mixed method approach.

Methods: The study was conducted in July 2016 in Chi Linh district, Hai Duong province – a mountainous area located in northern Vietnam. Structured questionnaire surveys and in-depth interviews were used to collect data on the current capacity of commune health centers in Chi Linh district. The capacity included six aspects: equipment and service availability, medicine, medical record system, service utilization and referral, financing and human resources. Ten facility staff members in the selected commune health centers were surveyed and interviewed. Five policy makers from the local level, the regional level, and the national level were also interviewed.

Results: A description of Chi Linh district’s commune health center capacity on CVD prevention and management was reported. (1) Equipment & Service Availability: Not all essential equipment and health services recommended by WHO was available at commune health centers. A few centers owned glucometers and no center had an ECG machine. (2) Medicine: No diabetic medicines were available in the commune health center; the essential medicines for other CVD conditions were inadequate in terms of quantity and diversity. (3) Medical record system: One fifth of the commune health centers had an electronic medical record system, others used a paper-based record. (4) Service Utilization & Referral: On average, each facility admitted 63 CVD out-patients per month (urban 152, rural 29); none of the facilities could provide in-patient service. (5) Financing: Government budget and social health insurance were the main sources of facility revenue. (6) Human resources: The human resources specialized in CVD were inadequate in commune health centers. On average, there were 0.328 medical doctors, 0.182 nurses and midwives and 0.009 pharmaceutical personnel per 1000 population.

Conclusion: The capacity of commune health centers to prevent and manage cardiovascular diseases in Vietnam is inadequate. The results of this study show critical gaps in primary healthcare facilities in Vietnam in six key areas. They include service delivery, health workforce, health information system, access to essential medicine, financing and governance. Thus, there is an urgent need to improve the capacity of commune health centers.

Burn injuries are devastating in both the acute and chronic phases. Survivors face life-lasting effects from such injuries, often decreasing general health, quality of life and employment status. With increased survival rates post-burn injury, increased research is needed to evaluate the recovery status of patients post discharge, and to identify residual patient needs.

This study measured depression, functional dependence in activities of daily living, quality of life (QoL) and return to work (RTW) 3- and 6-months, and identified factors associated with poor outcomes. Inpatients at Wuhan Third Hospital were asked to join the study as they were being discharged. 280 participants completed the baseline survey, where depression severity and functional dependence were measured using Patient Health Questionnaire-9 and the Barthel Index, respectively. QoL was measured using the Burn Specific Health Survey Brief (BSHS-B) 3- and 6-month, and RTW was collected at the same time-points. Factors associated with each outcome were identified through hypothesis tests and logistic regression models.

Nearly 15% of participants met the depression cut-off score, but over 70% required at least some assistance in daily living according to the BI results. Longer length of stay (LOS) resulted in greater odds of having a depressive PHQ-9 score. LOS, along with older age, female gender and full-thickness burns was significantly associated with functional dependence. 64.7% and 70.3% of participants reported a good QoL at 3- and 6- month follow-ups, respectively. Larger total body surface affected by burn and longer

LOS greatly decreases participant odds of having a good QoL at both time points. Three iv

months after hospital discharge, 66.4% of participants returned to work, and increased to 67.2% 6 months after discharge. Significant differences in RTW rate existed by age, education level, burn depth, LOS and BI score. Participants with LOS longer than two weeks had nearly 7 times lower odds of returning to work than those with stays one week or shorter, even after adjusting for burn depth and size.

There does not appear to be a large residual need for mental health services for burn injury patients at Wuhan Third Hospital, and high percentage of participants with favorable high QoL is reassuring that current burn care largely addresses patient needs. The percentage of patients reporting need for assistance in daily activities and lack of RTW demand the most attention in future rehabilitation interventions. The study reveals that participants with LOS longer than two weeks have much higher odds of having poor outcomes compared to patients with shorter stays. Further research should be carried out to establish the direction of the relationship between LOS and recovery outcomes to form plans to mitigate modifiable determinants. This would affect multiple adverse burn injury outcomes.

Background: The prevalence of smoking among Chinese men has been one of the highest globally despite decades of smoking cessation efforts. Previous studies suggest that smoking cessation interventions could be more effective in achieving abstinence when they are culturally adapted. Based on the “smoking rationalization belief” framework and recent development on electronic health (eHealth) technology, we developed the Community Centered eHealth Smoking Cessation Intervention (CCeSCI).Research question: What are the common beliefs of East and Southeast Asian male smokers that make quitting so difficult, and how can we inform and refine the CCeSCI trial design and implementation in order to address those cognitive misconceptions and to achieve a better quitting outcome? Method: We conducted a comprehensive literature review on the common beliefs of East and Southeast Asian smokers and a qualitative study on beliefs and attitudes of Chinese smokers and community workers to inform the CCeSCI study design and implementation. A total of eighteen in-depth interviews were conducted, including five with community workers and thirteen with adult male smokers. The smoking rationalization belief framework (including six domains) was used to guide the thematic analyses of the qualitative data. Findings: Both the literature review and the qualitative study revealed that the six domains in the rationalization beliefs framework -- smoking functional beliefs, risk generalization beliefs, social acceptability beliefs, safe smoking beliefs, self-exempting beliefs, and "quitting is harmful" beliefs -- were the major themes of male smokers. In addition, fatalism, family matters, no need for help, indifference and pessimism, and "I can quit when I decide to" were the most popular attitudes among smokers. For community workers, the major themes were "environmental factors are the most important," "leadership support is crucial," "mixed attitudes regarding cessation clinics," and "individual willingness matters." We also identified some common barriers to smoking cessation efforts. We found high heterogeneity among smokers in their beliefs and attitudes, but less so for community workers. Conclusions: Current smoking cessation efforts have largely neglected the rich diversity of rationalization beliefs among smokers and the misalignment of perceptions between community workers and smokers. Future interventions should focus more on addressing the specific psychological dependence of smokers and their rationalization beliefs by placing them at the center of their decision-making. Integrated with supply-side intervention in the communities and eHealth technologies, CCeSCI has a promising future in improving smoking abstinence with better acceptability, feasibility, and generalizability among adult male smokers in East and Southeast Asian countries.

Background: According to the WHO 2020 NCD report, the COVID-19 pandemic disrupted diabetes care in 49% of countries. eHealth emerged as a solution to disease management challenges during the unprecedented outbreak. Due to the rapidly expanding nature of eHealth use during the pandemic, this study aimed to determine 1) the sociodemographic factors associated with eHealth during COVID-19 and 2) whether eHealth was associated with diabetes management and clinical outcomes. Methods: Using quantitative data from cross-sectional surveys from Kunshan and Taicang, China (n=309) and Manila, Philippines (n=150) (data sets uncombined), we performed Chi-squared and Fisher’s exact tests and univariate logistic regressions to determine the relationship of eHealth use and sociodemographic characteristics. We then performed logistic and linear regression to determine the association of eHealth use with diabetes disease outcomes. Results: In China, younger age (p=0.02), higher education level (p=0.001), married marital status (p=0.03), suburban residence type (p=0.001), and higher household monthly income during COVID-19 (p=0.004) were associated with using eHealth. In the Philippines, younger age (p= 0.009) and higher education level (p=0.01) were associated with eHealth use. eHealth use was associated with undergoing FBS testing in the last three months (OR = 2.19, 95%CI = 1.00, 4.78), undergoing HbA1c testing in the last three months (OR = 3.64, 95%CI = 1.01, 13.15), and reporting disease control per their last HbA1c test (OR = 9.98, 95%CI = 3.41, 29.18) in the Philippines, adjusting for various demographic characteristics. Conclusions: Our data indicated eHealth use could positively affect diabetes clinical and management outcomes for people with diabetes in China and the Philippines. We posit more research is needed for the impacts of eHealth on clinical outcomes as well as the methods for eHealth implementation and integration in LMIC.

Abstract

BACKGROUND: Cardiovascular disease (CVD) is the greatest killer of mankind. In Nepal, a small, landlocked country in South Asia and one of the poorest countries in the world, the burden of cardiovascular disease is high; national CVD monitoring has substantial gaps; and CVD risk factors are poorly controlled. Primary healthcare (PHC) is often at the front lines of prevention and control of CVD. Thus, strengthening local and national primary healthcare systems is an essential step toward prevention and management of CVD in low- and middle-income countries (LMICs). To inform further research and policy development, we conducted an exploratory, mixed-methods study to understand patient-side utilization of CVD services in rural and urban areas in Nepal.

METHODS: We surveyed 114 CVD patients from 10 PHC facilities across two regions of Nepal. Survey contents included sociodemographic information, disease history, and data on accessibility, affordability, availability, and utilization of PHC services. We further completed 20 in-depth interviews within our sample to understand patient-side perceptions of CVD-related PHC care.

RESULTS: In the final cohort, 23% had experienced a stroke, 26% had some form of existing heart disease, 76% presented with hypertension, and 67% had diabetes. For all conditions, hospitals were a more common place of diagnosis than PHC facilities. The mean visitation frequency to PHC facilities in the past year was 10.7 times, with healthier patients having higher visitation rates than those with poorer health. 69% of patients reported difficulty obtaining CVD medicine from their local PHC facility. Qualitative data revealed that PHC facilities lacked resources for diagnosing and managing CVD conditions. Additionally, behavior of physicians and affordability were both considered important components of PHC satisfaction. Patient recommendations included increased diagnostic equipment in PHC facilities, free essential medicines, and community awareness initiatives for cardiovascular disease.

CONCLUSION: There are clear shortcomings between national aims and objectives – such as free essential medicines and universal PHC services – and the reality faced by CVD patients in resource-limited settings in Nepal. Despite PHC facilities generally being close to patients, participants reported inadequate resources when seeking care for CVD and expressed a strong desire that such services could be provided locally. Based on the challenges articulated by CVD patients in our study, mhealth may be a relevant direction of future research for connecting hospital-based specialists to CVD patients in rural areas, improving follow-up, and decreasing expensive visits to far away tertiary care centers. Overall, we recommend increased national CVD monitoring, prioritization of NCDs and CVDs in national policymaking and strategizing, and continued provision of PHC facilities close to patients in their communities.

Keywords: primary care, cardiovascular, utilization, Nepal, public healthcare facilities

DEDICATION

Background: In pace with globalization, the ethnic disparity in hypertension control is becoming a threat to positive outcomes in global health. Within countries with high ethnic diversity, for example, the Netherlands, ethnic disparity is a significant issue. The reasons for ethnic disparity in hypertension control are not well understood. Dutch health professionals directly interface with the health system and patients. As such, evaluating Dutch health professionals’ perceptions plays a pivotal role in understanding ethnic disparity in hypertension control. Although collecting ethnicity information may be useful in studying and reducing ethnic disparity in hypertension control, within the Dutch health system, ethnic information is hardly complete. Additionally, it is important to explore the health professionals’ attitude towards collecting ethnicity information.

Methods: This is a cross-sectional mixed-methods study, using both quantitative (online survey) and qualitative (in-depth interviews) data collection methods. Convenient and snowball sampling were utilized when identifying potential participants practicing in the Dutch urban Randstad area. After sending out invitation letter to potential participants through email, 77 online surveys were collected using Qualtrics. In addition, 13 in-depth interviews were conducted.

Results: Respondents were mainly general practitioners (80.5%), female (58.4%), and predominantly White Dutch (76.6%)—noting that in Amsterdam, 48% of the general population is White Dutch (Republiek Allochtonie, 2016). Most providers (79.2%) had ethnically diverse patients. Nearly all the respondents (98.8%) reported the collection of patients’ ethnicity data as important. The most frequently cited reason was that these data can help respondents to better evaluate patients’ risk and make better treatment plans. While 81.3% of the participants reported that ethnic disparity in hypertension control was a problem in the Netherlands, only 55.8% thought it was a problem among their own patients. The argument they claimed was that compared with the general situation in big cities in the Netherlands, their own patients were not that ethnically diverse. Also, some of them reported that they performed better than other health professionals. The majority of health professionals placed more emphasis on the contribution of patient-related factors to ethnic disparity in hypertension control compared with health professional-related factors. They argued that in the end it was patients who should take the medication and change their unhealthy lifestyle, so the biggest responsibility was on them. The program most frequently cited as “Very effective” was aimed at improving health professionals’ awareness of ethnic disparity in hypertension control (50.6%). Nearly 88.5% of participants acknowledged the ethnic- specific training they received in reducing ethnic disparity in hypertension control. Other strategies, including programs targeting at nurses, were also recommended by participants in reducing ethnic disparity in hypertension control.

Conclusion: The majority of health professionals supported collecting ethnicity information and acknowledged it could help reduce ethnic disparity in hypertension control. Therefore, the health system in the Netherlands should launch programs facilitating the collection of ethnicity information in primary care. However, few studies have assessed patients’ attitudes towards having their ethnicity information collected, and more research will be needed. Also, as nurses spend more time working with hypertensives than doctors and other care providers, they should be the target population in future studies assessing health professionals’ knowledge, attitudes, and perceptions on ethnic disparity in hypertension care.

Background: Hyperlipidemia is increasingly prevalent in China. Gaps are found between 2016 Chinese guideline for lipid management and other international guidelines. This study aims to identify attitudes and reported practice patterns for hyperlipidemia among Chinese physicians in tertiary hospitals. Methods: We collected data for 309 physicians on their adoption of guidelines, their attitudes of statin therapy and reported statin prescription patterns in four hypothetical patient scenarios (low risk/high LDL, high risk/high LDL, low risk/low LDL, and high risk/low LDL patients). Results: Overall, 63.75% of physicians adopted 2016 Chinese guideline. Most highly agreed with statins’ effectiveness, but 57.94% concerned about the safety of high-intensity statins in the Chinese population. Physicians reported various LDL-C value for treatment target. In hypothetical scenarios, the prescription rate was highest for the high risk/high LDL patient (90.03%). Those who believed statins could prevent stroke and heart attack were more likely to prescribe statins (OR=5.67,p=0.002). The prescription rate was 81.42% for the patient at risk/low LDL. Those who believed statins could prolong life were more likely to prescribe (OR=2.51, P=0.009). Only 7.78% 2016 Chinese guideline adopters prescribed statins as guideline recommended on all four hypothetical patients. Most physicians (56.73%-73.91%) preferred moderate-intensity statins. Those who considered high-intensity statins shouldn’t be routinely used in Chinese were less likely to prescribe high-intensity statins(OR=0.33, p=0.004). Conclusions: Physicians concerned about statins’ safety; We didn’t find a specific practice pattern among physicians and guideline adopters’ reported practices were not always concordant with the recommendations; Future studies are expected to focus on high-intensity statins and LDL-C target for treatment and training on guideline use is necessary;

Background and aim: This study aimed at building the prediction model of all-cause mortality among Chinese dwelling elderly with different methods including regression models and machine learning models and to compare the performance of machine learning models with regression models on predicting mortality. Additionally, this study also aimed at ranking the predictors of mortality within different models and comparing the predictive value of different groups of predictors using the model with the best performance.Method: I used data from the Healthy Ageing and Biomarkers Cohort Study, a sub-study of the Chinese Longitudinal Healthy Longevity Survey (CLHLS). The baseline survey was conducted in 2008 and participants were followed every 2-3 years till 2018. The analysis sample included 2,448 participants. I used totally 117 predictors to build the prediction model, including 65 questionnaires, 39 biomarkers, and 15 genetics predictors. Four models were built (XG-Boost, random survival forest [RSF], Cox regression with all variables, and Cox-backward). I used C-index and integrated Brier score to evaluate the performance of those four models. Results: The XG-Boost model and RSF model shows slightly better predictive performance than Cox models and Cox-backward models based on the C-index and integrated Brier score. Age. The activity of daily living and Mini-Mental State Examination score were identified as the top 3 predictors in the XG-Boost and RSF models. Biomarker and questionnaire predictors have a similar predictive value, while genetic predictors have no addictive predictive value when combined with questionnaire or biomarker predictors. Conclusion: In this work, it is shown that machine learning techniques can be a useful tool for both prediction and its performance sightly outperformed the regression model in predicting survival.

Background and Aim: Depression is a growing burden in China. There is limited national data on epidemiological studies of depression in China, as well as consistent estimates on the prevalence of depression. Therefore, we used data from two nationwide surveys to estimate prevalence of depression among middle-aged and older Chinese adults (by pre-determined subgroups). We also used multivariate analysis to explore main factors associated with depression among Chinese adults.Method: A nationally representative cross-sectional sample of 15,011 adults aged 45 to 79 years from the China Health and Retirement Longitudinal Study (CHARLS) and 8,140 adults aged 80 years and above from the Chinese Longitudinal Healthy Longevity Survey (CLHLS). Depressive symptoms were measure by the 10-item Center for Epidemiologic Studies Depression Scale (CESD-10), while probable depression was indicated by a CESD-10 score over 10. Prevalence rates of depression were estimated by age group (45-65, 65-79, 80+), sex (male, female), residence (rural, urban), and education level (no, some), incorporating sample weights. The associations between depression and marital status (married living with spouse, widowed, others including separated, unmarried), drinking status (never, former, current drinker), smoking status (never, former, current smoker), and any self-report disease (i.e., have at least one from hypertension, diabetes, cancer, lung disease, heart disease, stroke, arthritis, dyslipidemia, liver disease, kidney disease, digestive disease or not ) were examined in multivariate logistic regression and linear regression. Results: There was high prevalence of depression in middle-aged and older Chinese adults and a big difference between the two surveys, 35.0% for those aged 45-79 in CHARLS and 30.5% for those aged 80+ in CLHLS. Female, rural adults without any education had higher prevalence of depression in all age groups (45-64, 65-79, 80+). Being married but not living with spouse temporarily, separated, divorced, never married, self-reported any chronic disease were associated with higher odds of having probable depression and higher CESD-10 scores at all ages. In both age groups, being current drinker was associated with lower odds of having depression and lower CESD-10 scores. Smoking had little association with having depression in both age groups; but being a former smoker was associated with higher CESD-10 scores in CHARLS and lower scores in CLHLS. Conclusion: More attention should be devoted to the mental health of middle-aged and older Chinese adult, rural elderly women in particular. Future studies should also be aware of systematic difference when analyzing secondary data from different surveys.

Background: Primary healthcare is an important facet of non-communicable disease treatment and eHealth is a viable strategy to strengthen PHC in urban low-middle income settings such as in Lima, Peru. This study aimed to describe the current use of eHealth technologies in primary healthcare settings in urban Peru, assess the perceived effectiveness of eHealth technologies in NCD service delivery at the PHC level, and identify barriers and facilitators to the utilization of eHealth technologies at the PHC level.

Methods: In-depth interviews using a semi-structured interview guide were conducted among identified and invited policy makers, researchers and experts, and healthcare workers in Lima, Peru. Three districts in Lima were selected and interviews with healthcare workers were conducted at facilities from those districts. Interviews were transcribed and thematic analysis was utilized to identify themes in the data.

Results: A total of 14 participants were interviewed, including 2 policymakers, 5 experts, and 7 healthcare workers. Current use of eHealth were electronic medical records and telehealth applications. Participants were in favor of eHealth use and perceived eHealth as being effective. Human resources and digital literacy were factors cited as facilitators while data security, political climate, and compatibility were seen as barriers to implementation and utilization of eHealth.

Conclusions: The use of eHealth in Peru is still in its early stages, particularly in PHC settings and for service delivery of NCDs. At the intersection of these three topics there has been little progression of integration and utilization. Sentiment towards eHealth among researchers, policymakers, and healthcare workers is high and a number of barriers must be addressed to implement and utilize eHealth and reap its benefits.

Background: Evidence-based medication and lifestyle modification are important for secondary prevention of cardiovascular disease but are underutilized. Mobile health strategies could address this gap but existing evidence is mixed. Therefore, we piloted a pre-post study to assess the impact of patient-directed text messages as a means of improving medication adherence and modifying major health risk behaviors among coronary heart disease (CHD) patients in Hainan, China.

Methods: 92 CVD patients were surveyed between June and August 2015 (before the intervention) and then between October and December 2015 (after 12 week intervention) about (a) medication use (b) smoking status,(c) fruit and vegetable consumption, and (d) physical activity uptake. Acceptability of text-messaging intervention was assessed at follow-up. Descriptive statistics, along with paired comparisons between the pre and post outcomes were conducted using both parametric (t-test) and non-parametric (Wilcoxon signed rank test) methods.

Results: The number of respondents at follow-up was 82 (89% retention rate). Significant improvements were observed for medication adherence (P<0.001) and for the number of cigarettes smoked per day (P=.022). However there was no change in the number of smokers who quitted smoking at follow-up. There were insignificant changes for physical activity (P=0.91) and fruit and vegetable consumption.

The study is to examine the association between BMI and all-cause mortality in the oldest old (≥80 years). The study used a large sample sized prospective cohort study design. Chinese Longitudinal Healthy Longevity Survey (CLHLS) is a dataset between 2008 and 2014. Population: 8026 participants aged 80 years and older were followed every two to three years. Body weight and height were measured. BMI was calculated based on weight, height using a validated equation. Deaths were ascertained from family members during follow-up. Compared with lower weight, higher BMI was associated with a lower mortality risk (HRs: 1.20 (95%CI 1.13-1.27) but overweight (HR 0.89 (95%CI 0.81-0.99)) were associated with a lower risk. Obesity had a HR 0.91 (95%CI 0.78-1.05) for mortality. Among oldest old Chinese, higher BMI is associated with an increased risk of all-cause mortality but further study of the association is still needed.

Background

Hypertension (HTN) is a serious public health problem causing an enormous disease burden globally. Non-adherence to medication among hypertensive patients has been identified as one of the major contributors to the poor control of blood pressure (BP). Despite the paucity of reliable, up-to-date data on hypertension in Kenya, existing literature suggests high HTN prevalence in that nation. Additionally, the control of hypertension in Kenya faces many challenges, including the low medication adherence rates among its hypertensive population.

Hypertension as a chronic disease requires long-term disease management, including taking medication daily and making important lifestyle changes. The role of family support for patients during this life-long process has been a topic of interest among many researchers.

The overarching goal of this study is to determine the quantitative and qualitative association between family support and medication adherence among hypertensive patients in Kenya.

Methods

A mixed-method cross-sectional study was conducted in three healthcare facilities in Nairobi, Kenya. A questionnaire and in-depth follow-up interview were included to achieve the quantitative and qualitative goals respectively.

The questionnaire consisted of five sections: demographic information; health and medical information; medication adherence measurements; family support and family function measurements; and BP measurements.

The in-depth follow-up interview was conducted among patients who were willing to participate after the questionnaire survey. An interview guide was designed to lead the semi-structured individual interview with a focus on exploring how family members may contribute to patients’ HTN management.

Descriptive statistics were used to describe the patient profiles; Fisher’s exact test and Chi-square test were used to compare the level of medication adherence and family support among different subgroups of patients; bivariate logistic regression was used to determine the predictors of medication adherence; and multiple logistic regression was used to examine the independent association between family support/function and medication adherence. Grounded theory was used to guide the thematic analysis of the qualitative data.

Results

A total of 104 patients participated in the study. The majority of participants were female (n = 71, 68.27%) and urban residents (n = 95, 91.35%), with a mean age of 56.61 (SD = 11.70).

The overall control rate of HTN among the patients was low, with only 33.98% of them under control. The percentage of highly adherent patients determined by the Morisky Green Scale was 55.77% and was 26.92% as determined by the Hill-Bone Scale. Based on the Perceived Social Support from Family Scale, most of the patients (82.69%) reported strong family support. The majority of patients (77.88%) were determined to have “functional” families by the Family Function APGAR Scale, and 22.12% had dysfunctional families. Both the bivariate logistic regression and multiple logistic regression generated non-significant results for the association between family support/function and medication adherence using either scale.

Three major themes were generated from the qualitative analysis: patients’ family relationship and situation, patients’ perceptions about HTN and medication, and patients’ family in HTN management. The qualitative results suggested that patients’ support from their family members is promising in improving HTN control and medication adherence. However, a low level of health knowledge among patients and their families may present substantial barriers to HTN patients’ medication adherence.

Conclusion

Despite strong family support and a good family function level, HTN patients in Kenya have low medication adherence and are in a critical situation concerning BP control. Lack of health knowledge, limited involvement in patients’ HTN care, and unavailability and unaffordability of antihypertensive medicines are important obstacles that compromise the positive effects of family support on HTN control in Kenya. Future HTN control interventions in Kenya should prioritize providing better health education to the patients and their families, raising people’s awareness for hypertension screening and treatment, and further engaging patients’ families in HTN care. Additionally, the Kenyan government should enhance its healthcare system to ensure people’s accessibility to hypertension medicines and services.

Background: Medication adherence is regarded as important to improve hypertension control. Therefore, research about how to improve hypertensive patients’ adherence to their regimens becomes a hot topic. Multidimensional social support, meaning support that one could obtain from family, friends and significant others, might be useful to increase medication adherence, and thus we tried to examine the relationship between multidimensional social support and medication adherence both quantitatively and qualitatively. Methods: The research setting is Kenya where is known as underserved. Convenient sampling was used to recruit hypertensive patients with the help from physicians in three clinics. After finishing a digital questionnaire, a follow-up interview was delivered to participants as long as they were willing to join. The independent variable, Multidimensional social support, was assessed by Multidimensional Scale of Perceived Social Support (MSPSS). Two different scales are used to measure one outcome variable: Medication Adherence Questionnaire (MAQ) and Hill-Bone Compliance Scale (HBCS). After identifying several potential confounders, ordered logistic regression and logistic regression were used to determine the relationship between independent and dependent variables. Results: Multidimensional social support is insignificantly correlated with medication adherence using both measurements of medication adherence. However, follow-up interviews provide relatively sufficient information about how multidimensional social support could affect medication adherence, and even hypertension control. Conclusions: Although there is no correlation between multidimensional social support and medication adherence among hypertensive patients in our study, further research is still needed to improve hypertension control from the perspective of social support or medication adherence.

Background

Cardiovascular disease (CVD) is increasingly becoming a serious public health challenge in Kenya, contributing not only to mounting mortality, morbidity and healthcare expenditure, but also widening health disparity and lost productivity, which in turn undermine the long-term development of the East African powerhouse.

Hypertension and diabetes are leading CVD risk factors presented at primary healthcare (PHC) centers in Kenya, however inadequate screening, underdiagnoses and suboptimal control of these risk factors have been found evident in both national surveys and small contextual studies, especially in limited-resource settings. Public PHC centers in Kenya, providing subsidized healthcare at community levels, are uniquely positioned to curb the CVD epidemic through early prevention and ongoing management, especially for the underprivileged.

Despite a newly formed enabling policy environment focusing on tackling non-communicable disease with a primary-care approach, there is currently a paucity of literature on the role that primary care plays in the prevention and management of cardiovascular diseases in Kenya. Our study aims to fill such gap by understanding CVD patients’ utilization experience at public PHC centers, in order to form evidence-based policy recommendation for targeted health system strengthening.

Methods

This cross-sectional descriptive study aims to explore the PHC utilization experience of adults who suffered from at least one of the four conditions of hypertension, diabetes, heart diseases and stroke.

Our study was conducted in five public health centers in urban slum settlements (Korogocho and Viwandani) in Nairobi County and five public health centers in the rural areas of Machackos County. A mixed method approach was adopted as we conducted face-to-face interviews with 105 patients who sought CVD-related care at the aforementioned 10 facilities using a structured questionnaire and further in-depth interviews with 12 out of the 105 patients using a semi-structured interview guide. Data on accessibility (travel time and wait time), affordability (travel cost, Out-of-Pocket (OOP) expenditure and ongoing medication cost), procedures received, medication use, emergency knowledge and overall satisfaction was collected to gain a holistic view of the utilization experience of the primary health care for their CVD conditions.

Results

From our study, it was evident that public PHC centers serve as important hubs for the screening, diagnosis and routine management of hypertensive and diabetic patients, as well as the follow-up care for non-emergency stroke and heart diseases conditions. CVD patients face considerable financial and geographic barriers, especially for those in rural areas as stark urban-rural disparity was evident in all dimension of accessibility and affordability. On average, patients who live in urban slums travel for a shorter time and spend less money travelling to a PHC for CVD-related care compared to their rural counterparts. Once they reach the PHC, urban patients wait a shorter time and incur lower OOP payments compared to their rural equivalents. Monthly CVD-related medication costs are also found to be lower in urban patients compared to rural patients. Out-of-pocket expenditure is a significant hindrance to routine care utilization overall although patients travelled far to obtain care. Medication availability is another barrier to long-term care as over half of the respondents had to visit elsewhere to complete their drug prescription. Urban facilities receive higher overall satisfaction ratings compared to their rural counterparts. Overall, a quarter of the patients lack knowledge of where to seek care in case of a CVD emergency especially in the rural area.

Stroke and heart diseases patients who utilized PHC for non-emergency CVD care incur higher expenses than hypertensive/diabetic patients who are yet to experience the onset of CVD, lending support to the cost-effectiveness of early detection and primary prevention of CVD. Financial protection among the sampled patients is especially absent given the remarkably low health insurance coverage of three percent. CVD-related OOP costs per outpatient visit is substantially higher compared to the average of national surveys.

Conclusion

The OOP expenses and ongoing medication costs constitute significant impediments to the management of CVD-related conditions by patients in limited-resource settings. Long distance and travel costs make it hard for rural patients seeking care. Bottlenecks including medication unavailability is prevalent among sampled facilities.

In the backdrop of a devolved political structure and the inspiration to achieve Universal Health Coverage, more strategic and innovative approaches are desired from both state and non-state actors to tackle the long-standing underfinanced nature of CVD care services, in order to improve access and utilization of quality CVD care for all Kenyans, especially the underprivileged.