Special Issue:community health service
Ten-year Development of General Practice in China：Opportunities and Challenges
To review the strengths and limitations of the development of general practice in China during the last decade (2010—2020) and to assess the opportunities and challenges for its future development.
Data were collected from statistic reports, journal articles and official policies and guidelines regarding general practice development in China from 2010—2020. Donabedian model was applied to examine and assess the quality of essential general practice services in China. SWOT analysis was used to identify internal and external determinants of general practice development in China.
(1) Structural quality of general practice: the ten-year policies about general practice development were a continuation of the past relevant policies in essence but with developments, with highlights on continuous construction of general practice workforce and discipline, tiered diagnosis and treatment and regional medical consortium, but relevant fiscal and management policies still need improvements. The number of general medical workers has increased rapidly, while the lion's share of them are still allocated at tertiary hospitals. Full-time equivalent is suggested to be used to predict the staffing and assess the performance of these workers. The number of community health centres showed a steady increase, but its growth rate was still slower than that of hospital facilities. Relevant health economics data need to be further supplemented. (2) Process quality of general practice: in 2020, there were 2.045 billion visits in community health centers (stations) and township health centers, that is, 1.5 visits per person per year on average. There was a significant development when found only 1 visit per person per year for primary care in 2010. However, the frequency of visits for primary care was still lower than that of visiting hospital-based outpatients (an average of 2.7 visits per person per year) . The COVID-19 pandemic had a significant impact on community health services/general medical services, and the number of outpatient visits dropped by about 20%. The number of general practice research articles reached a peak in 2018, mainly focusing on bi-directional referrals, tiered diagnosis and treatment, general practitioners (GPs) /family doctors, general medicine, community health services, chronic disease management (especially hypertension and diabetes) , and analysis of factors associated with aspects involved in general medical services. General practice research is expected to provide more support for developing innovative and critical thoughts, more practice-based evidence for clinical services, and more assistance for service quality and patient outcomes improvement as the discipline advances. (3) Results of implementing general medical services: there is no sufficient evidence on the influence of general medical services on people's health. The experiences and views of people including healthy individuals and patients indicated that those receiving general medical services or contracted family doctor services perceived positive experience and expressed high satisfaction, but perceptions and views of general population in the community toward general medical services need to be explored. GPs' own experience and opinions on general practice were quite different. Gender, age, professional title, urban and rural areas, and geographical location may be associated with their experience and job satisfaction. There may be instability in the general practice workforce, mainly due to personal income, workload and time pressure. (4) The major strengths of developing general practice in China are as follows: strong policy-based promotion and government leadership; rapidly constructing and developing GPs teams owing to the excellent resource allocating ability shown by the centralized system from central to all local governments; significantly enhanced general practice education and training systems; increased core professionals as general practice educators and trainers; special development of general practice characterized by the integration of medical sciences and Chinese traditional humanistic theories. (5) The development of general practice in China has been facing limitations similar to those in other countries. Besides that, its special limitations include late development of the discipline, unsatisfactory quality of workforce, high work pressure and high prevalence of burnout in the workforce, as well as impact of generation gap on education and practice among GPs. In addition, the relation between specialists and GPs is on transition of from undifferentiated attachment to self-recognised uniquity, and further seeking transdisciplinary. The teaching competences of GPs teachers, especially those teaching community and clinical care, are inadequate. GPs team building and management need to advance from the formation to the storming and performing phases. (6) Opportunities for further development of general practice in China include strategies for achieving the goals of Healthy China, and an all-round well-off society, the important role of primary health care in sustainable development and universal health coverage reaffirmed by the Declaration of Astana, as well as significantly improved health literacy of people. (7) Challenges for the development of general practice in China include population ageing, and aging-related changes in burden of disease and socio-economic status, the aging and dynamic changes of GPs human resources, the variation of urban and rural areas and regional differences, and the inverted pyramid structure of allocation of medical and health resources (namely, the largest part is allocated to tertiary care while the smallest to primary care) . Relevant recommendations to address these challenges comprise strengthening the advocacy of the development of general practice services, establishing a wide-ranging community collaborative network, and developing general practice professional organizations.
The development of general practice in China is advancing, which is manifested as rapidly increased number of general medical workers, strong government promotion, quickly improved accessibility of essential medical services, and notably increased utilization rate of primary care services. However, the development is facing challenges, such as high discipline and social expectations regarding general practice, instability in the workforce due to high work pressure of the knowledge- and labor-intensive job, GPs' insufficient recognition of their self-identity, and unclear status of financial funding for general practice development. Given that there are unprecedented favorable conditions for general practice development, medical industries and general medical workers are suggested to make efforts to turn challenges into opportunities to develop general medical services, thereby universal health outcomes will be improved.
本文对《欧洲全科医学/家庭医学和基本医疗保健科研纲要》的中文译稿进行了重点摘登。该文件由欧洲全科医学科研网络制订，包括7部分内容：序言、导言、方法、结果、独立章节，讨论和启示。作为在欧洲发展全科医学科研的核心指南，该文件对欧洲的全科医学学科和科研发展产生了深远的影响。欧洲的全科医学体系和以此为基础而构建的学科理论共识与我国全科医学当前的实际情况可能更为接近。因篇幅所限，本文刊登了其中最重要，对中国研究者也最实用的5部分内容，包括：（1）导言——全科医学的核心能力/特征以及全科医学科研的意义；（2）结果——全科医学的6个核心领域（基本保健管理、"以人为本"的照护、解决具体问题的技能、综合的方法、以社区为导向、整体的方法）的科研范畴，研究需求和适用方法；（3）独立章节——如何发展基本的科研能力和避免常见的科研失误；（4）讨论——未来的全科医学科研重点；（5）启示——科学协会、研究机构、患者参与、科研工作、期刊、科研政策在发展学科方面应注重的问题。因欧洲的全科医学体制和我国较为相似，且存在一定的科研发展代差，该文件在当前阶段也可为我国全科医学研究者所用，基于全科医学学科的视角，从概念、分类学、范围和科研方法等方面，为我国全科医学科研的发展提供参照。
Community-acquired pneumonia (CAP), one of the common infectious diseases, exhibits increasing morbidity and mortality with age, posing significant clinical challenges. Although Chinese patent medicines (CPMs) demonstrate efficacy in adult CAP treatment, high-quality evidence-based guidelines have been lacking. To address this gap, we organized a multidisciplinary expert panel to develop the Guideline on Treating Community-acquired Pneumonia with Chinese Patent Medicines, adhering to the principles of evidence-based, consensus-supplemented, and experience-referred and following standardized clinical practice guideline development procedures. Through literature review and Delphi questionnaires, six clinical questions were identified. Systematic evidence retrieval and synthesis of the best available evidence were conducted, integrating factors such as evidence quality, patient preferences, value orientations, and resource allocation. After two rounds of Delphi surveys and expert consensus meetings, the guideline was finalized and published in 2023 in Pharmacological Research. This updated edition systematically incorporates recent evidence, adds pharmacoeconomic evaluations and recommendation rationales, and presents 14 recommendations covering nine CPMs, covers 9 kinds of traditional Chinese patent medicines. The guideline has been restructured according to the first edition of reporting checklist for Chinese patent medicine guidelines (RIGHT for CPM) to enhance clinical applicability, accessibility, and operationalizability, thereby promoting the rational use of CPMs in adult CAP treatment.
Differences of Community Health Service Quality Evaluation in China and Abroad：a Systematic Review
In China, the assessment of community health services has been increasingly valued as the development of such services advances, but relevant research is still at the exploratory stage. Therefore, establishing a community health service quality evaluation system suitable for China's national conditions is critical to domestic development of such services.
To perform a review of studies about community health service quality evaluation in China and abroad to identify the similarities and differences in terms of assessment perspectives and contents between them, providing theoretic evidence for further implementation of such evaluations in China.
Studies regarding community health service quality evaluation were systematically searched in databases of China National Knowledge Infrastructure, CQVIP, Wanfang and PubMed from inception to October 15, 2020. Two researchers performed literature screening, data extraction, and comparative analysis of community health service quality evaluation at home and abroad by assessment perspectives and contents, separately. Descriptive analysis was used to analyze the comparative results.
In total, 62 articles in English, and 16 articles in Chinese were included, among which 10 in English and 7 in Chinese evaluated the quality of community health services in terms of the major factors of features of community health services (first contact, humanization, accessibility, continuity, coordination and comprehensiveness) . The top 3 highlights of these 10 foreign articles were coordination (7/10) , humanization (6/10) and accessibility (5/10) , while those of 7 domestic articles were humanization (6/7) , comprehensiveness (4/7) and accessibility (4/7) . Fifty-two articles in English and 9 articles in Chinese assessed the quality of specific community health services, and these foreign articles mostly focused on the management of chronic diseases〔type 2 diabetes (12/52) , cardiovascular and cerebrovascular diseases (11/52) , hypertension (7/52) , respiratory diseases (7/52) , chronic kidney disease (5/52) 〕, followed by the use of antibiotics (5/52) , cancer screening (5/52) , medication safety (5/52) , child health care (5/52) and geriatric care (5/52) , while domestic articles mostly focused on the management of chronic diseases〔type 2 diabetes (3/9) , hypertension (3/9) 〕, and maternal health management (3/9) .
The quality of community health services is increasingly valued by relevant academic circles. Compared to foreign studies, domestic studies are far less concerned about first contact and coordination, and the assessed specific services in which are not complete, with no quality assessment of diagnosis and treatment of common diseases and frequently-occurring diseases. It is suggested to address the above-mentioned issues to promote the community health service quality evaluation, and improve the depth and breadth of relevant research, thereby the community health service quality evaluation system could be improved constantly.
The Development Status of Community Health Management in Japan and Its Enlightenment to China
Community health management is an important element in promoting the Health China initiative and health promotion. As the world's longest-living country, Japan's community health management has become increasingly mature. This paper briefly reviews the development of community health management in Japan under the guidance of the National Health Strategy, compares the assessment framework of its community health management, and summarizes its specific actions in three areas: health check-ups and cancer screening, lifestyle and behavioral interventions and health management of key populations, and proposes inspirations for Japan's community health management for China based on its successful experience.
Quality of General Medical Care in Community Health Centers in 2019—2020：Overview and Problems Analysis
Strengtheningclinical quality control and supervision is one of the effective ways to ensure medical quality. Supervising the quality of general medical care in primary care settings in the local region could contribute to the systematical assessment of general medical care quality and identification of relevantproblems in such settings.
To analyze the supervision of quality of general medical care in Shanghai's primary care settings conducted in 2019 and 2020, and based on this, to give targeted, rational recommendations on the identified problems in quality management of general medical care.
The quality of general medical care in a cluster sample of community health centers (CHCs) of Shanghai was supervised in 2019 and 2020 by relevant experts from Shanghai's municipal and district general practice quality control departments using the Clinical Quality Control and Supervision Standards for General Medical Care in Shanghai's Community Health Centers (hereinafter referred to as CQCSS) developed by Shanghai General Practice Clinical Quality Control Center. In May 2021, the supervision results of the two years were analyzed using descriptive analysis, then compared, and the identified problems were summarized and analyzed.
Two hundred and forty-three CHCs were involved in the 2019 supervision, and 244 were involved in the 2020 supervision. The average total CQCSS score for 2019 was (87.32±5.97) points, and that for 2020 was (86.67±5.36) points. Compared to the results in 2019, the scores of first-level indicators of basic conditions (99.93% vs 99.80%) , staffing and determining job responsibilities of general practitioners (GPs) (93.44% vs 91.90%) , diagnosis and treatment ability of GPs (85.82% vs 85.72%) , chronic disease management ability of GPs (81.07% vs 80.95%) and scientific research and teaching levels (29.99% vs 28.87%) increased in 2020. The problems mentioned were mainly distributed in five aspects: staffing〔176 (22.03%) 〕, GPs' clinical management ability〔154 (19.27%) 〕, quality of inpatient medical records〔92 (11.51%) 〕, quality of home sickbed patients' medical records〔91 (11.39%) 〕, allocation of facilities〔91 (11.39%) 〕. In terms of the mentioned frequency, the top five problems were: ineligible senior GPs to registered GPs ratio〔84 (10.51%) 〕, poor scientific research〔84 (10.51%) 〕, less than 3.5 GPs per 1 000 residents〔61 (7.63%) 〕, unsatisfactory clinical skills〔40 (5.01%) 〕, and insufficient number of home sickbeds〔36 (4.51%) 〕.
These two years of quality control supervision has initially promoted the quality improvementof general medical care in CHCs. To further improve it, it is suggested to take actions to deepen the core essence of general medical care quality management, improve the diagnosis and treatment ability of GPs, as well as their teaching and research ability.
In 2019, the National Health Commission issued the Capacity Standards for Community Health Service Center (2018 version), which proposed that the 56 common disease species should be offered diagnosis and treatment services by CHSC, but it did not specify the common disease species of children in the community, which to some extent affects the assessment and construction of CHSC capacity in the community.
To investigate and analyze the common childhood disease species and their characteristics in community health services, in order to provide a reference basis for further community child health service capacity building.
In April 2020, a convenience sampling method was adopted to select community health service agencies in 11 different level cities in China as the sample unit. A self-designed questionnaire was administered to cover the subject's basic condition, the common childhood disease conditions suitable for diagnosis and treatment in the community, and their sequencing. Filled out online voluntarily anonymously by child health service personnel at the sample institution, 3 090 cases were successfully investigated. Respondents ranked the common degree of children's related disorders from low to high, assigning 1 to 5 points to each of the top 5 common childhood disorders, which is, assigning 5 points to ranked 1, 1 point to ranked 5, and 0 points to unselected, calculating a total and sorting by total score.
The top 5 disease categories for children in the community were acute upper respiratory infection, diarrhea, bronchitis, pneumonia, and eczema. Of the top 10 ranked community common childhood disorders, 3 were respiratory, 3 were facial and dermatologic, 2 were infectious, and 1 each was a digestive and growth and development related disorder. The top 5 common childhood diseases ranked by different regions, different levels of cities and different posts were consistent, but the ranking order was different, but there were differences in the 6th-10th disease species and order.
The current coverage of common childhood diseases in community health services is high. There is regional, urban, and post heterogeneity in common childhood disease species in communities. Construction of community child health service capacity should be oriented to improve the capacity of diagnosis and treatment service of common childhood diseases in the community, and fully consider the disease species variability in different regions, cities, and posts.
Cuba's Community Health Services：Introduction and Implications to China
Cuba has a three-level healthcare system, and offers free universal healthcare, of which community health services occupy a decisive position. Cuba has accumulated abundant experience in implementing public health services, primary healthcare, and general practitioner training. China has gained fruitful achievements in decades of developing primary healthcare, but there is still much room for development. We introduced Cuba's development and current status of healthcare system, implementation of community health services and general practitioner trainings, as well as community-based measures taken for chronic disease management and infectious disease prevention and control, and compared theses aspects with relevant information of China, offering insights into further development of community health services in China.
As population aging progresses, the prevalence of multimorbidity and polypharmacy is increasing in older adults, which may increase the risk of potentially inappropriate medication, causing adverse health outcomes.
To systematically assess the prevalence and associated factors of potentially inappropriate medication in community-dwelling Chinese older adults, in order to provide a reference for developing relevant intervention strategies.
In June 2022, we searched databases of CNKI, CQVIP, Wanfang Data, SinoMed, PubMed, EmBase, and Web of Science from inception to June 2022 for studies on potentially inappropriate medication in community-dwelling older adults in China. Two reviewers independently selected studies, extracted data and assessed the quality of included studies according to the Agency for Healthcare Research and Quality methodology checklist. Meta-analysis was conducted using Stata 12.0.
A total of 24 studies were included, including two with high quality and 22 with moderate quality. Meta-analysis showed that the pooled prevalence of potentially inappropriate medication was 34.8%〔95%CI (31.3%, 38.3%) 〕in community-dwelling older adults in China. Pooled estimates showed 75 years or above〔OR (95%CI) =1.261 (1.074, 1.481) 〕, five or more comorbidities〔OR (95%CI) =3.287 (1.405, 7.691) 〕, and taking five or more medications〔OR (95%CI) =1.800 (1.305, 2.481) 〕or taking 10 or more medications〔OR (95%CI) =4.380 (2.612, 7.347) 〕were associated factors of potentially inappropriate medication.
Potentially inappropriate medication is common in community-dwelling older adults in China, whose risk is associated with older age, multimorbidity and polypharmacy. Prevention and management of potentially inappropriate medication should be paid attention to individuals with the above characteristics.
Utilization and Associated Factors of Community Health Management Services in Hypertensive and Diabetic Patients
Hypertension and diabetes have been included in the list of China's essential public health services since 2009. During these years, the use and associated factors of community health management services in community-living hypertensive and diabetic patients are not very clear and need to be further studied.
To investigate the use and potential associated factors of community health management services in Shenzhen community-living hypertensive and diabetic residents.
Data stemmed from the results of Shenzhen Epidemiological Survey on Chronic Non-communicable Diseases and Risk Factors conducted between September and November 2018. The chi-square test and multinomial Logistic regression were used to examine the association of sex, age, place of hukou registration (Shenzhen or not) , marital status, monthly household income per capita, occupation type, years of living in Shenzhen, prevalence of medical insurance enrollment, and the level of medical institutions making a definite diagnosis with the use of community health management services.
Altogether, 10 042 participants were finally enrolled, including 1 132 with self-reported hypertension, and 402 with self-reported diabetes. Among the hypertensive participants, 530 (46.82%) indicated that they received follow-up management of hypertension from the community health center. Specifically, 436 (82.31%) received blood pressure measurement by the doctor, and 399 (75.25%) received medication guidance from the doctor. Of the diabetic patients, 194 (48.26%) indicated that they received follow-up management of diabetes from the community health center. Specifically, 173 (89.37%) of the 193 cases (one case was excluded due to missed information) received blood glucose measurement by the doctor, and 154 (79.62%) received medication guidance from the doctor. The prevalence of hypertensive participants receiving guidance on smoking cessation or smoking less from the doctor was relatively low (lower than 40%) , and so was that of diabetic participants. The prevalence of hypertensive participants receiving guidance on drinking cessation or drinking less from the doctor was relatively low (lower than 40%) , and so was that of diabetic participants. Multinomial Logistic regression analysis revealed that sex, age, monthly household income per capita, years of living in Shenzhen, and prevalence of medical insurance enrollment were associated with the utilization of community health management services in hypertensive patients (P<0.05) . Age, occupational type, and monthly household income per capita were associated with the utilization of community health management services in diabetic patients (P<0.05) .
Less than half of the community-living hypertensive and diabetic participants used or were involved in community health management services. Being female, 18-44-year-old, low or moderate monthly household income per capita, and short years of living in Shenzhen were associated with lower rate of utilizing such services. Moreover, hypertensive cases without medical insurance, and diabetics engaging in a manual labor job were far less likely to utilize the services. In view of this, it is suggested to strengthen the publicity of essential public health services in the above-mentioned priority groups. Besides that, the awareness of doctors in community health centers should be strengthened to provide patients with guidance on developing healthy lifestyles, such as stopping smoking and drinking.
Community home-based hospice care service plays an important role in hospice care service. Focusing on community home-based hospice care is the future direction of hospice care service development. As the early countries to develop community home-based hospice care delivery, the United Kingdom and the United States have accumulated rich experience in patient admission standard, service team and content, and funding guarantee of community home-based hospice care delivery, a relatively sound community home-based hospice care delivery system has been established in these two countries. China can appropriately learn from the development experience of community home-based hospice care in the United Kingdom and the United States, in order to formulate the admission standards of community home-based hospice care, strengthen the construction of multidisciplinary hospice care teams, incorporate the non-drug therapy into the scope of community home-based hospice care, implement the payment method of per-diem, so that the patients can die peacefully and dignifiedly in a familiar environment with their hospice rights protected.
Dyslipidemia is the most important and causal independent risk factor for atherosclerotic cardiovascular disease (ASCVD) . The prevalence of dyslipidemia in elderly residents in Guangdong Province is high, and it is urgent to analyze the specific prevalence of dyslipidemia and its influencing factors among the elderly, and to carry out targeted preventive and control measures for dyslipidemia.
To investigate the epidemiological status of dyslipidemia and its risk factors among elderly residents included in the national basic public health service in Yuexiu District, Guangzhou.
A total of 41 469 elderly residents aged 65 years and above with complete important variables were selected as subjects from the information system of community health service center in Yuexiu District, Guangzhou City in 2020, the 2020 health checkup data was used to describe the epidemiological characteristics of the included patients such as basic information, BMI and blood lipid levels. Restricted cubic spline (RCS) fitting Logistic regression model was used to analyze the relationship between age, BMI and the prevalence of dyslipidemia.
The prevalence of dyslipidemia in 41 469 elderly residents was 53.65% (22 247/41 469) , with a standardized prevalence of 53.89%. The prevalence of hypercholesterolemia (HTC) , hypertriglyceridemia (HTG) , mixed hyperlipidemia and low high-density lipoprotein cholesterol was 21.43%, 16.50%, 14.51% and 3.80%, with the standardized prevalence of 21.57%, 16.53%, 14.61%, 3.78%, respectively. Multivariate Logistic regression analysis showed that gender, age, education level, exercise status, and BMI were all influencing factors for dyslipidemia in elderly residents, among which female, low age group, and high BMI were risk factors for dyslipidemia in elderly residents (P<0.05) . The results of RCS fitting showed a non-linear relationship between age, BMI and the prevalence of dyslipidemia in elderly residents. The overall prevalence of dyslipidemia in elderly residents showed a decreasing trend with the increase of age. The risk of dyslipidemia showed on increasing and then decreasing trend with the increase of BMI, the OR increased significantly at low BMI, while decreased at high BMI.
The prevalence of dyslipidemia is relative high among elderly residents aged 65 years and above included in the national basic public health services in Yuexiu District, Guangzhou. The prevalence of dyslipidemia in the elderly group tends to decrease with the increase of age, and the risk of dyslipidemia prevalence tends to increase and then decrease with the increase of BMI, suggesting special features in the management of dyslipidemia among the elderly, the analysis of risk factors for dyslipidemia in the elderly should be focused on and early preventive and control measures should be carried out.
Due to susceptibility to multiple chronic diseases, polypharmacy is often needed in older adults, which may easily lead to increased risk of potentially inappropriate medications (PIM) if polypharmacy is accompanied by various alterations in pharmacokinetics and pharmacodynamics of medications. PIM are highly prevalent in older adults, which may be asociated with higher risks of frailty, falls, cognitive decline, and other adverse drug events. In China, the research on PIM is relatively weak, and PIM are insufficiently focused and often managed with non-standardized and non-intelligent approaches in primary care. We systematically reviewed recent studies in the prevalence, screening and assessment tools and management strategies of PIM in older adults, providing theoretical support and practical reference for reducing the harm of PIM and standardizing drug management.
Factors Associated with Older Adults' Intention to Use Community-based Elderly Care：a Study Using the Decision Tree and Logistic Regression Models
Community-based elderly care may effectively contribute to the handling of serious elderly care challenges brought by an increasingly aging population in China.
To explore the factors associated with older adults' intention to choose community-based elderly care using the decision tree and Logistic regression models.
This questionnaire survey was conducted in three communities selected from Daqing by convenient sampling from August to December 2020. 500 eligible community-dwelling older adults (≥60 years old) were selected as the research objects. The decision tree and Logistic regression models were used to explore factors associated with these older adults' intention to choose community-based elderly care via analyzing their demographics, self-rated physical and mental health, and family and social support collected by the survey.
Altogether, 489 cases (97.8%) who effectively responded to the survey were included for analysis. The prevalence of intending to choose community-based elderly care in the respondents was 32.5% (159/489) . Logistic regression analysis revealed that the older adults' understanding level of community-based elderly care, views of elderly care, sense of loneliness, and intergenerational relationship had varying degrees of influence on their intention to choose community-based elderly care (P<0.05) . The decision tree analysis found that the older adults' understanding level of community-based elderly care, views of elderly care, sense of loneliness, social network, self-rated health, education level, and living status (alone or not) were key factors influencing their intention to choose community-based elderly care (P<0.05) . By both Logistic regression and decision tree analyses, understanding level of community-based elderly care, views of elderly care, and sense of loneliness were found to be three factors influencing older adults' intention to use community-based elderly care most. In exploring the factors associated with older adults' intention to choose community-based elderly care, Logistic regression analysis had an AUC of 0.985 (0.974, 0.996) with 94.34% sensitivity and 95.75% specificity, and decision tree analysis had an AUC of 0.980 (0.968, 0.992) with 88.05% sensitivity and 97.87% specificity, the performance of the two was similar (Z=-0.625, P=0.268) .
The combination of decision tree and Logistic regression model has high application value in the study of influencing factors of community pension willingness of the elderly. The prevalence of intending to use community-based elderly care was relatively low in Daqing older adults. To improve this, it is suggested to take actions to change older adults' traditional views of elderly care, to better their physical and mental health and family relationships.
The high incidence of chronic diseases is associated with the inadequate knowledge of health and disease risks. At the national level, traditional health education remains popular in community health services. The health education conducted by primary healthcare providers are often limited, and lacks specificity in the content. Additionally, community residents generally show a low enthusiasm for participating in health education. The quality and effectiveness of health education for chronic disease patients need an improvement.
To explore the effectiveness of individualized health education interventions generated through the application of an information-based knowledge base model on middle-aged and elderly patients with chronic diseases in the community. The findings are expected to provide insights to further enhance the management of community-based chronic diseases.
In 2021, a total of 7 390 patients at the age of 50-70 years with the chronic diseases of hypertension, diabetes, coronary heart disease, and stroke in Beijing Dongcheng District Community Health Service Center were selected as study subjects. A one-year cluster randomized controlled trial was conducted. Patients in both groups received routine follow-up management strategies for chronic diseases, with the preservation of the existing basic public health services for chronic diseases. Those in the intervention group were additionally given individualized health education programs generated through an information-based knowledge base model, including health education prescriptions and individualized health management. Follow-up visits and interventions were conducted every three months, for a total of 12 months. An end-point survey was conducted one year after recruitment. The primary outcome measures were the differences between the baseline and end-point results of the knowledge awareness of chronic diseases, self-management attitudes, self-efficacy, medication adherence, and acceptance of health information technology.
A total of 7 390 patients with the four types of chronic diseases were included in the study, involving 3 673 patients in the intervention group and 3 717 in the control group. There were no significant differences in the age distribution, gender, education level, and employment status between groups (P>0.05). However, there was a significant difference in the type of medical insurance coverage between groups (P<0.05). After the intervention, patients in the intervention group demonstrated significantly higher correct awareness rates of overall disease knowledge, basic knowledge of chronic diseases, diabetes knowledge, coronary heart disease knowledge, and stroke knowledge compared to pre-intervention levels (P<0.05), while that of hypertension knowledge was not statistically significant (P>0.05). In the control group, there were no significant changes in the correct awareness rates of overall disease knowledge, basic knowledge of chronic diseases, hypertension knowledge, diabetes knowledge, or coronary heart disease knowledge before and after the intervention (P>0.05). However, the correct awareness rate of stroke knowledge in the control group was significantly lower after the intervention compared to pre-intervention levels (P<0.05). The scores of the self-management attitude questionnaire, self-efficacy questionnaire, medication adherence questionnaire, and health information acceptance questionnaire in the intervention group were significantly higher than those of the control group after the intervention (P<0.05). Additionally, in the intervention group, the scores on the self-management attitude questionnaire, self-efficacy questionnaire, medication adherence questionnaire, and health information acceptance questionnaire after the intervention were significantly higher compared to pre-intervention levels (P<0.05). In the control group, the scores of the self-efficacy questionnaire and medication adherence questionnaire improved significantly after the intervention compared to pre-intervention levels (P<0.05), while no significant changes in the scores of the self-management attitude questionnaire and health information acceptance questionnaire were detected (P>0.05) .
Knowledge awareness of chronic diseases, self-management attitude, and health information acceptance are more significantly improved in the intervention group than the control group. Both groups showed improvements in self-efficacy and medication adherence following the intervention, especially in the intervention group. Overall, an individualized health education based on an information-based knowledge base model is beneficial for enhancing the health literacy of patients with chronic diseases.
Prevalence and Associated Factors of Behaviors of Monitoring to Prevent Chronic Diabetic Complications among Type 2 Diabetes Patients Involved in Community-based Management
Chronic diabetic complications are highly prevalent, which may be an underlying cause of diabetes-related disability and death. Regularly and continuously self-monitoring may contribute to early detection, diagnosis and treatment of various diabetic complications, which is essential to reducing the adverse consequences of diabetes, and is a key program in community-based management that should be highly valued.
To investigate the prevalence and associated factors (such as diabetes prevalence and monitoring and other factors) of behaviors of monitoring (self-observation and screening tests) to prevent chronic diabetic complications among type 2 diabetes patients receiving community-based management.
The convenience sampling was used to select 785 type 2 diabetes patients from Chengdu's central urban areas who received community-based type 2 diabetic management from May to November 2019. They were invited to attend a survey for understanding their socio-demographic information and monitoring behaviors to prevent chronic diabetic complications using a questionnaire developed by us.
Only 103 (13.1%) of the patients did not suffer from any chronic complications, and 435 (55.4%) suffered from both metabolic syndrome and chronic diabetic complications. The average total score for self-observation of chronic diabetic complications in the participants was (2.58±0.86) , but the average total score of regularly self-observation of pulsations of the dorsalis pedis artery was only (1.47±0.84) . The average total score of performing screening tests for chronic diabetic complications was (2.77±0.57) . The average score of diabetic retinopathy screening, peripheral neuropathy screening, and lower extremity vascular disease screening was (1.88±0.99) , (1.46±0.84) , and (1.47±0.84) , respectively. About 78.2% (614/785) of patients underwent screening tests following the doctors' advices. But only 9.9% (78/785) took the initiative to conduct regular tests. About 17.7% (139/785) and 49.0% (385/785) of the patients could not correctly manage the abnormal results of self-observation and the screening test results. Multiple linear regression analysis indicated that the duration of diabetes since diagnosis, prevalence of chronic diabetic complications, and management of self-observed abnormalities were associated with the score of self-observation of chronic diabetic complications (P<0.05) . The duration of diabetes since diagnosis, the most recently measured HbA1c value, prevalence of chronic diabetic complications, causes and results management of screening tests for chronic diabetic complications were associated with average total score of performing screening tests for chronic diabetic complications (P<0.05) .
The prevalence of behaviors of monitoring to prevent chronic diabetic complications in community-dwelling type 2 diabetes patients was unsatisfactory, which was affected by the duration of diabetes since diagnosis, prevalence of chronic diabetic complications, the most recently measured HbA1c value, causes and results management of screening tests for chronic diabetic complications. In view of this, in the delivery of community-based management services, attentions should be paid to improving patients' initiative to actively and regularly observe their conditions and undergo relevant screening tests, thereby improving early diagnosis and treatment rates of chronic type 2 diabetic complications.
The integrated medical-elderly-nursing (IMEN) services are promising to be very effective in addressing healthcare problems in multiple chronic disease patients in an aging society, but the quality of the services has been less focused.
To identify the factors associated with community-dwelling chronic disease patients' experience of IMEN services, so as to provide a reference for improving the quality of IMEN services and the experience of this group.
From June to September 2020, a questionnaire survey was conducted with a convenience sample of 525 community-dwelling chronic disease patients with IMEN services selected from Hanghou, Zhejiang Province, to collect their individual characteristics, process of IMEN services, and experience of IMEN services. The Chinese version of SERVQUAL developed based on the GAP Model of Service Quality was used to measure the discrepancy between patients' expectations for IMEN services and their perceptions of the services. With referring to the structure-process-outcome model, a structural equation model was developed, assuming that the features of IMEN services (process factors) were influenced by patients' individual characteristics (structure factors) , and both of them affected patients' experience of IMEN services (outcome factors) .
The total average score of feeling and expectation of IMEN services for community patients with chronic diseases in Hangzhou was (5.14±0.44) , (6.80±0.01) , and the total average score of the gap between feeling and expectation was (-1.65±0.44) . Multiple linear regression analysis showed that gender, monthly income, payment method of medical expenses, number of illnesses suffered, prevalence of changing the service team, service items and number of service delivery patterns were associated with the discrepancy between patients' expectations for IMEN services and their perceptions of the services (P<0.05) . The analysis based on the structural equation model revealed that patients' experience of IMEN services was mainly directly affected by the features (duration of contracting the IMEN services, service items, and delivery patterns, smart medical care) of IMEN services (path coefficient=-0.51, P<0.001; direct effect size=-0.51, P=0.002) . Moreover, patients' experience of IMEN services was also directly influenced by individual characteristics (age, education level, self-care ability, number of illnesses) (direct effect size=-0.14, P=0.026) , and indirectly influenced by such individual characteristics through features of IMEN services (indirect effect size=-0.24, P=0.002) .
Community-dwelling chronic disease patients accepted the IMEN services, but their service experience needed to be improved further by interventions such as improving the utilization of IMEN services, enriching the service delivery patterns, making full use of smart medical care and providing more personalized services.
Development of an Incentive Model for General Practitioners in Fengxian District of Shanghai Based on Herzberg's Motivation-hygiene Theory
In view of the shortage of general practitioners (GPs) and limited community healthcare resources, it is urgently necessary for community health institutions to find accurate and scientific incentive methods to retain GPs and help them to realize their full potential, as well as promote the development of both community health institutions and GPs, thereby benefiting the health promotion of community residents.
To develop an incentive model for GPs to test the performance and effectiveness of current incentives for GPs, so as to put forward suggestions to improve the mechanisms of employing and retaining GPs.
In August 2019, we recruited 204 GPs from 11 community health centers (CHCs) in Shanghai's Fengxian District using stratified random sampling to attend an online survey using a questionnaire named General Practitioners' Perception and Evaluation of Incentive Measures developed based on our previous research results and Herzberg's motivation-hygiene theory. Then from August to September 2019, we invited directors responsible for medical care or public health issues, and medical quality control department heads from the above-mentioned 11 CHCs to attend an online survey using a questionnaire named Workload for General Practitioners in Community Health Centers of Fengxian District developed by usbased on a literature review. Then under the guidance of Herzberg's motivation-hygiene theory, we constructed a structural equation to develop an incentive model for GPs within Fengxian District with representative incentive policies, systems and initiatives related to GPs selected from the survey results as latent independent variables to measure GPs' (responders') perception and assessment of incentives, and with willingness to work, service radius, and workload of GPs as dependent variables.
The average scores for the implementation of incentive measures, and its associated influence on GPs' work status assessed by the 204 GPs were (0.77±0.14) , and (0.73±0.19) , respectively. The assessment score for implementation of incentive measures for GPs differed significantly by personal health condition and administrative position in the respondents (P<0.05) . The assessment score for the influence of implementing incentive measures on GPs' work status differed significantly by personal health condition in the respondents (P<0.05) . Spearman correlation analysis showed that GPs' work status was associated with the implementation of 25 incentive measures (one incentive measure at the subdistrict level was not included for analysis) (P<0.05) . The top three most highly correlated incentive measures were performance distribution (rs=0.652) , performance-based salary calculation (rs=0.621) , and wages and benefits (rs=0.614) . Partial correlation analysis indicated that, after controlling for variables such as the regional policy environment, the street and town government, and the work unit, the assessment score for implementation of either regional, or subdistrict or institutional incentive measures for GPs, was positively correlated with the assessment score for the influence of implementation of incentive measures for GPs on GPs' work status (r=0.381, 0.387, 0.528, P<0.001) . Theaverage assessment score for willingness to work by the respondents was (0.76±0.18) points. Theassessment scores of willingness to work by the respondents differed significantly by work unit (P<0.05) . Structural equation modeling revealed that the implementation of policy incentive measures influenced GPs' workload via GPs' willingness to work. Specifically, the implementation of policy incentive measures increased GPs' willingness to work (w1=0.43) , while GPs' willingness to work decreased with the increase of weighted workload (w2=-0.156) .
The GPs in Fengxian District showed higher level of willingness to work, namely, relatively high job stability, but they had not been incentivized by policy incentives to be competitive in obtaining improved performance, indicating that although policy incentives have produced partial effects on incentivizing GPs, the effects are still unsatisfactory. In the long run, it is necessary to consider whether there will be changes in GPs' retention status due to the lack of work initiative. For GPs, besides a guarantee of stable income, incentives to get more by doing more are also needed, which may be achieved by increasing the incentive authority and proportion of community health institutions when the total amount of incentives is limited.
Burnout and Associated Factors among Family Doctor Team Members in Different Types of Primary Healthcare Institutions：a Comparative Study
Burnout has become a prominent issue as the increase of workload in family doctor team members in primary healthcare institutions during the promotion of contracted family doctor services. There is still a lack of research comparing the differences in burnout among family doctor team members in different types of primary healthcare institutions.
To compare burnout prevalence and associated factors between family doctors in community/township health centers, and those in community health stations/village clinics, providing a basis for improving the mental health status and team stability of family doctors, as well as the quality of services provided by them.
From August 1 to 21, 2020, a multistage cluster random sampling method was used to select 760 family doctor team members〔201 (26.4%) working at community/township health centers, and 559 (73.6%) working at community health stations/village clinics〕 as the participants from primary healthcare institutions in 6 counties/county-level cities /districts of Taian City, Shandong Province. They were invited to attend a survey to complete Demographic Questionnaire and the Chinese version of Maslach Burnout Inventory-General Survey (MBI-GS) .
Overall, the prevalence of burnout among the participants was 68.9% (524/760) . Overall, the prevalence of burnout among the participants was 68.9% (524/760) , and the prevalence of burnoutof family doctor team members in community/township health centers and community health stations/village clinics was 63.7% (128/201) and 70.8% (396/559) , respectively. The levels of burnout of family doctor team members in community health stations/village clinics was higher than that of those in community/township health centers, with a statistically significant difference (P<0.05) . Family doctor team members in community health stations/village clinics had higher total score of MBI-GS and higher subscale score of reduction of professional efficacy than did those in community /township health centers, with a statistically significant difference (P<0.05) . Multivariate Logistic regression analysis showed that: for family doctor team members in community/township health centers, the risk of burnout of those aged 41-50 years is higher than that aged≤30 years〔OR (95%CI) =7.119 (1.770, 28.638) 〕, the risk of burnout of those with monthly income >4 000 yuan is lower than that with monthly income <2 000 yuan〔OR (95%CI) =0.194 (0.040, 0.941) 〕, the risk of burnout of those with high/very high self-rated work pressure is higher than that of those without/little self-rated work pressure〔OR (95%CI) =3.629 (1.475, 8.929) 〕, the risk of job burnout of those who evaluated the incentive mechanism as ordinary and relative effective/very effective was lower than that evaluated the incentive mechanism as very ineffective/less effective〔OR (95%CI) were 0.196 (0.052, 0.739) and 0.235 (0.066, 0.834) 〕. For the family doctor team members in community health stations/village clinics, the risk of burnout in women is lower than that in men〔OR (95%CI) =0.603 (0.396, 0.920) 〕, the risk of job burnout of those with general and relatively high/very high self-assessment residents' recognition is lower than that with very low/relatively low self-assessment residents' recognition〔OR (95%CI) were 0.258 (0.113, 0.590) and 0.428 (0.199, 0.918) 〕, the risk of burnout of those with high/very high self-rated job stress is higher than that without/little self-rated job stress〔OR (95%CI) =2.320 (1.368, 3.935) 〕.
Family doctor team members in community health stations/village clinics demonstrated higher burnout prevalence, and lower professional efficacy. To reduce the burnout prevalence and improve professional efficacy in family doctor team members, it is suggested to strengthen trainings, increase salary and further improve incentive mechanism for those in community/township health centers, and to increase the number of officially budgeted posts, and promotion opportunities as well as the propaganda of contracted family doctor services for those in community health stations/village clinics. Moreover, the workflow of contracting family doctor services should be simplified in all these institutions.
Sleep problems are increasingly common in residents with the acceleration of pace of life. Studies have shown that sleep duration is associated with chronic diseases such as hypertension and diabetes, but there is a lack of research on its association with hyperuricemia.
To assess the association and its dose-response level between sleep duration and hyperuricemia.
Data stemmed from the 2019 surveillance of epidemiology and risk factors of chronic diseases in adult residents in Haidian District, Beijing, involving individuals aged 18-79 years old, with an experience of living in Haidian District at least six months. The information was obtained via a face-to-face questionnaire survey, including the following aspects: demographics (sex, age, education level, marital status, occupation) , lifestyle factors (smoking and drinking, physical activity level, sleep duration) , history of chronic diseases (hypertension and diabetes) , height, weight, blood pressure, laboratory indices (fasting blood glucose, serum uric acid, and serum creatinine) . A multivariable Logistic regression model was used to assess the association between sleep duration and the risk of hyperuricemia, whose dose-response relationship was analysed using restricted cubic spline regression.
A total of 5 380 people were enrolled, with an average age of (46.9±16.0) years and an average sleep duration of (7.24±1.16) hours. Univariate Logistic regression analysis showed that, compared with those with 7-9 hours of sleep duration, the risk of hyperuricemia increased in those with less than 7 hours of sleep duration and in those with greater than 9 hours of sleep duration 〔OR (95%CI) =1.30 (1.12, 1.51) ; OR (95%CI) =1.48 (1.15, 1.89) 〕. After adjusting for age, gender, education level, marital status, occupation, smoking, drinking, physical activity level, BMI, hypertension, diabetes, and serum creatinine, the risk of hyperuricemia still increased in those with less than 7 hours of sleep duration and in those with greater than 9 hours of sleep duration 〔OR (95%CI) =1.37 (1.17, 1.62) ; OR (95%CI) =1.39 (1.07, 1.81) 〕. Restricted cubic spline regression analysis showed that sleep duration had a U-shaped association with hyperuricemia (non-linear test, χ2=27.530, P<0.001) .
Too longer or shorter sleep duration was a factor responsible for increased risk of hyperuricemia among adults in Haidian District of Beijing.
Barriers and Improving Paths to the Implementation of Contracted Family Doctor Services in China：an Analysis Using Smith's Policy Implementation Process Model
The contracted family doctor services (CFDSs) is a key action selected to be implemented to deepen the reform of the pharmaceutical and healthcare system, enrich primary care services, and achieve the strategic goals of health China. Moreover, the implementation of CFDSs is a main approach to better safeguarding people's health. To effectively promote the development of CFDSs, China has successively launched various relevant supportive policies, and the local governments have been actively exploring practicing approaches. So far, remarkable results have been achieved nationwide, yet there are still many challenges, among which implementation difficulty is a major factor influencing further promotion of CFDSs. We analyzed the implementation process of CFDSs using Smith's policy implementation process model, and identified many barriers to the implementation of CFDSs, such as lack of rule of law, low level of policy executors, insufficient incentives, and impact of policy environment. In view of this, we put forward the following recommendations on exploring innovative policies for sustainable development of CFDSs: designing top-level policy objectives for CFDSs development from perspectives of law and system, improving qualities and professional identity of providers of CFDSs, establishing mutual trust between doctors and patients, and optimizing the policy implementation environment.
Chronic Disease Patients Involved in Shared-decision Making in General Outpatient Care in the Community：Current Status and Associated Factors
The general practice clinic in community health centers is facing increasingly complex challenges to meet the medical needs of patients with chronic diseases. To improve chronic disease patients' health outcome and healthcare satisfaction, it will be of great significance to use shared decision-making (SDM) in the diagnostic and therapeutic process in the community, since SDM is a model based on doctor-patient mutual respect and cooperation and shows great promise as a possible major medical decision-making model.
To understand the status and associated factors of chronic disease patients involved in SDM in general outpatient care in the community, aiming to provide evidence for promoting the implementation of SDM in primary care.
We used cluster sampling to select seven general practitioners (GPs) in the clinic of Shuangyushu Community Health Center, Beijing, and 149 chronic disease patients seen by them between October 2019 and January 2020 as the participants. Through non-participant observation at the clinic, we used the Chinese version of the Observer OPTION 5 (OPTION-5) as an assessment tool to evaluate the extent to which GPs facilitated patient participating in SDM during the consultation. We used a self-developed general demographic questionnaire to collect patients' demographics, status of illness and treatment, as well as GPs' demographics. We compared the OPTION-5 score of the patients by demographic factors, and used stepwise multiple linear regression to explore the factors affecting patients' participation in SDM.
The mean visit length, and OPTION-5 score for the 149 patients were (4.1±2.7) minutes, and〔6.00 (3.00) 〕, respectively. The OPTION-5 score varied significantly across patients by age group and visit length (P<0.05) . Multiple linear regression analysis showed that patient visit length, prevalence of interruption of counseling due to other people, and prevalence of family member accompaniment to medical visits were associated with patients' participation in SDM (P<0.05) .
The participation of these patients in SDM was relatively low. Prolonging GP-patient communication time, ensuring that the diagnosis and treatment process is not interrupted, and giving patients a private space during diagnosis and treatment process may be feasible interventions to improve the participation of chronic disease patients in SDM in primary care.
With the rapid population aging in China, cognitive impairment in older adults has become a growing public health concern.
To examine the association between nighttime sleep duration and cognitive impairment among community-dwelling older adults.
Data were derived from the cohort of Older Adult Health and Modifiable Environmental Factors established in Fuyang City from July to September 2018, among whom a total of 4 837 older adults with complete data on cognitive function and sleep time were included in this study. General demographic characteristics〔gender, age, living area (urban or rural), education level, occupation, marital status〕, living habits, the history of chronic diseases, sleep duration, and overall cognitive function were extracted. Binary Logistic regression models were used to analyze the association between nighttime sleep duration and cognitive impairment. Restrictive cubic splines were used to further determine potential dose-response relationships between them.
The participants had a mean nighttime sleep duration of (6.95±1.75) hours, among whom 1 773 (36.65%) slept ≤6 hours per day, 2 088 (43.17%) slept >6-8 hours per day, and 976 (20.18%) slept >8 hours per day. The detection rate of cognitive impairment was 37.44% (1 811/4 837). After adjusting for gender, age, living area, education level and other confounding factors, the detection rate of cognitive impairment was 1.26〔95%CI (1.09, 1.46) 〕 times higher in older adults with nighttime sleep duration of ≤6 hours, and was 1.22〔95%CI (1.03, 1.46) 〕 times higher in older adults with nighttime sleep duration of >8 hours than in those with nighttime sleep duration of >6-8 hours (P<0.05). The detection rate of cognitive impairment in male older adults with nighttime sleep duration of >8 hours was 1.35〔 (95%CI (1.06, 1.72) 〕 times higher than in those with nighttime sleep duration of >6-8 hours (P<0.05). The detection rate of cognitive impairment in female older adults with nighttime sleep duration of≤6 hours was 1.29〔95%CI (1.06, 1.58) 〕 times higher than in those with nighttime sleep duration of >6-8 hours (P<0.05). The restriction cube spline curve showed an approximate U-shaped relationship between nighttime sleep duration and the risk for cognitive impairment, with the lowest risk at 7 hours.
Both shorter and longer nighttime sleep duration may be independent and dose-dependent risk factors for cognitive impairment in older adults. The optimal sleep time is about 7 hours. The association between longer sleep duration and cognitive impairment is pronounced in males, while the association between shorter sleep duration and cognitive impairment is pronounced in females.
Effect of Core Values of General Practice on Adherence of Patients with Diabetes
Treatment adherence is closely related to disease control for patients with diabetes. Primary care is general, and continuous, which may satisfy the general and continuous healthcare needs of diabetic patients. But the association of core values of general practices with adherence of diabetic patients is not yet clear.
To explore the effect of core values of general practice (first contact/first line care, continuity, accessibility, comprehensiveness, coordination and patient-oriented) on the adherence (medication adherence, diet adherence, exercise adherence, self-monitoring adherence and regular hospital visits adherence) of type 2 diabetic patients, providing a reference for improving the adherence of such patients by precisely enhancing the core values of general practices.
A survey was conducted between August and September 2019 with a convenience sample of type 2 diabetics receiving contacted family doctor services from Shayuan Community Health Center of Guangzhou using a questionnaire consisting of three parts〔demographic information, the Chinese version of Primary Care Assessment Survey (ASPC) , and Adherence to Out-of-hospital Treatment of Type 2 Diabetics (AOTTD) 〕. Treatment adherence was compared by various personal factors. Multiple linear regression was used to analyze the association of the core values of general practice with treatment adherence.
Altogether, 224 cases who handed in responsive questionnaires were included for final analysis. The average scores of AOTTD, and ASPC of the respondents were (80.57±11.27) and (72.95±11.40) , respectively. The scores of AOTTD differed significantly by sex and understanding level of type 2 diabetes (P<0.05) . The total score of ASPC and the score of its each domain were associated with the total score of AOTTD, or the domain score of regular hospital visits (P<0.10) . The scores of two domains (accessibility and coordination) of the ASPC were associated with the medication adherence score (P<0.10) . The domain score of coordination was associated with the diet adherence score (P<0.10) . The score of each domain of the ASPC (except for coordination) was associated with the self-monitoring adherence score (P<0.10) .
For type 2 diabetics, strengthening each of the core values of general practice could contribute to the increase of their treatment adherence, and regular hospital visits adherence. Improving the accessibility of general practice could enhance their medication adherence. Improving the coordination of general practice could enhance their medication adherence and diet adherence. Improving first contact/first line care, continuity, accessibility, comprehensiveness, coordination and patient-oriented values of general practice could contribute to the increase of their medication adherence. But no association was found between the core values of general practice and patients'exercise adherence, which suggests that providing more exercise resources and environmental support for these patients may be a solution.
Maintaining brain health is an advanced goal of healthy ageing. Eating a diet with appropriate nutrients has been identified as a promising approach to reducing the risk of dementia, but community-dwelling residents have inadequate or no health guidance from medical workers since there is no detailed and comprehensive clinical dietary nutrients management program for brain health promotion for community-dwelling people .
To search, evaluate and summarize the evidence on dietary nutrients management for brain health promotion in community-dwelling people, providing an evidence-based basis for clinical implementation of such management for this group of population.
In March 2022, we searched UpToDate, BMJ Best Practice, JBI Model of Evidence-based Healthcare, National Institute on Aging, Registered Nurses' Association of Ontario, the Cochrane Library, PubMed, CNKI, Medlive and other databases to collect literature (involving clinical decisions, recommended practices, guidelines, evidence summaries, expert consensuses and systematic reviews) regarding dietary nutrients management for brain health promotion in community-dwelling people. The retrieval period was from January 1, 2017 to March 29, 2022. Two researchers systematically trained in evidence-based medicine independently screened literature, extracted data, and evaluated the quality of the included literature. Then evidence was extracted from the included literature, and its quality was graded, then the best evidence was summarized.
A total of 28 studies with an overall high methodological quality were included, including three clinical guidelines, five expert consensuses, one clinical decision and 19 systematic reviews. Finally, 23 pieces of best evidence were summarized, involving seven aspects of intervention timing, dietary nutrients assessment and screening, dietary patterns and components, specific nutrients, coffee intake, body weight management, health education and guidance.
Eating a diet with appropriate nutrients can promote brain health of residents. Community medical workers should develop an individualized dietary nutrients management program for brain health for them in accordance with the practical clinical situation, residents' current dietary nutrients status and preferences, and insights from the best evidence.
It is a great challenge to ensure medication safety in healthcare for older adults, since polypharmacy in this group may increase the risk of potentially inappropriate medications, leading to adverse drug reactions, drug-drug interactions, hospitalizations, increased medical costs, and even deaths. Deprescribing improves patient prognosis and reduces adverse drug events through patient participation, and shared decision-making. The prevalence of multimorbidity and polypharmacy in older adults is notably in community care, the frontline for the management of use of multiple drugs. As primary care physicians have a deep understanding of patients' past and current diagnoses and treatments, they play a vital role in reviewing and managing patients' medications. However, there are few reports on deprescribing in primary care in China. We described the definition of deprescribing, and reviewed its recent advances, with a focus on the implementation process of deprescribing in the community, and the impact of deprescribing on chronic disease management by primary care physicians. This review may provide a reference for further study and policy making regarding deprescribing in the community in China.
Hypertensive patients with moderate or high risk of ASCVD had low lipid goal attainment rate. And those with high risk of ASCVD and concomitant other high risk factors had unsatisfactory lipid control status. Attention should be paid to the management of blood lipid in hypertension patients to improve their blood lipid control rate and reduce their risk of ASCVD.
Prevalence and Influencing Factors of Sedentary Behavior in Community Stroke Patients
As a kind of unhealthy lifestyle, sedentary behavior is closely related to poor prognosis of stroke patients. So it is of great significance to understand sedentary behavior prevalence in stroke patients, and to formulate intervention measures based on its influencing factors.
To investigate sedentary behavior prevalence and associated factors in stroke patients in the community, providing a reference for the development of targeted interventions.
From August to December 2020, by use of convenience sampling, 230 eligible community stroke patients from Zhengzhou (including individuals who underwent reexaminations in neurology and neurosurgery clinics of three grade A tertiary hospitals and those who were from three communities) were selected to attend a survey using Demographic Questionnaire, Sedentary Behavior Questionnaire, the Chinese version of Fatigue Severity Scale, the Chinese version of Stroke Self-Efficacy Questionnaire, and Social Support Scale. Binary Logistic regression analysis was used to explore associated factors of sedentary behavior.
The survey achieved a response rate of 97.8%. The average daily sedentary time of the respondents was (7.10±2.75) hours, and 179 cases (79.6%) had daily sedentary time ≥5 hours. The daily sedentary time differed significantly by age, living in rural or urban areas, education level, number of complications, number of chronic diseases and fatigue (P<0.05) . Binary Logistic regression analysis showed that age, number of complications, number of chronic diseases and fatigue had significant impacts on sedentary behavior (P<0.05) .
The prevalence of sedentary behavior in community-dwelling patients with stroke was high. It is recommended that health managers develop targeted interventions measures based on the above factors associated with sedentary behavior, thereby reducing sedentary behavior prevalence in this group.
Difficult problems such as poor diagnosis and treatment capacity of diabetes in the community, low screening rate of complications, low standardized monitoring rate of blood glucose, and low rate of blood glucose compliance are the problems that general practitioners need to think about and solve when carrying out management of diabetes patients. It is necessary to explore and innovate the standardized management mode of diabetes in the community for making general practitioners become specialists in the general practice and achieve "precision management combining general care and specialty care".
To understand the management effect of diabetes "1358 model" on community diabetes patients based on "precision management combining general care and specialty care".
A total of 212 patients with diabetes who visited the outpatient clinic at the Hongkou District North Bund Street Community Health Service Center from May to July 2020 and had signed a contract with the community general practitioner were selected as the research subjects and divided into 106 cases in the control group and 106 cases in the intervention group by the random number table method. The patients in the control group received routine follow-up management, and the patients in the intervention group received the "1358 model" of diabetes based on "precision management combining general care and specialty care". One year after the intervention, the cognitive and behavioral levels of diabetes, the attainment of key indicators and the experience of visiting community health centers were compared between the two groups.
There was no statistically significant difference in the cognition and behavior related to diabetes management and the attainment rate of key indicators between the two groups (P>0.05). After intervention, the proportions of patients in the intervention group who monitored FPG within 1 month, monitored 2 hPG within 1 month, carried out comprehensive blood glucose monitoring within 1 month, monitored HbA1c within 6 months, carried out self-monitoring of blood glucose, recorded a blood glucose diary, standardized the use of medication, followed the doctor's advice on diet, screened for peripheral vascular complications within 1 year, screened for urinary albumin/creatinine within 1 year, screened for carotid artery plaques within 1 year, screened for the inner ocular fundus within 1 year were higher than those of the control group, and the difference was statistically significant (P<0.05) ; however, there was no significant difference in the proportions of patients with regular exercise and weekly foot examination between the two groups (P>0.05). After the intervention, the rates of FPG attainment, HbA1c attainment and ABC composite attainment of patients in the intervention group was higher than those of the control group, and the difference was statistically significant (P<0.05) ; however, there was no statistically significant difference in the 2 hPG attainment rate between the two groups (P<0.05). The proportions of patients who thought that the community diagnosis and treatment capacity was good, the community drugs basically met the demand, the community had testing equipment for blood glucose-related indexes, the community could solve the basic health problems, the community could carry out screening for complications, the community consultation and guidance for specialized diseases was convenient in the intervention group were higher than those of the control group, and the difference was statistically significant (P<0.05) .
The "1358 model" of diabetes based on "precision management combining general care and specialty care" is of positive significance in promoting and improving patients' health beliefs, standardizing blood glucose monitoring behavior, improving the rate of compliance with key indicators, and enhancing community medical experience, which can be promoted and applied in the community. This model may break through the bottleneck of insufficient resources of diabetes specialty in the community, and further improve the management level and service connotation of diabetes specialty of general practitioners.
Myopia is an important cause of visual impairment and has become a public health problem all over the world. In China, myopia has a high incidence rate and age of onset of which is becoming younger. There is no clinical method to reverse myopia in children. Therefore, it is important to standardize the screening for ametropia to realize early detection and intervention of myopia. As a primary care institution, a community health center may accurately understand the prevalence of myopia in teenagers in its service coverage area. So giving full play to the role of community health center has important practical significance for the containment of myopia in children and adolescents.
To explore the feasibility of community-based prevention and control of myopia in school-age children.
A cohort study was conducted. The information about visual acuity and refractive status of students in a primary school in Beijing's Chaoyang District from September 2019 to September 2021 were collected for statistical analysis, among which four groups of data in September 2019, September 2020, March 2021 and September 2021 were finally included according to the inclusion and exclusion criteria, with a total of 5 558 records. Then, based on the data, an electronic students' refractive database was established, with uncorrected visual acuity, corrected visual acuity, refractive status (power of a spherical lens, power of a cylindrical lens, axis) , prevalence of wearing glasses or orthokeratology incorporated. The warning levels of vision screening were set to be 0, 1, 2 and 3 from low to high. The visual change, visual warning level, spherical equivalent (SE) of students were compared by grade. The visual changes and warning level evolution at different times were compared at the individual level. Corresponding interventions were implemented for different warning levels, and the intervention results were analyzed and discussed.
There were statistically significant differences in uncorrected distance visual acuity (UDVA) among students by grade (F=100.413, P<0.05) . The UDVA differed significantly in male or female students (F=47.168, 53.042, P<0.05) . Compared with the lower grade students (grades 1 and 2) , middle and higher grade students (grades 3, 4, 5 and 6) had lower UDVA (P<0.003) . The UDVA decreased with the increase in grade in male and female students, and the decline in female students was faster. The composition of the warning levels of myopia risk assessed based on the UDVA in male and female students in all grades was similar, mainly composed of 0, 1, and 3 levels. With the increase in grade, the number of low warning level (level 0) gradually decreased, while that of high warning level (level 3) gradually increased. The SE in students differed obviously by grade (F=474.728, P<0.05) . The SE also differed much in male or female students (F=121.704, 123.807, P<0.05) . With the increase of grade, SE tended to be negative, and the difference in SE between left and right eyes was statistically significant (t=-4.67, P<0.05) . The negative trend of SE for the right eye was more remarkable, suggesting that the warning level of the right eye was higher, and the right eye was more prone to myopia. The follow-up of three consecutive years for assessing individual visual changes revealed that the results of four UDVA screening differed significantly in all students and female students (F=8.727, 10.221, P<0.05) . The UDVA result screened in March 2021 for all students decreased significantly compared with that screened in September 2019 or September 2020 (P<0.008) , so did the UDVA result screened in September 2021 (P<0.008) . During the evolution of warning level, higher warning level was associated with lower possibility of returning to the low warning level, and the possibility of progressing to a higher warning level increased with the growth of warning level.
The visual acuity and refractive status of students in this primary school in Beijing's Chaoyang District were not optimistic. With the increase in grade, the UDVA decreased and the number of high warning level gradually increased. To actively contain myopia in school-age children, it is suggested to establish a community-based vision screening and warning mechanism, and to promote the containing of myopia by home-school-community collaboration efforts.
Poor sleep quality in older adults is closely associated with a range of adverse health outcomes. Strengthening sleep health and rehabilitation management within existing primary healthcare for older adults can help prevent or slow the onset and progression of many chronic diseases, thereby saving substantial medical resources. However, a comprehensive sleep-rehabilitation management system has yet to be established at the primary healthcare level. To address this gap, the Community Rehabilitation Working Committee of Chinese Rehabilitation Medical Association, has developed the Chinese Expert Consensus on Sleep Health and Rehabilitation Management for Community-dwelling Older Adults (2025 Edition), in collaboration with experts from multiple domestic institutions. Grounded in evidence-based research on sleep rehabilitation and informed by multidisciplinary clinical experience, the consensus considers the current availability of community-level rehabilitation resources and future trends in primary healthcare. It offers consensus-based recommendations on age-related changes in sleep physiology, goals and requirements for sleep management, rehabilitation screening and assessment, management content, and procedural workflows. The publication of this consensus is expected to play a pivotal role in guiding primary healthcare institutions to implement standardized and evidence-based management of sleep rehabilitation in older adults.
With the further aging of the population, the incidence of cognitive impairment is increasing, and there is a lack of effective treatments. The construction of an accurate risk prediction model can be used to help community healthcare workers to identify, warn and intervene with potential patients at an early stage, and to reduce the pressure on social healthcare.
This study aims to construct a prediction model for the risk of cognitive impairment in older adults in the community, analyse the influencing factors of cognitive impairment in older adults, and provide empirical references for the development of targeted interventions.
In April 2024, elderly people aged ≥60 years were selected from the China Health and Retirement Longitudinal Survey (CHARLS) 2020 database (n=7 334) , and their socio-demographic characteristics and data on their health status and behaviours, activities of daily living (ADL) , depression, and cognitive abilities were collected. They were randomly divided into a training set (n=5 133) and a validation set (n=2 201) in a ratio of 7∶3. The best predictor variables were screened using LASSO regression ten-fold cross-validation, the factors influencing cognitive impairment in older adults were analysed using Logistic regression, and nomagram were constructed, and the performance of the predicion model was assessed using the area under the curve of the subject work characteristics (ROC) curves and the analysis of the calibration curves.
The detection rate of cognitive impairment in older adults was 14.48% (1 062/7 334) . LASSO regression screened nine potential predictor variables, which were age, type of residence, marital status, gender, education, exercise, society, activity of daily living, and depression. The results of multifactorial Logistic regression analysis showed that age [OR (95%CI) =1.238 (1.109-1.504) for 70-79 years old and OR (95%CI) =2.231 (1.546-3.222) for ≥80 years old using 60-69 years old as a reference] , type of residence [OR (95%CI) =2.144 (1.617-2.842) for rural using urban as a reference] , marital status [OR (95%CI) =0.691 (0.562-0.851) for no spouse, using spousal as a reference] , education [OR (95%CI) =0.209 (0.173-0.254) for primary school and below, using illiteracy as a reference, and for junior high school OR (95%CI) =0.059 (0.038-0.090) , OR (95%CI) for high school/vocational high school=0.043 (0.021-0.089) , and OR (95%CI) for college and above=0.038 (0.005-0.280) ] , and society [with no society as a reference, and OR (95%CI) with society=0.746 (0.624-0.892) ] , ability to perform ADL [OR (95%CI) =1.529 (1.171-1.997) with no impairment as a reference and OR (95%CI) =1.580 (1.319-1.891) with impairment] , and depression [OR (95%CI) =1.580 (1.319-1.891) with no depression as a reference and OR (95%CI) =1.580 (1.319-1.891) with depression] were the influencing factors of cognitive impairment (P<0.05) . Based on the seven predictor variables screened by multifactor Logistic regression analysis, a prediction model was established. The areas under the ROC curves of the prediction model in the training and validation sets were 0.821 (95%CI=0.805-0.836) and 0.839 (95%CI=0.817-0.861) , respectively; the Hosmer-Lemeshow test χ2=5.022 (P=0.755) and χ2=3.963 (P=0.860) ; calibration curves showed significant agreement between predicted and actual values.
In this study, a prediction model for the risk of cognitive impairment in community-dwelling older adults containing a total of seven indicators, including age, residence, and so on, was established, and the prediction model had good accuracy and differentiation, which can be used to identify the risk of developing cognitive impairment in older adults.
With the deepening of the new medical reform, the "short slabs" of the current financial compensation mechanism for primary care institutions has been gradually revealed. Compensation mechanism still needs to be further improved for the existence of painful and difficult problems such as insufficient "endogenous power" of primary care institutions, low efficiency in the use of financial funds, and the compensation mechanism still needs to be improved.
To explore and establish a service output, more simple and easy-to-use, scientific and reasonable financial compensation calculation model based on equivalent method, so as to provide a reference for the financial compensation of government-run community health service institutions.
Based on the cost calculation of the equivalent method, the policy analysis and literature review method were used to sort out the financial compensation policies, and the important parameters of the model were determined through expert consultation to build the financial compensation calculation model and financial compensation budget model. The application effect of the model was further evaluated by calculating the financial compensation of 14 community health care institutions in Beijing from 2019 to 2021.
The constructed financial compensation calculation model was mainly composed of three parts, including service equivalent (D), compensation standard per equivalent (PG) and adjustment coefficient (T), the financial compensation budget model was built on this basis. 14 institutions were taken as examples to calculate the financial compensation, the average calculated financial compensation amount of each institution in 2021 was 45.961 0 million yuan, and the average actual subsidy income of each institution was 44.546 8 million yuan, slightly lower than the calculated financial compensation amount. The average budgeted service equivalent for the 14 institutions in 2022 was 1 139 900 000 equivalents and the average budgeted financial compensation was 50.234 3 million yuan.
The data source of financial compensation calculation model based on equivalent method is standardized and easily available, which is convenient for promotion and use. It was suggested to explore a new model of financial compensation and flexibly use the adjustment coefficients, so that the financial compensation model can better meet the needs of high-quality development.
All levels of China gevernment departments have attached importance to community health management services, an important way for disease prevention and resident saveealth improvement, and successively promulgated relevant management policies. However, there is a lack of systematic review and research on the diffusion paths and characteristics of these policies, which are still unclear due to the diversity of promulgating agencies and types of polices.
To explore the process and features of the diffusion of China community health management policies, providing a reference for the formulation and promotion of these kinds of policies.
From June to September 2021, we searched policy documents related to community health management services published from January 1997 to September 2021 in the official websites of all levels of government and health administrative departments, as well as authoritative databases such as PKULAW.com and so on, then quantitatively analyzed the process and features of diffusion of them in terms of four aspects (intensity, breadth, speed, and direction of diffusion) using policy network analysis and keyword analysis by time series.
A total of 1 540 policies related to community health management were retrieved (including 159 central policies and 1 381 local policies) . The development of community health management services in China may be divided into five stages: germination (1997—2004) , formation (2005—2008) , transition (2009—2012) , initial development (2013—2015) and innovation and development (2016—2021) . Policies which were diffused more intensively and widely were promulgated by central agencies of higher administrative levels, and mainly classified as planning, opinions, and laws. The absolute diffusion breadth of the top 10 policies in terms of diffusion intensity exceeded 30, and the absolute diffusion breadth of the top 10 policies in terms of spreading breadth exceeded 20. The diffusion speed of most policies showed a trend of first increasing and then slowing down over time. The diffusion of Chinese medicine health management policies mainly presented parallel diffusion among policy promulgating agencies at the same level, and top-to-bottom diffusion from the central policy promulgating agencies to the local ones.
Through policy diffusion research, we had a comprehensive understanding of the process and characteristics of diffusion of China's community health management policies, and drew a number of conclusions, including the five-stage development of these policies, and the policy diffusion process may be affected by the attributes of the administrative level of the promulgating agencies and types of policies. In addition, the diffusion of these policies could be achieved via multiple paths, with many mechanisms of action such as learning and imitation, with a speed of "first increasing, then slowing down" over time.
Community-based Emergency Care for Older Adults: Current Status in China and International Research Advances
Due to high chronic disease prevalence and attacks as well as high incidence of injuries, the needs of emergency care resources are growing in the increasing number of older people. The traditional hospital-based emergency care in China has many limitations, such as high rate of invalid ambulance attendance in prehospital emergency care, long ambulance response time, and the occupation of a great amount of emergency care resources by non-urgent callers. Against the background of advocating tiered diagnosis and treatment, communities have been increasingly appreciated for their roles in prehospital emergency care for older adults, including monitoring and early warning, emergency dispatch and on-site treatment, and health education. In foreign countries, communities have demonstrated better practice. In China, despite many scholars' implementation recommendations, communities still have a lot of room for development. We reviewed the advances in above-mentioned three roles of communities in prehospital emergency care for older people, providing insights into the use of communities for emergency care in an aging society.
Exploration of Primary General Medical Care Quality Management：a Case Study of Shanghai General Practice Clinical Quality Control Center
The general medical care quality management system plays an essential and key role in assuring the quality of general medical care and patient safety in primary care settings. There are no unified criteria and methods for assessing the primary general medical care quality, and rare relevant quality improvement research and practical explorations in China.We reviewed the primary general medical care quality management nationwide, and highlighted the problems, then particularly detailed the three-year (2018—2020) implementation status and achievements of Shanghai, in which the primary general medical care quality was managed by Shanghai General Practice Clinical Quality Control Center (hereinafter referred to as Quality Control Center) in an exploratory way. And the management actions taken by the quality control center were as follows: defining the organizational objectives and tasks; developing the organizational framework and allocating workers; establishing municipal-and district-level organizational networks and operational systems for primary general medical care quality control; developing the inspection indicators for assuring primary general medical care quality; conducting an annual investigation of the general medical care in each of the primary care settings in Shanghai, and providing targeted guidance as well as supervision. The actions of the Quality Control Center provide strong support for quality improvement and safety assurance of primary general medical care. And the practical explorations of the Quality Control Center could be a reference for improving primary general medical care quality management nationwide. To improve the primary general medical care quality management at the naitonal level, which is still in its early phase, we put forward four recommendations: improving the development of the organization system, developing a scientific system for assessing the primary general medical care quality, comprehensively and dynamically carrying out quality controlsupervision regarding primary general medical care, and strengthening the quality controlsupervision.
Special Issue:community health service
