Strengthening China’s National Essential Public Health Services Package for hypertension and diabetes care: protocol for an interrupted time series study with mixed-methods process evaluation and health economic evaluation

Background: Despite major primary health care (PHC) reforms in China with the 2009 launch of the National Essential Public Health Service Package, the country experiences many challenges in improving the management of non-communicable diseases in PHC facilities. “EMERALD” is a multifaceted implementation strategy to strengthen the management of hypertension and type-2 diabetes mellitus (T2DM) in PHC facilities. The study aims to: (1) examine the effectiveness of EMERALD in improving hypertension and T2DM management; (2) evaluate the implementation of the interventions; and (3) use the study findings to model the long-term health economic impact of the interventions. Methods: The EMERALD intervention components include: (1) empowerment for PHC providers through training and capacity building; (2) empowerment for patient communities through multi-media health education; and (3) empowerment for local health administrators through health data monitoring and strengthening governance of local PHC programs. An interrupted time series design will be used to determine the effectiveness of the interventions based on routinely collected health data extracted from local health information systems. The primary effectiveness outcome is the guideline-recommended treatment rates for people with hypertension and T2DM. Secondary effectiveness outcomes include hypertension and T2DM diagnosis and control rates, and enrolment and adherence rates to the recommended care processes in the National Essential Public Health Service Package. A mixed-methods process evaluation will be conducted to evaluate the implementation of the interventions, including the reach of the target population, adequacy of adoption, level of implementation fidelity, and maintenance. Qualitative interviews with policy makers, health administrators, PHC providers, and patients with hypertension and/or T2DM will be conducted to further identify factors influencing the implementation. In addition, health economic modelling will be performed to explore the long-term incremental costs and benefits of the interventions. Discussion: This study is expected to generate important evidence on the effectiveness, implementation, and health economic impact of complex PHC interventions to strengthen the primary care sector’s contribution to addressing the growing burden of non-communicable diseases in China. Trial registration: The study has been registered on Chinese Clinical Trial Registry at https://www.chictr.org.cn/ (Registration number ChiCTR2400082036, on March 19th 2024)

The Human Phenotype Ontology in 2024: phenotypes around the world.

The Human Phenotype Ontology (HPO) is a widely used resource that comprehensively organizes and defines the phenotypic features of human disease, enabling computational inference and supporting genomic and phenotypic analyses through semantic similarity and machine learning algorithms. The HPO has widespread applications in clinical diagnostics and translational research, including genomic diagnostics, gene-disease discovery, and cohort analytics. In recent years, groups around the world have developed translations of the HPO from English to other languages, and the HPO browser has been internationalized, allowing users to view HPO term labels and in many cases synonyms and definitions in ten languages in addition to English. Since our last report, a total of 2239 new HPO terms and 49235 new HPO annotations were developed, many in collaboration with external groups in the fields of psychiatry, arthrogryposis, immunology and cardiology. The Medical Action Ontology (MAxO) is a new effort to model treatments and other measures taken for clinical management. Finally, the HPO consortium is contributing to efforts to integrate the HPO and the GA4GH Phenopacket Schema into electronic health records (EHRs) with the goal of more standardized and computable integration of rare disease data in EHRs

Robust estimation of bacterial cell count from optical density

Optical density (OD) is widely used to estimate the density of cells in liquid culture, but cannot be compared between instruments without a standardized calibration protocol and is challenging to relate to actual cell count. We address this with an interlaboratory study comparing three simple, low-cost, and highly accessible OD calibration protocols across 244 laboratories, applied to eight strains of constitutive GFP-expressing E. coli. Based on our results, we recommend calibrating OD to estimated cell count using serial dilution of silica microspheres, which produces highly precise calibration (95.5% of residuals <1.2-fold), is easily assessed for quality control, also assesses instrument effective linear range, and can be combined with fluorescence calibration to obtain units of Molecules of Equivalent Fluorescein (MEFL) per cell, allowing direct comparison and data fusion with flow cytometry measurements: in our study, fluorescence per cell measurements showed only a 1.07-fold mean difference between plate reader and flow cytometry data

Leveraging Primary Health Care to Improve Hypertension and Type 2 Diabetes Management in China

Introduction To combat the growing burden from non-communicable diseases (NCDs), the Chinese government has committed to strengthening its primary health care (PHC) sector over the past decade. One key policy is the National Essential Public Health Service Package (NEPHSP) launched in 2009, which requires PHC facilities to provide basic public health services to all residents, including two NCDs – hypertension and type 2 diabetes mellitus (T2DM). Despite this major reform initiative, there remain substantial systemic challenges in improving PHC capacity to prevent and manage NCDs in China. This thesis aims to: (1) comprehensively appraise the current management of hypertension and T2DM within the NEPHSP in PHC settings; and (2) work with stakeholders to develop strategies for improvements in selected sites. Methods This thesis consists of five independent but inter-related studies, using a mixture of review, quantitative and qualitative evaluations. I first conducted a scoping review of China’s central government policies on strengthening the management of NCDs in PHC since 2009 (Chapter 2). Then, I conducted a mixed-methods evaluation of the uptake of NEPHSP for hypertension and T2DM management at selected sites in China, combining PHC facility surveys and qualitative interviews with key informants (Chapter 3). Following these two studies, I constructed “care cascades” to understand gaps in care for hypertension and T2DM in three provinces, based on routinely collected data from local health information systems (Chapter 4). I then conducted a co-design study to develop a suite of interventions to strengthen hypertension and T2DM management in China’s PHC, engaging academic experts, policy makers, local health administrators, PHC providers, and people living with NCDs (Chapter 5). Finally, I developed a trial protocol using an interrupted time series design and mixed methods process evaluation to examine the effectiveness and implementation of the interventions (Chapter 6). Results The scoping review identified 14 major policy initiatives on PHC strengthening for NCD control in China, including the NEPHSP, cultivation of PHC providers, and digitisation of health systems. There was a limited emphasis on multi-sectoral collaboration, mobilisation of non-health-professionals, and quality-oriented services evaluations. In the mixed methods study (seven study sites, 518 facility surveys, 48 individual interviews, and 19 focus group discussions), despite evidence of improvements in PHC workforce capacity and infrastructure, there remained ongoing challenges with insufficient and under-qualified PHC personnel, variable access to essential medicines and equipment, fragmented information systems, and low community trust in and utilisation of PHC services compared with hospital-based services. The care cascade study found that only 46.0% and 45.6% of those estimated with hypertension and T2DM respectively were diagnosed. Of those diagnosed with hypertension and T2DM, 37.5% and 40.2%, respectively, were enrolled in the NEPHSP, receiving treatments, and achieving control targets. Working closely with key stakeholders, three major intervention strategies were identified in the co-design study, including strengthening PHC workforce capacity through regular training, enhancing patient and community health literacy through multi-media health education, and supporting local health administrators through routinely collected data monitoring and strengthening the governance of local public health programs. Conclusions Taken together, the five studies provide a contemporary evidence base for PHC policy and practice for NCD management in China. Key strategies to optimise PHC capacity and service quality include workforce capacity enhancements, greater engagement with communities, and strengthening local governance. The co-designed interventions developed in three provinces will be rigorously evaluated to assess their potential to improve PHC management of NCDs in China

Strengthening urban primary healthcare service delivery using electronic health technologies: A qualitative study in urban Nepal

Background Nepal is a South Asian country with a high burden of non-communicable diseases. Electronic health technologies are a promising strategy to mitigate the rising burden of non-communicable diseases by strengthening primary healthcare center service delivery. However, electronic health implementation in Nepal is limited. Furthermore, electronic health use at the primary healthcare center level is chronically understudied. This qualitative study seeks to understand the perceived awareness, benefits, and determinants of electronic health uptake in Nepal, focusing on primary healthcare center-level non-communicable disease management. Methods We conducted in-depth interviews with 27 participants including policymakers, health experts, facility administrators, providers, and non-communicable diseases patients in 2019. We selected six urban primary healthcare center facilities via cluster convenience sampling for recruiting facility administrators, providers, and patients, and used convenience sampling to recruit policymakers and experts. We conducted thematic data analysis inductively and deductively using the electronic health readiness assessment framework to understand perceived barriers and facilitators of electronic health implementation. Results While there was general awareness and acceptance of electronic health, multiple barriers impede readiness for implementation. These include policy making gaps, language barriers, low user technical literacy, concerns of overreliance on technology, and inadequate training for administrators and providers. Stakeholder suggestions include creating electronic health interfaces that meet the needs of end users (providers and patients), providing training to enable end users to effectively use electronic health technologies, and strong policy support at the national level. Conclusion We identify several determinants for effectively promoting the use of electronic health for non-communicable diseases service delivery at the primary healthcare center level in Nepal

Association of Maternal Longitudinal Hemoglobin with Small for Gestational Age during Pregnancy: A Prospective Cohort Study

Background: Few studies have investigated the association of maternal longitudinal hemoglobin (Hb) with small for gestational age during pregnancy. The current study examined the associations of maternal Hb concentrations and Hb changes throughout the middle and late stages of pregnancy with small for gestational age (SGA) in a large prospective cohort study. Methods: This was a prospective cohort study, which enrolled pregnant women at 8–16 weeks of gestation and followed up regularly. Maternal Hb concentrations were measured at the middle (14–27 weeks) and late (28–42 weeks) stages of pregnancy, and the Hb change from the middle to late stage of pregnancy was assessed. The Log-Poisson regression model was used to identify the association of maternal Hb with SGA, including the implications of Hb during specific pregnancy periods and Hb change across the middle to late stages of pregnancy. Of the total 3233 singleton live births, 208 (6.4%) were SGA. After adjusting for potential confounders, compared with Hb 110–119 g/L, Hb ≥ 130 g/L at late pregnancy was significantly associated with a higher risk of SGA (adjusted RR: 2.16; 95% CI: 1.49, 3.13). When Hb changes from the middle to late stages of pregnancy were classified by tertiles, the greatest change in the Hb group (<−6.0 g/L) was significantly associated with a lower risk of SGA (adjusted RR: 0.56; 95% CI: 0.37, 0.85) compared with the intermediate group (−6.0~1.9 g/L). In conclusion, for women at low risk of iron deficiency, both higher Hb concentrations in late pregnancy and less Hb reduction during pregnancy were associated with an increased risk of SGA

Digital health interventions for non-communicable disease management in primary health care in low-and middle-income countries

Current evidence on digital health interventions is disproportionately concerned with high-income countries and hospital settings. This scoping review evaluates the extent of use and effectiveness of digital health interventions for non-communicable disease (NCD) management in primary healthcare settings of low- and middle-income countries (LMICs) and identifies factors influencing digital health interventions' uptake. We use PubMed, Embase, and Web of Science search results from January 2010 to 2021. Of 8866 results, 52 met eligibility criteria (31 reviews, 21 trials). Benchmarked against World Health Organization's digital health classifications, only 14 out of 28 digital health intervention categories are found, suggesting critical under-use and lagging innovation. Digital health interventions' effectiveness vary across outcomes: clinical (mixed), behavioral (positively inclined), and service implementation outcomes (clear effectiveness). We further identify multiple factors influencing digital health intervention uptake, including political commitment, interactivity, user-centered design, and integration with existing systems, which points to future research and practices to invigorate digital health interventions for NCD management in primary health care of LMICs.Published versionThis research was funded by Asia Pacific Observatory on Health System and Policies, with additional financial support from Duke Kunshan University, Jiangsu Province, China, and the George Institute for Global Health, University of New South Wales, Sydney, Australia

DataSheet1_Nation-Wide Routinely Collected Health Datasets in China: A Scoping Review.docx

Objectives: The potential for using routinely collected data for medical research in China remains unclear. We sought to conduct a scoping review to systematically characterise nation-wide routinely collected datasets in China that may be of value for clinical research.Methods: We searched public databases and the websites of government agencies, and non-government organizations. We included nation-wide routinely collected databases related to communicable diseases, non-communicable diseases, injuries, and maternal and child health. Database characteristics, including disease area, data custodianship, data volume, frequency of update and accessibility were extracted and summarised.Results: There were 70 databases identified, of which 46 related to communicable diseases, 20 to non-communicable diseases, 1 to injury and 3 to maternal and child health. The data volume varied from below 1000 to over 100,000 records. Over half (64%) of the databases were accessible for medical research mostly comprising communicable diseases.Conclusion: There are large quantities of routinely collected data in China. Challenges to using such data in medical research remain with various accessibility. The potential of routinely collected data may also be applicable to other low- and middle-income countries.</p