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)

Testing Multivariate Normality Based on <i>t</i>-Representative Points

Testing multivariate normality is an ever-lasting interest in the goodness-of-fit area since the classical Pearson’s chi-squared test. Among the numerous approaches in the construction of tests for multivariate normality, normal characterization is one of the common approaches, which can be divided into the necessary and sufficient characterization and necessary-only characterization. We construct a test for multivariate normality by combining the necessary-only characterization and the idea of statistical representative points in this paper. The main idea is to transform a high-dimensional sample into a one-dimensional one through the necessary normal characterization and then employ the representative-point-based Pearson’s chi-squared test. A limited Monte Carlo study shows a considerable power improvement of the representative-point-based chi-square test over the traditional one. An illustrative example is given to show the supplemental function of the new test when used together with existing ones in the literature

Characterization-based Q-Q plots for testing multinormality

Three quantile-quantile (Q-Q) plots are derived from a characterization for the multivariate normal distribution. The Q-Q plots can be easily used for detecting a possible departure from multinormality in high-dimensional data analysis. An example is illustrated to employ the plots in practice.Characterization Multinormality Quantile-quantile plot Spherical distribution

Transcriptome analysis of gene expression profiles reveals wood formation mechanisms in Chinese fir at different stand ages

Forests are crucial sustainable sources of natural ecosystems and contribute to human welfare. Cunninghamia lanceolata (Chinese fir) is an economically important conifer and occupies the largest area in China that produces global wood resources. Although Chinese fir has high economic value in China, little information is known regarding its mechanisms of wood formation. Therefore, transcriptome analysis was conducted to study the gene expression patterns and associated timber formation mechanisms in Chinese fir at different stand ages. In the present study, a total of 837,156 unigenes were identified in 84 samples from Chinese fir (pith and root) at different stand ages via RNA-Seq. Among them, most of the differentially expressed genes (DEGs) were significantly enrichment in plant hormone signal transduction, flavonoid metabolism pathway, starch and sucrose metabolism, and MAPK signal transduction pathway, which might be associated with the diameter formation in Chinese fir. The DEGs in these pathways were analyzed in Chinese fir and were related to lignin synthesis, cell wall formation and cell wall reinforcement/thickening. These genes might play an important role in regulating timber formation/growth in Chinese fir. In addition, certain transcriptome factors (TFs) related to Chinese fir timber formation were identified, including WRKY33, WRKY22, PYR/PYL, and MYC2. Weighted co-expression network analysis (WGCNA) showed that glucan endo-1,3-beta-d-glucosidase was a hub gene significantly correlated with the growth-related genes in Chinese fir. Sixteen key genes that related to diameter regulation in Chinese fir were verified by qRT-PCR analysis. These key genes might have a fine regulatory role in timber formation in Chinese fir. Our results pave the way for research on the regulatory mechanisms of wood formation, and provide an insight for improving the quality production of Chinese fir