HIV/AIDS related stigma interferes with the provision of appropriate care and support for people living with HIV/AIDS. Currently, programs to address the stigma approach it as if it occurs in isolation, separate from the co-stigmas related to the various modes of disease transmission including injection drug use (IDU) and commercial sex (CS). In order to develop better programs to address HIV/AIDS related stigma, the inter-relationship (or 'layering') between HIV/AIDS stigma and the co-stigmas needs to be better understood. This paper describes an experimental study for disentangling the layering of HIV/AIDS related stigmas.The study used a factorial survey design. 352 medical students from Guangzhou were presented with four random vignettes each describing a hypothetical male. The vignettes were identical except for the presence of a disease diagnosis (AIDS, leukaemia, or no disease) and a co-characteristic (IDU, CS, commercial blood donation (CBD), blood transfusion or no co-characteristic). After reading each vignette, participants completed a measure of social distance that assessed the level of stigmatising attitudes.Bivariate and multivariable analyses revealed statistically significant levels of stigma associated with AIDS, IDU, CS and CBD. The layering of stigma was explored using a recently developed technique. Strong interactions between the stigmas of AIDS and the co-characteristics were also found. AIDS was significantly less stigmatising than IDU or CS. Critically, the stigma of AIDS in combination with either the stigmas of IDU or CS was significantly less than the stigma of IDU alone or CS alone.The findings pose several surprising challenges to conventional beliefs about HIV/AIDS related stigma and stigma interventions that have focused exclusively on the disease stigma. Contrary to the belief that having a co-stigma would add to the intensity of stigma attached to people with HIV/AIDS, the findings indicate the presence of an illness might have a moderating effect on the stigma of certain co-characteristics like IDU. The strong interdependence between the stigmas of HIV/AIDS and the co-stigmas of IDU and CS suggest that reducing the co-stigmas should be an integral part of HIV/AIDS stigma intervention within this context.
Crowdsourcing has become an increasingly important tool to address many problems - from government elections in democracies, stock market prices, to modern online tools such as TripAdvisor or Internet Movie Database (IMDB). The CHNRI method (the acronym for the Child Health and Nutrition Research Initiative) for setting health research priorities has crowdsourcing as the major component, which it uses to generate, assess and prioritize between many competing health research ideas.We conducted a series of analyses using data from a group of 91 scorers to explore the quantitative properties of their collective opinion. We were interested in the stability of their collective opinion as the sample size increases from 15 to 90. From a pool of 91 scorers who took part in a previous CHNRI exercise, we used sampling with replacement to generate multiple random samples of different size. First, for each sample generated, we identified the top 20 ranked research ideas, among 205 that were proposed and scored, and calculated the concordance with the ranking generated by the 91 original scorers. Second, we used rank correlation coefficients to compare the ranks assigned to all 205 proposed research ideas when samples of different size are used. We also analysed the original pool of 91 scorers to to look for evidence of scoring variations based on scorers' characteristics.The sample sizes investigated ranged from 15 to 90. The concordance for the top 20 scored research ideas increased with sample sizes up to about 55 experts. At this point, the median level of concordance stabilized at 15/20 top ranked questions (75%), with the interquartile range also generally stable (14-16). There was little further increase in overlap when the sample size increased from 55 to 90. When analysing the ranking of all 205 ideas, the rank correlation coefficient increased as the sample size increased, with a median correlation of 0.95 reached at the sample size of 45 experts (median of the rank correlation coefficient = 0.95; IQR 0.94-0.96).Our analyses suggest that the collective opinion of an expert group on a large number of research ideas, expressed through categorical variables (Yes/No/Not Sure/Don't know), stabilises relatively quickly in terms of identifying the ideas that have most support. In the exercise we found a high degree of reproducibility of the identified research priorities was achieved with as few as 45-55 experts.
A paucity of data has made it challenging to construct a deprivation index at the lowest administrative, or county, level in China. An index is required to guide health equity monitoring and resource allocation to regions of greatest need. This study used China's 2010 census data to construct a county-level area-deprivation index (CADI).Data for 2869 counties from China's 2010 census were used to generate a CADI. Eleven indicators across four domains of deprivation were selected for principal component analysis with standardisation of the first principal component. Sensitivity analysis was used to test whether the population size and weighting method affected the index's robustness. Deprived counties identified by the CADI were then compared with China's official list of poverty-stricken counties.The first principal component explained 60.38% of the total variation in the deprivation indicators. The CADI ranged from the least deprived value of -2.71 to the most deprived value of 2.92, with SD of 1. The CADI was found to be robust against county-level population size and different weighting methods. When compared with the official list of poverty-stricken counties in China, the deprived counties identified by the CADI were found to be even more deprived.Constructing a robust area-deprivation index for China at the county level based on population census data is feasible. The CADI is a potential policy tool to identify China's most deprived areas. In the future, it may support health equity monitoring and comparison at the national and subnational levels.
Among the environmental risk factors for schizophrenia, evidence supports a role of urbanicity 1-3. In recent decades, urbanization has been occurring at a massive scale in low- and middle-income countries 4, 5. It is therefore of global public health importance to explore how rapid urbanization might have affected the burden of schizophrenia in growing economies, with China being a prime example. Epidemiological evidence in China has improved over the past two decades and Chinese academic journals have become accessible in electronic databases 6. Moreover, China recently underwent urbanization and economic development at an unprecedented scale: 26.4% of its 1.1 billion inhabitants lived in urban areas in 1990, rising to 49.2-49.7% of 1.3 billion in 2010 4, 7. We may expect a significant increase of schizophrenia burden in China as a result. To explore this, we conducted a systematic review of the Chinese and English literature, through China National Knowledge Infrastructure, Wanfang and PubMed, for the years from 1990 to 2010. Only studies that had applied a case definition based on DSM-III or IV, ICD-9 or 10, or Chinese Classification of Mental Disorders (CCMD-2, 2R or 3) were retained. Based on pre-defined minimum quality criteria, 42 prevalence studies were selected. They were mostly large population-based studies, typically using a two-stage data collection design in which trained assessors performed an initial screening and psychiatrists followed up with a detailed evaluation. Direct contact was made with the corresponding authors of 13 studies to obtain any missing information. Geographically, the retained studies covered 21 of mainland China's 31 provinces, municipalities and autonomous regions. Bayesian methods were applied to predict maximum likelihood for point prevalence and lifetime prevalence in urban and rural China in the years 1990, 2000 and 2010. The analyses of the 42 studies combined information from 2,284,957 people, 10,506 of whom were diagnosed with schizophrenia in their lifetime. In urban areas, the point prevalence (≥15 years) of the disorder was 0.32% (95% CI: 0.29-0.36) in 1990, 0.47% (95% CI: 0.44-0.50) in 2000, and 0.68% (95% CI: 0.57-0.81) in 2010. In contrast, in rural areas, the corresponding estimates were 0.37% (95% CI: 0.33-0.42), 0.36% (95% CI: 0.35-0.38), and 0.35% (95% CI: 0.33-0.38). Lifetime prevalence (≥15 years) in urban China was 0.39% (95% CI: 0.37-0.41) in 1990, 0.57% (95% CI: 0.55-0.59) in 2000, and 0.83% (95% CI: 0.75-0.91) in 2010. The corresponding estimates for rural areas were 0.37% (95% CI: 0.34-0.40), 0.43% (95% CI: 0.42-0.44), and 0.50% (95% CI: 0.47-0.53). Applying these prevalence estimates to the corresponding population of China, there were 3.09 (95% CI: 2.87-3.32) million persons affected during their lifetime in the year 1990. Twenty-seven percent of the cases were from urban areas, which corresponds to the overall proportion of urban residents in China in the same year (26.4%). By 2010, the number of persons affected with schizophrenia rose to 7.16 (95% CI: 6.57-7.75) million, a 132% increase, while the total population of China only increased by 18% during this period 4. Moreover, the contribution of expected cases from urban areas to the overall burden increased from 27% in 1990 to 62% in 2010, well above the proportion of urban residents in China in 2010 (49.2-49.7%). This study helps to establish the universality of urbanicity as a risk factor and the extent to which it affects the burden of schizophrenia in a large country that underwent rapid urbanization. As schizophrenia prevalence was found to be similar in rural and urban China at the beginning of industrialization (late 1980s) 8, our findings suggest that the mechanisms driving the risks of illness in urban areas are likely to be associated with modern urban lifestyles. The lower rates of schizophrenia found when China was less industrialized are consistent with studies that reported lower rates of the illness in low- and middle-income countries 3. This analysis has broad implications. Many populous parts of the world, particularly in low- and middle-income countries, are undergoing urbanization at a scale and rate that took Western countries centuries to achieve 9. Global urbanization may therefore result in an increased global prevalence of schizophrenia through mechanisms that need to be further explored. Kit Yee Chan1,2, Fei-fei Zhao3, Shijiao Meng3, Alessandro R. Demaio4,5, Craig Reed1,Evropi Theodoratou1, Harry Campbell1,Wei Wang3, Igor Rudan1 1Centre for Population Health Sciences and Global Health Academy, University of Edinburgh Medical School, Edinburgh, Scotland, UK; 2Nossal Institute for Global Health, University of Melbourne, Melbourne, Australia; 3Municipal Key Laboratory of Clinical Epidemiology, School of Public Health, Capital Medical University, Beijing, China; 4Harvard Global Equity Initiative, Harvard Medical School, Boston, MA, USA; 5Copenhagen School of Global Health, University of Copenhagen, Copenhagen, Denmark The study was supported by the Nossal Institute of Global Health, University of Melbourne; the National 12th Five-Year Major Projects of China; the Australian National Health and Medical Research Council; the Importation and Development of High-Calibre Talents Project of Beijing Municipal Institutions; and the Bill and Melinda Gates Foundation. The first three authors contributed equally to this work.
Crowdsourcing, outsourcing problems and tasks to a crowd, has grown exponentially since the term was coined a decade ago. Being a rapid and inexpensive approach, it is particularly amenable to addressing problems in global health, conflict and humanitarian settings, but its potential has not been systematically assessed. We employed the Child Health and Nutrition Research Initiative's (CHNRI) method to generate a ranked list of potential uses of crowdsourcing in global health and conflict.94 experts in global health and crowdsourcing submitted their ideas, and 239 ideas were scored. Each expert scored ideas against three of seven criteria, which were tailored specifically for the exercise. A relative ranking was calculated, along with an Average Expert Agreement (AEA).On a scale from 0-100, the scores assigned to proposed ideas ranged from 80.39 to 42.01. Most ideas were related to problem solving (n = 112) or data generation (n = 91). Using health care workers to share information about disease outbreaks to ensure global response had the highest score and agreement. Within the top 15, four additional ideas related to containing communicable diseases, two ideas related to using crowdsourcing for vital registration and two to improve maternal and child health. The top conflict ideas related to epidemic responses and various aspects of disease spread. Wisdom of the crowds and machine learning scored low despite being promising in literature.Experts were invited to generate ideas during the Ebola crisis and to score during reports of Zika, which may have affected the scoring. However, crowdsourcing's rapid, inexpensive characteristics make it suitable for addressing epidemics. Given that many ideas reflected Sustainable Development Goals (SDGs), crowdsourcing may be an innovative solution to achieving some of the SDGs.
Abstract Background The Chinese Government has announced plans to reform provider-payment methods at public hospitals by moving from fee-for-service to prospective and aggregated methods including diagnosis-related groups (DRG) to control health expenditures. In 2012, Beijing pioneered China's first DRG payment system in six hospitals. The aim of this study was to explore the effectiveness of Beijing's DRG pilot reform in reducing expenditures, out-of-pocket payments, and potential behaviors to circumvent payment control, including readmissions, selection, and cost-shifting. Methods We obtained discharge data from the Beijing Health Insurance Bureau for the period January, 2010, to September, 2012, from 14 tertiary general hospitals, which included six hospitals piloting DRGs within a portion of their payment system and eight control hospitals that implemented purely fee-for-service-based payment. Using a differences-in-differences design, we used hospital discharge data to assess the pilot's impact on cost containment. We did regression analyses to assess associations of DRG payment with outcome variables of health expenditures, length-of-stay, and out-of-pocket payment. The study was approved by Peking University Committee for Biomedical Researches. Findings Post-reform, there were 36 780 cases using DRG payments and 50 322 cases in the control hospitals paid through fee-for-service. Our findings showed that DRG payment led to ¥1251 (6·2%) reductions in health expenditure and ¥647 (10·5%) reductions in out-of-pocket payment per admission. Length of stay or cost-shifting did not differ between DRG and non-DRG cases. Readmission rates were reduced (–1·4%) with DRG payment relative to non-DRG. About 19 814 (35%) potential DRG cases, however, were reverted back to fee-for-service-based payment. Hospitals processed the payment of older patients with more complications through fee-for-service payment, circumventing the effectiveness of payment reform. Interpretation For China and other low-income and middle-income countries to fully implement prospective payment systems, such as DRG payments, without allowing circumvention seen in a partially implemented system, it might first be necessary to strengthen core monitoring and technological systems that would support feasibility of DRG payments. Continuous evidence-based monitoring and assessment, partnered with adequate management systems, are necessary to enable these countries to broadly implement DRGs and refine payment systems. Funding China Medical Board (grant number CMB-OC-12-120).
Background: Chronic obstructive pulmonary disease (COPD) is among the leading causes of death globally, accounting for about 3 million deaths worldwide in 2011. We aimed to estimate the prevalence of COPD in Africa in the year 2010 to provide the information that could assist health policy in the region. Methods: We conducted a systematic review of Medline, EMBASE and Global Health for studies on COPD published between 1990 and 2012. We included original population based studies providing estimates of the prevalence of COPD. We considered the reported estimates in terms of the mean age of the sample, sex ratio, the year of study and the country of the study as possible covariates. Results from two different types of studies, i.e., based on spirometric and non-spirometric diagnosis of COPD, were further compared. The United Nation Population Division's population figures were used to estimate the number of COPD cases in the year 2010. Results: Our search returned 243 studies, from which only 13 met our selection criteria and only five were based on spirometry. The difference in the median prevalence of COPD in persons aged 40 years or older based on spirometry data (13.4%; IQR: 9.4%–22.1%) and non-spirometry data (4.0%; IQR: 2.1%–8.9%) was statistically significant (p = 0.001). There was no significant effect of the gender or the year of the study on the reported prevalence of COPD in either set of studies. The prevalence of COPD increased with age in spirometry-based studies (p = 0.017), which is a plausible finding suggesting internal consistency of spirometry-based estimates, while this trend was not observed in studies using other case definitions. When applied to the appropriate age group (40 years or more), which accounted for 196.4 million people in Africa in 2010, the estimated prevalence translates into 26.3 million (18.5–43.4 million) cases of COPD. Comparable figures for the year 2000 based on the same prevalence rates would amount to 20.0 million (14.1–33.1), suggesting an increase of 31.5% over a decade that is attributable to ageing of the African population alone. Conclusion: Our findings suggest that COPD is likely to already represent a very large public health problem in Africa. Moreover, rapidly ageing African population should expect a steady increase in the number of COPD cases in the next decade and beyond. The quantity and quality of available evidence does not match the size of the problem. There is a need for more research on COPD prevalence, but also incidence, mortality and risk factors in Africa. We hope this study will raise awareness of COPD in Africa and encourage further research.
Injuries result in substantial number of deaths among children globally. The burden across many settings is largely unknown. We estimated global and regional child deaths due to injuries from publicly available evidence.We searched for community-based studies and nationally representative data reporting on child injury deaths published after year 1990 from CINAHL, EMBASE, IndMed, LILACS, Global Health, MEDLINE, SCOPUS, and Web of Science. Specific and all-cause mortality due to injuries were extracted for three age groups (0-11 months, 1-4 years, and 0-4 years). We conducted random-effects meta-analysis on extracted crude estimates, and developed a meta-regression model to determine the number of deaths due to injuries among children aged 0-4 years globally and across the World Health Organization (WHO) regions.Twenty-nine studies from 16 countries met the selection criteria. A total of 230 data-points on 15 causes of injury deaths were retrieved from all studies. Eighteen studies were rated as high quality, although heterogeneity was high (I2 = 99.7%, P < 0.001) reflecting variable data sources and study designs. For children aged 0-11 months, the pooled crude injury mortality rate was 29.6 (95% confidence interval (CI) = 21.1-38.1) per 100 000 child population, with asphyxiation being the leading cause of death (neonatal) at 189.1 (95% CI = 142.7-235.4) per 100 000 followed by suffocation (post-neonatal) at 18.7 (95% CI = 11.8-25.7) per 100 000. Among children aged 1-4 years, the pooled crude injury mortality rate was 32.7 (95% CI = 27.3-38.1) per 100 000, with traffic injuries and drowning the leading causes of deaths at 10.8 (95% CI = 8.9-12.8) and 8.8 (95% CI = 7.5-10.2) per 100 000, respectively. Among children under five years, the pooled injury mortality rate was 37.7 (95% CI = 32.7-42.7) per 100 000, with traffic injuries and drowning also the leading causes of deaths at 10.3 (95% CI = 8.8-11.8) and 8.9 (95% CI = 7.8-9.9) per 100 000 respectively. When crude mortality changes over age, WHO regions, and study period were accounted for in our model, we estimated that in 2015 there were 522 167 (95% CI = 395 823-648 630) deaths among children aged 0-4 years, with South East Asia (SEARO) recording the highest number of deaths at 195 084 (95% CI = 159476-230502), closely followed by the Africa region (AFRO) with 176523 (95% CI = 115 040-237 831) deaths. Globally, traffic injuries and drowning were the leading causes of under-five injury fatalities in 2015 with 142 661 (22.0/100 000) and 123 270 (19.0/100 000) child deaths, respectively. The exception being burns in AFRO with 57 784 deaths (38.6/100 000).Varying study designs, case definitions, and particularly limited country representation from Africa and South-East Asia (where we reported higher estimates), imply a need for more studies for better population representative estimates. This study may have however provided improved understanding on child injury death profiles needed to guide further research, policy reforms and relevant strategies globally.
Background Cataract is the second leading cause of visual impairment and the first of blindness globally. However, for the most populous country, China, much remains to be understood about the scale of cataract and cataract blindness. We aimed to investigate the prevalence of cataract and cataract blindness in China at both the national and subnational levels, with projections till 2050. Methods In this systematic review and meta-analysis, China National Knowledge Infrastructure (CNKI), Wanfang, Chinese Biomedicine Literature Database (CBM-SinoMed), PubMed, Embase, and Medline were searched using a comprehensive search strategy to identify all relevant articles on the prevalence of cataract or cataract blindness in Chinese population published from January 1990 onwards. We fitted a multilevel mixed-effects meta-regression model to estimate the prevalence of cataract, and a random-effects meta-analysis model to pool the overall prevalence of cataract blindness. The United Nations Population Division (UNPD) data were used to estimate and project the number of people with cataract and cataract blindness from 1990 to 2050. According to different demographic and geographic features in the six geographic regions in China, the national numbers of people with cataract in the years 2000 and 2010 were distributed to each region. Results In males, the prevalence of any cataract (including post-surgical cases) ranged from 6.71% (95% CI = 5.06-8.83) in people aged 45-49 years to 73.01% (95% CI = 65.78-79.2) in elderly aged 85-89 years. In females, the prevalence of any cataract increased from 8.39% (95% CI = 6.36-10.98) in individuals aged 45-49 years to 77.51% (95% CI = 71.00-82.90) in those aged 85-89 years. For age-related cataract (ARC, including post-surgical cases), in males, the prevalence rates ranged from 3.23% (95% CI = 1.51-6.80) in adults aged 45-49 years to 65.78% (95% CI = 46.72-80.82) in those aged 85-89 years. The prevalence of ARC in females was 4.72% (95% CI = 2.22-9.76) in the 45-49 years age group and 74.03% (95% CI = 56.53-86.21) in the 85-89 years age group. The pooled prevalence rate of cataract blindness (including post-surgical cases) by best corrected visual acuity (BCVA)<0.05 among middle-aged and older Chinese was 2.30% (95% CI = 1.72-3.07), and those of cataract blindness by BCVA<0.10 and cataract blindness by presenting visual acuity (PVA)<0.10 were 2.56% (95% CI = 1.94-3.38) and 4.51% (95% CI = 3.53-5.75) respectively. In people aged 45-89 years, the number of any cataract cases was 50.75 million (95% CI = 42.17-60.37) in 1990 and 111.74 million (95% CI = 92.94-132.84) in 2015, and that of ARC rose from 35.77 million (95% CI = 19.81-59.55) in 1990 to 79.04 million (95% CI = 44.14-130.85) in 2015. By 2050, it is projected that the number of people (45-89 years of age) affected by any cataract will be 240.83 million (95% CI = 206.07-277.35), and that of those with ARC will be 187.26 million (95% CI = 113.17-281.23). During 2000 and 2010, South Central China consistently owed the most cases of any cataract, whereas Northwest China the least. Conclusions The prevalence of cataract and cataract blindness in China was unmasked. In the coming decades, cataract and cataract blindness will continue to be a leading public-health issue in China due to the ageing population. Future work should be prioritized to the promotion of high-quality epidemiological studies on cataract.
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