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1.  Effect of aerobic exercise and low carbohydrate diet on pre-diabetic non-alcoholic fatty liver disease in postmenopausal women and middle aged men – the role of gut microbiota composition: study protocol for the AELC randomized controlled trial 
BMC Public Health  2014;14:48.
Pre-diabetes and non-alcoholic fatty liver disease (NAFLD) are associated with an unhealthy lifestyle and pose extremely high costs to the healthcare system. In this study, we aim to explore whether individualized aerobic exercise (AEx) and low carbohydrate diet (LCh) intervention affect hepatic fat content (HFC) in pre-diabetes via modification of gut microbiota composition and other post-interventional effects.
A 6-month randomized intervention with 6-month follow-up is conducted from January 2013 to December 2015. The target sample size for intervention is 200 postmenopausal women and middle-aged men aged 50–65 year-old with pre-diabetes and NAFLD. The qualified subjects are randomized into 4 groups with 50 subjects in each group: 1 = AEx, 2 = LCh, 3 = AEx + LCh, and 4 = control. In addition, two age-matched reference groups (5 = pre-diabetes without NAFLD (n = 50) and 6 = Healthy without pre-diabetes or NAFLD (n = 50)) are included. The exercise program consists of progressive and variable aerobic exercise (intensity of 60 to 75% of initial fitness level, 3–5 times/week and 30–60 min/time). The diet program includes dietary consultation plus supplementation with a special lunch meal (40% of total energy intake/day) which aims to reduce the amount of carbohydrate consumption (30%). The control and reference groups are advised to maintain their habitual habits during the intervention. The primary outcome measures are HFC, serum metabolomics and gut microbiota composition. The secondary outcome measures include body composition and cytokines. In addition, socio-psychological aspects, social support, physical activity and diet will be performed by means of questionnaire and interview.
Specific individualized exercise and diet intervention in this study offers a more efficient approach for liver fat reduction and diabetes prevention via modification of gut microbiota composition. Besides, the study explores the importance of incorporating fitness assessment and exercise in the management of patients with pre-diabetes and fatty liver disorders. If our program is shown to be effective, it will open new strategies to combat these chronic diseases.
Trial registration
Current Controlled Trials: ISRCTN42622771.
PMCID: PMC3897962  PMID: 24438438
Liver fat content; Glucose metabolism; Lipid metabolism; Gut microbiota; Metabonomics; Human; Clinical setting
2.  Prevalence of hyperuricemia and its related risk factors in healthy adults from Northern and Northeastern Chinese provinces 
BMC Public Health  2013;13:664.
Hyperuricemia (HUA) is a potential risk factor for developing insulin resistance, hypertension, dyslipidemia and cardiovascular disease. Therefore, we studied the prevalence of HUA and associated risk factors in the population of two provinces in northern China.
Based on the research of Chinese Physiological Constant and Health Conditions conducted in 2008–2010, we enrolled 29,639 subjects in a randomized, stratified study in four sampling areas in Heilongjiang Province and the Inner Mongolia Autonomous Region. We collected 13,140 serum samples to determine biochemical indicators including uric acid(UA), glucose, blood lipids, liver function, and renal function, and finally a representative sample of 8439 aged 18 years and older was determined. We also defined and stratified HUA, hypertension, diabetes, obesity and lipid abnormalities according to international guidelines.
There were significant differences in the UA levels between different genders and regions. The total prevalence of HUA is 13.7%. Men had a higher prevalence of HUA than women (21% vs. 7.9%; P < 0.0001). As age increased, HUA prevalence decreased in men but rose in women. The suburbs of big cities had the highest HUA prevalence (18.7%), and in high-prevalence areas the proportion of women with HUA also increased. A stepwise logistic regression model was used to filter out twelve HUA risk factors, including age, gender, residence, hypercholesterolemia, hypertriglyceridemia, impaired fasting glucose, hypertension, obesity, abdominal obesity, CKD, drinking and sleeping. After adjusting for these factors, the odds ratio of HUA was 1.92 times higher in men than in women. Compared with agricultural and pastoral areas, the odds ratio of having HUA was 2.14 for participants in the suburbs of big cities and 1.57 in the center of big cities.
The prevalence of HUA is high in northern China. The differences in HUA prevalence by geographic region suggested that unbalanced economic development and health education, therefore HUA prevention measures should be strengthened to improve quality of life and reduce health care costs.
PMCID: PMC3722003  PMID: 23866159
Prevalence; Hyperuricemia; Risk factors
3.  Epidemiology of general obesity, abdominal obesity and related risk factors in urban adults from 33 communities of northeast china: the CHPSNE study 
BMC Public Health  2012;12:967.
Obesity increases the risk of many diseases. However, there has been little literature about the epidemiology of obesity classified by body mass index (BMI) or waist (abdominal obesity) among urban Chinese adults. This study is to fill the gap by assessing the prevalence of obesity and associated risk factors among urban Chinese adults.
A representative sample of 25,196 urban adults aged 18 to 74 years in Northeast China was selected and measurements of height, weight and waist circumference (WC) were taken from 2009–2010. Definitions of overweight and obesity by the World Health Organization (WHO) were used.
The overall prevalence rates of general obesity and overweight classified by BMI were 15.0% (15.7% for men and 14.3% for women, p<0.01) and 19.2% (20.8% for men and 17.7% for women, p<0.01), respectively, and the overall prevalence rate of abdominal obesity was 37.6% (31.1% for men and women 43.9% for women, p<0.01). Multivariable logistic regression showed that the elderly and those who had a history of parental obesity, alcohol drinking, or former cigarette smoking were at high risk of obesity classified by BMI or WC, whereas those with a higher level of education, higher family income, or a healthy and balanced diet were at low risk of obesity. Analysis stratified by gender showed that men with a higher level education level, a white-collar job, a cadre job, or higher family income were the high risk group, and women with a higher level of education or higher family income were the low risk group.
Obesity and overweight have become epidemic in urban populations in China; associations of risk factors with obesity differ between men and women.
PMCID: PMC3509037  PMID: 23146089
General obesity; Abdominal obesity; Risk factors; Gender difference; Chinese urban adults
4.  A novel quantitative body shape score for detecting association between obesity and hypertension in China 
BMC Public Health  2015;15:7.
Obesity is a major independent risk factor for chronic diseases such as hypertension and coronary diseases, it might not be only related to the amount of body fat but its distribution. The single body mass index (BMI), waist circumference (WC), waist to hip ratio (WHR) or waist to stature ratio (WSR) provides limited information on fat distribution, and the debate about which one is the best remained. On the other hand, the current classification of body shape is qualitative rather than quantitative, and only crudely measure fat distribution. Therefore, a synthetical index is highly desirable to quantify body shape.
Based on the China Health and Nutrition Survey (CHNS) data, using Lohmäller PLSPM algorithm, six Partial Least Squares Path Models (PLSPMs) between the different obesity measurements and hypertension as well as two synthetical body shape scores (BSS1 by BMI/WC/Hip circumference, BSS2 by BMI/WC/WHR/WSR) were created. Simulation and real data analysis were conducted to assess their performance.
Statistical simulation showed the proposed model was stable and powerful. Totally 15,172 (6,939 male and 8,233 female) participants aged from 18 to 87 years old were included. It indicated that age, height, weight, WC, WHR, WSR, SBP, DBP, the prevalence of hypertension and obesity were significantly sex-different. BMI, WC, WHR, WSR, Hip, BSS1 and BSS2 between hypertension and normotensive group are significantly different (p < 0.05). PLSPM method illustrated the biggest path coefficients (95% confidence interval, CI) were 0.220(0.196, 0.244) for male and 0.205(0.182, 0.228) for female in model of BSS1. The area under receiver-operating characteristic curve (AUC(95% CI)) of BSS1(0.839(0.831,0.847)) was significantly larger than that of BSS2(0.834(0.825,0.842)) as well as the four single indices for female, and similar trend can be found for male.
BSS1 was an excellent measurement for quantifying body shape and detecting the association between body shape and hypertension.
PMCID: PMC4308906  PMID: 25595192
Chinese adults; China Health and Nutrition Survey; Anthropometric indices; Obesity; Hypertension; Body shape score
5.  Smoking, smoking cessation and tobacco control in rural China: a qualitative study in Shandong Province 
BMC Public Health  2014;14(1):916.
Smoking prevalence is high in China and even higher among rural residents. The aims of this study were: 1) to gain insights into the motivations of tobacco use and barriers to smoking cessation among rural village residents; 2) to understand the current tobacco control measures in the rural villages and barriers encountered or perceived for implementation.
Qualitative semi-structured face-to-face interviews and focus group discussions were conducted of 59 rural villagers including 37 village residents, 10 village leaders and 12 village doctors in three counties in Shandong Province, China.
Smoking initiation was most often out of curiosity when seeing others smoke, but pressure from cigarette sharing and gifting custom was the major barrier to smoking cessation. The most important reason for quitting successfully was a detrimental health problem. Although many attempted to quit at the advice of other family members, relapses were common and few were able to quit completely and for long-term unless accompanied by significant health issues. Although doctor’s advice to quit is effective, many doctors do not offer advice to all patients. There is a lack of true understanding of the harm of smoking and second-hand smoking among the villagers and a lack of access to and knowledge of effective smoking cessation tools among both smokers and village doctors. Tobacco control activities at villages were rare and infrequent.
This study highlighted the need to develop tobacco control measures that reflect the unique culture in rural China. Smoking cessation measures are not likely to achieve large scale effect unless the prevailing cigarette sharing and gifting custom is drastically changed. More educations of the hazards of smoking and second-hand smoking to village residents and educations of effective smoking cessation treatment to both village residents and healthcare providers are needed.
PMCID: PMC4169812  PMID: 25190269
Smoking cessation; Rural residents; China
6.  Role of the new rural cooperative medical system in alleviating catastrophic medical payments for hypertension, stroke and coronary heart disease in poor rural areas of China 
BMC Public Health  2014;14(1):907.
Hypertension, stroke and coronary heart disease (CHD) are common diseases that impose a heavy burden on patients and their families, particularly on those living in poor areas. This study examined catastrophic medical payments faced by patients with these diseases and the effectiveness of the new rural cooperative medical system (NRCMS) at alleviating the impact of the said diseases in fourth-class rural areas (i.e. those with annual income of less than RMB1500/$240.2 per capita) of China.
Data on medical payments, including out-of-pocket and NRCMS-reimbursed expenses were collected through self-administered questionnaires. The pre- and post-reimbursement (via the NRCMS) prevalence of household poverty, catastrophic medical payment (CMP) incidence (Hcat), mean CMP gap (Gcat), mean positive CMP gap (MPGcat) and other determinants of CMP incidence were identified.
Out-of-pocket payments for treatment of hypertension, stroke and CHD averaged RMB580.1/$92.9, RMB3028.4/$484.8 and RMB1561.4/$250.0 per capita, respectively, in 2008. Hcat, Gcat and MPGcat due to the three diseases were 17.0%, 16.6% and 97.6%, respectively, and reimbursement through the NRCMS reduced them to 13.5%, 11.8% and 87.4%, respectively. The difference between pre- and post-reimbursement Hcat was not statistically significant. After adjusting the covariates for age [OR = 1.87, 95% confidence interval (CI) = 1.19-2.95], education (OR = 1.56, 95% CI = 1.07-2.27), marital status (OR = 1.67, 95% CI = 1.11-2.51), occupation (OR = 1.96, 95% CI = 1.34-2.85), annual income (OR = 4.95, 95% CI = 3.28-7.48), the multiple logistic regression analysis revealed that patients with stroke (OR = 3.94, 95% CI = 2.38-6.51) or CHD (OR = 2.25, 95% CI = 1.38-3.65) were more susceptible to CMP compared with patients with hypertension only.
Out-of-pocket medical spending on hypertension, stroke and CHD imposes a heavy financial burden on the residents of fourth-class rural areas of China. The NRCMS has some impact on reducing catastrophic medical payments associated with these diseases, but improvement of the reimbursement rate is necessary to further improve its effectiveness.
PMCID: PMC4162941  PMID: 25182027
Catastrophic impact; Out-of-pocket payment; Hypertension; Stroke; Coronary heart disease; New rural cooperative medical system
7.  Risk Factors of Stroke in Western and Asian Countries: A Systematic Review and Meta-analysis of Prospective Cohort Studies 
BMC Public Health  2014;14(1):776.
There has been an increasing trend in the incidence of stroke worldwide in recent years, and the number of studies focusing on the risk factors for stroke has also increased every year. To comprehensively evaluate the risk factors of stroke identified in prospective Western and Asian cohort studies.
Population-based cohort studies on stroke were searched in databases (PubMed, EMBASE, Web of Science, Google Scholar, etc.), and the library of the Third Military Medical University was manually searched for relevant information. A meta-analysis of Western and Asian studies on risk factors was performed. The pooled hazard ratios (HRs) with 95% confidence intervals (CIs) were calculated to assess the final group of cohort studies.
After screening, 22 prospective cohort studies were included in the analyses of this investigation. Two factors, smoking and alcohol consumption, showed statistically significant differences between Western and Asian populations, and the results were as follows (W/A): 2.05 (95% CI, 1.68 ~ 2.49)/1.27 (95% CI, 1.04 ~ 1.55) and 0.89 (95% CI, 0.76 ~ 1.04)/1.28 (95% CI, 1.07 ~ 1.53). The factor BMI = 18.5-21.9 kg/m2 showed statistically significant differences only in Western populations, 0.96 (95% CI, 0.93 ~ 0.99); the factor SBP = 120-139 mm Hg showed statistically significant differences only in Asian populations, 2.29 (95% CI, 1.04 ~ 5.09).
The prevalences of risk factors affect the stroke morbidity in Western and Asian populations, which may be biased by race. The meta-analysis of population-based studies suggests that different preventive measures should be adopted for Western and Asian population groups that are at high risk for stroke.
Electronic supplementary material
The online version of this article (doi:10.1186/1471-2458-14-776) contains supplementary material, which is available to authorized users.
PMCID: PMC4246444  PMID: 25081994
Stroke; Risk factors; Prospective study; Epidemiology; Systematic review; Public health
8.  A meta-analysis of risk factors for depression in adults and children after natural disasters 
BMC Public Health  2014;14:623.
A number of studies have shown a range of negative psychological symptoms (e.g. depression) after exposure to natural disasters. The aim of this study was to determine risk factors for depression in both children and adults who have survived natural disasters.
Four electronic databases (PubMed, Embase, Web of Science, and PsychInfo) were used to search for observational studies (case–control, cross-sectional, and cohort studies) about depression following natural disasters. The literature search, study selection, and data extraction were conducted independently by two authors. Thirty-one articles were included in the study, of which twenty included adult participants and eleven included child participants. Summary estimates were obtained using random-effects models. Subgroup analysis, sensitivity analysis, and publication bias tests were performed on the data.
The prevalence of depression after natural disasters ranged from 5.8% to 54.0% in adults and from 7.5% to 44.8% in children. We found a number of risk factors for depression after exposure to natural disasters. For adults, the significant predictors were being female ;not married;holding religious beliefs; having poor education; prior trauma; experiencing fear, injury, or bereavement during the disaster; or losing employment or property, suffering house damage as a result of the disaster. For children, the significant predictors were prior trauma; being trapped during the disaster; experiencing injury, fear, or bereavement during the disaster; witnessing injury/death during the disaster; or having poor social support.
The current analysis provides evidence of risk factors for depression in survivors of natural disasters. Further research is necessary to design interventions to improve the mental health of survivors of natural disasters.
PMCID: PMC4077641  PMID: 24941890
Depression; Risk factors; Children; Adults; Natural disasters
9.  The status and correlates of depression and anxiety among breast-cancer survivors in Eastern China: a population-based, cross-sectional case–control study 
BMC Public Health  2014;14:326.
Breast cancer presents specific challenges both physiologically and psychologically to women, and consequently affect the patients’ mental health. Psychosocial factors may play important roles in the symptoms and development of mental disorders among breast-cancer survivors. This study assesses the depression and anxiety status of breast-cancer survivors and further identifies the risk factors.
A 1:1 matched, case–control study was conducted with a total sample of 222 individuals. Participants were selected from a national epidemiological survey. The Center for Epidemiological Studies—Depression Scale and State-Trait Anxiety Inventory were used to assess depression and anxiety. The Social Support Rating Scale and Perceived Social Support Scale were used as measures of social support and perceived social support, and the Rosenberg Self-Esteem Scale as a measure of self-esteem. Coping style was assessed using the Simplified Coping Style Questionnaire. The predictive effect of these psychosocial factors for depression and anxiety was investigated with hierarchical linear regressions.
Breast-cancer survivors experienced a high level of depressive and anxious symptoms. Multivariate analysis revealed that breast cancer functions as an independent but not a main risk factor of both depression and anxiety. Higher levels of depression and anxiety were positively associated with a higher level of passive coping style, and negatively with perceived social support, objective social support and an active coping style.
The mental health of breast-cancer survivors should be promoted through the transformation of coping styles and improvement of social support.
PMCID: PMC3997219  PMID: 24708474
Breast cancer; Depression; Anxiety; Coping style; Social support; Predictor
10.  The utility of fat mass index vs. body mass index and percentage of body fat in the screening of metabolic syndrome 
BMC Public Health  2013;13:629.
It has been well documented that obesity is closely associated with metabolic syndrome (MetS). Although body mass index (BMI) is the most frequently used method to assess overweightness and obesity, this method has been criticized because BMI does not always reflect true body fatness, which may be better evaluated by assessment of body fat and fat-free mass. The objective of this study was to investigate the best indicator to predict the presence of MetS among fat mass index, BMI and percentage of body fat (BF %) and determine its optimal cut-off value in the screening of MetS in practice.
A cross-sectional study of 1698 subjects (aged 20–79 years) who participated in the annual health check-ups was employed. Body composition was measured by bioelectrical impedance analysis (BIA). Fat mass index (FMI) was calculated. Sex-specific FMI quartiles were defined as follows: Q1: <4.39, Q2:4.39- < 5.65, Q3:5.65- < 7.03, Q4:≥7.03,in men; and Q1:<5.25, Q2:5.25- < 6.33, Q3:6.33- < 7.93,Q4:≥7.93, in women. MetS was defined by National Cholesterol Education Program/Adult Treatment Panel III criteria. The association between FMI quartiles and MetS was assessed using Binary logistic regression. Receiver operating curve(ROC) analysis was used to determine optimal cutoff points for BMI,BF% and FMI in relation to the area under the curve(AUC),sensitivity and specificity in men and women.
The adjusted odds ratios (95% CI) for the presence of MetS in the highest FMI quartile versus lowest quartile were 79.143(21.243-294.852) for men( P < 0.01) and 52.039(4.144-653.436) for women( P < 0.01) after adjusting age, BMI, BF%, TC, LDL, CRP, smoking status and exercise status, and the odds ratios were 9.166(2.157-38.952) for men( P < 0.01) and 25.574(1.945-336.228) for women( P < 0.05) when WC was also added into the adjustment. It was determined that BMI values of 27.45 and 23.85 kg/m2, BF% of 23.95% and 31.35% and FMI of 7.00 and 7.90 kg/m2 were the optimal cutoff values to predict the presence of MetS among men and women according to the ROC curve analysis. Among the indicators used to predict MetS, FMI was the index that showed the greatest area under the ROC curve in both sexes.
Higher FMI levels appear to be independently and positively associated with the presence of MetS regardless of BMI and BF%. FMI seems to be a better screening tool in prediction of the presence of metabolic syndrome than BMI and percentage of body fat in men and women.
PMCID: PMC3703297  PMID: 23819808
Metabolic syndrome X; Body composition; Fat mass index; Body mass index; Percentage of body fat; Screening
11.  Glycemic control among patients in China with type 2 diabetes mellitus receiving oral drugs or injectables 
BMC Public Health  2013;13:602.
The prevalence of type 2 diabetes mellitus (T2DM) is increasing rapidly among Chinese adults, and limited data are available on T2DM management and the status of glycemic control in China. We assessed the efficacy of oral antidiabetes drugs (OADs), glucagon-like peptide-1 (GLP-1) receptor agonists, and insulin for treatment of T2DM across multiple regions in China.
This was a multicenter, cross-sectional survey of outpatients conducted in 606 hospitals across China. Data from all the patients were collected between April and June, 2011.
A total of 238,639 patients were included in the survey. Eligible patients were treated with either OADs alone (n=157,212 [65.88%]), OADs plus insulin (n=80,973 [33.93%]), or OADs plus GLP-1 receptor agonists (n=454 [0.19%]). The OAD monotherapy, OAD + insulin, and OAD + GLP-1 receptor agonist groups had mean glycosylated hemoglobin (HbA1c) levels (±SD) of 7.67% (±1.58%), 8.21% (±1.91%), and 7.80% (±1.76%), respectively. Among those three groups, 34.63%, 26.21%, and 36.12% met the goal of HbA1c <7.0%, respectively. Mean HbA1c and achievement of A1c <7.0% was related to the duration of T2DM.
Less than one third of the patients had achieved the goal of HbA1c <7.0%. Glycemic control decreased and insulin use increased with the duration of diabetes.
PMCID: PMC3729491  PMID: 23800082
China; GLP-1 receptor agonists; HbA1c; Insulin; Oral antidiabetes drugs (OADs); Type 2 diabetes mellitus
12.  Burden of self-reported acute gastrointestinal illness in China: a population-based survey 
BMC Public Health  2013;13:456.
Acute gastrointestinal illness (AGI) is an important public-health problem worldwide. Previous national studies of the incidence of AGI in China were performed decades ago, and detailed information was not available. This study therefore sought to determine the magnitude, distribution, and burden of self-reported AGI in China.
Twelve-month, retrospective face-to-face surveys were conducted in 20 sentinel sites from six provinces between July 2010 and July 2011.
In total, 39686 interviews were completed. The overall adjusted monthly prevalence of AGI was 4.2% (95% confidence interval, 4.0–4.4), corresponding to 0.56 episodes of AGI per person-year. Rates of AGI were highest in children aged < 5 years. Healthcare was sought by 56.1% of those reporting illness. Of the cases who visited a doctor, 32.7% submitted a stool sample. The use of antibiotics was reported by 49.7% of the cases who sought medical care and 54.0% took antidiarrhoeals. In the multivariable model, gender, age, education, household type, residence, season, province and travel were significant risk factors of being a case of AGI.
This first population-based study in China indicated that AGI represents a substantial burden of health. Further research into the specific pathogens is needed to better estimate the burden of AGI and foodborne disease in China.
PMCID: PMC3655923  PMID: 23656835
13.  A summary index of infant and child feeding practices is associated with child growth in urban Shanghai 
BMC Public Health  2012;12:568.
Recently, an infant and child feeding index (ICFI) constructed on brief recalls of breastfeeding, feeding frequency and food diversification was assumed to provide long-term prediction about child feeding practices. The aim of this study was to investigate the association between the cross-sectional ICFI (CS-ICFI) or longitudinal ICFI (L-ICFI) and child anthropometric indices in downtown Shanghai, China.
The prospective cohort study included 180 infants aged 5-7 mo with their main caregivers who were visited 3 times every 6 months over 12 months. A CS-ICFI was constructed for each visit by using data on feeding practices based on 24-h and 7-d recalls. An L-ICFI was constructed with use of the 3 CS-ICFIs. The associations between ICFI and length-for-age z score (LAZ), weight-for-age z score (WAZ), and weight-for-length z score (WLZ) were examined. The stability of the CS-ICFI was assessed by using repeatability coefficient (RC).
The L-ICFI was positively associated with LAZ and WAZ at Visit 3(beta = 0.151, P = 0.040 and beta = 0.173, P = 0.024, respectively). Moreover, the CS-ICFI at Visit 1 was positively associated with LAZ, WAZ and WLZ (beta = 0.160, P = 0.029; beta = 0.191, P = 0.009; beta = 0.176, P = 0.020) at Visit 3, and the CS-ICFI at Visit 3 was also positively associated with LAZ (beta = 0.176, P = 0.016). Stability of the CS-ICFI was shown by the value of 0.14 (95% CI: 0.07, 0.31) of the RC, which differed significantly from 0 (P < 0.05).
The ICFI constructed on brief recalls based on cross-sectional studies can be used to evaluate the effects of child feeding practice on child growth.
PMCID: PMC3487749  PMID: 22839527
Child feeding practice; Brief recalls; Anthropometric indices; Repeatability coefficient
14.  Spatial-temporal analysis of malaria and the effect of environmental factors on its incidence in Yongcheng, China, 2006–2010 
BMC Public Health  2012;12:544.
In 2003, Plasmodium vivax malaria has re-emerged in central eastern China including Yongcheng prefecture, Henan Province, where no case has been reported for eleven years. Our goals were to detect the space-time distribution pattern of malaria and to determine significant environmental variables contributing to malaria incidence in Yongcheng from 2006 to 2010, thus providing scientific basis for further optimizing current malaria surveillance and control programs.
This study examined the spatial and temporal heterogeneities in the risk of malaria and the influencing factors on malaria incidence using geographical information system (GIS) and time series analysis. Univariate analysis was conducted to estimate the crude correlations between malaria incidence and environmental variables, such as mosquito abundance and climatic factors. Multivariate analysis was implemented to construct predictive models to explore the principal environmental determinants on malaria epidemic using a Generalized Estimating Equation (GEE) approach.
Annual malaria incidence at town-level decreased from the north to south, and monthly incidence at prefecture-level demonstrated a strong seasonal pattern with a peak from July to November. Yearly malaria incidence had a visual spatial association with yearly average temperature. Moreover, the best-fit temporal model (model 2) (QIC = 16.934, P<0.001, R2 = 0.818) indicated that significant factors contributing to malaria incidence were maximum temperature at one month lag, average humidity at one month lag, and malaria incidence of the previous month.
Findings supported the effects of environment factors on malaria incidence and indicated that malaria control targets should vary with intensity of malaria incidence, with more public resource allocated to control the source of infections instead of large scale An. sinensis control when malaria incidence was at a low level, which would benefit for optimizing the malaria surveillance project in China and some other countries with unstable or low malaria transmission.
PMCID: PMC3488337  PMID: 22823998
Malaria; Anopheles; Weather; Geographic information system; Modeling
15.  Impact of genital warts on health related quality of life in men and women in mainland China: a multicenter hospital-based cross-sectional study 
BMC Public Health  2012;12:153.
Information on the health-related quality of life (HRQoL) of patients with genital warts (GW) in populations in mainland China is still limited. The aim of the study was to use a generic instrument to measure the impact of genital warts on HRQoL in men and women in this setting.
A multi-centre hospital-based cross-sectional study across 18 centers in China was conducted to interview patients using the European quality of life-5 dimension (EQ-5D) instrument; respondents' demographic and clinical data were also collected.
A total of 1,358 GW patients (612 men, 746 women) were included in the analysis, with a mean age of 32.0 ± 10.6 years. 56.4% of the patients reported some problems in the dimension of Anxiety/Depression (highest), followed by Pain/Discomfort (24.7%) and Mobility (3.5%). The overall visual analogue scale (VAS) score of the study population was found to be 65.2 ± 22.0, and the EQ-5D index score was found to be 0.843 ± 0.129 using Japanese preference weights (the Chinese preference was unavailable yet). Patients with lower VAS means and EQ-5D index scores were more often female, living in urban area, and suffering multiple GW (all p values < 0.05), but the values did not differ notably by age (p values > 0.05).
The HRQoL of patients with GW was substantially lower, compared to a national representative general population in China (VAS = ~80); the findings of different subgroups are informative for future GW prevention and control efforts.
PMCID: PMC3359232  PMID: 22381149
16.  Prevalence of cardiovascular disease and risk factors in a rural district of Beijing, China: a population-based survey of 58,308 residents 
BMC Public Health  2012;12:34.
Cardiovascular disease (CVD) is the leading cause of global disease burden. Although stroke was thought to be more prevalent than coronary heart disease (CHD) in Chinese, the epidemic pattern might have been changed in some rural areas nowadays. This study was to estimate up-to-date prevalence of CVD and its risk factors in rural communities of Fangshan District, Beijing, China.
A cross-sectional population survey was carried out by stratified cluster sampling. A total of 58,308 rural residents aged over 40 years were surveyed by face-to-face interview and physical examination during 2008 and 2010. The standardized prevalence was calculated according to adult sample data of China's 5th Population Census in 2000, and the adjusted prevalence odds ratio (POR) was calculated for the association of CHD/stroke with its cardiovascular risk factors in multivariate logistic regression models.
Age- and sex-standardized prevalence was 5.6% for CHD (5.2% in males and 5.9% in females), higher than the counterpart of 3.7% (4.7% in males and 2.6% in females) for stroke. Compared with previous studies, higher prevalence of 7.7%, 47.2%, 53.3% in males and 8.2%, 44.8%, 60.7% in females for diabetes, hypertension and overweight/obesity were presented accordingly. Moreover, adjusted POR (95% confidence interval) of diabetes, obesity, stage 1 and stage 2 hypertension for CHD as 2.51 (2.29 to 2.75), 1.53 (1.38 to 1.70), 1.13 (1.02 to 1.26) and 1.35 (1.20 to 1.52), and for stroke as 2.24 (1.98 to 2.52), 1.25 (1.09 to 1.44), 1.44 (1.25 to 1.66) and 1.70 (1.46 to 1.98) were shown respectively in the multivariate logistic regression models.
High prevalence of CVD and probably changed epidemic pattern in rural communities of Beijing, together with the prevalent cardiovascular risk factors and population aging, might cause public health challenges in rural Chinese population.
PMCID: PMC3292979  PMID: 22248490
17.  The prevalence of hyperuricemia in China: a meta-analysis 
B, Liu | T, Wang | HN, Zhao | WW, Yue | HP, Yu | CX, Liu | J, Yin | RY, Jia | HW, Nie
BMC Public Health  2011;11:832.
The prevalence of hyperuricemia varied in different populations and it appeared to be increasing in the past decades. Recent studies suggest that hyperuricemia is an independent risk factor for cardiovascular disease. However, there has not yet been a systematic analysis of the prevalence of hyperuricemia in China.
Epidemiological investigations on hyperuricemia in China published in journals were identified manually and on-line by using CBMDISC, Chongqing VIP database and CNKI database. Those Reported in English journals were identified using MEDLINE database. Selected studies had to describe an original study defined by strict screening and diagnostic criteria. The fixed effects model or random effects model was employed according to statistical test for homogeneity.
Fifty-nine studies were selected, the statistical information of which was collected for systematic analysis. The results showed that the pooled prevalence of hyperuricemia in male was 21.6% (95%CI: 18.9%-24.6%), but it was only 8.6% (95%CI: 8.2%-10.2%) in female. It was found that thirty years was the risk point age in male and it was fifty years in female.
The prevalence of hyperuricemia is different as the period of age and it increases after 30 years in male and 50 in female. Interventions are necessary to change the risk factors before the key age which is 30 years in male and 50 in female.
PMCID: PMC3213156  PMID: 22032610
18.  Psychometric assessment of HIV/STI sexual risk scale among MSM: A Rasch model approach 
BMC Public Health  2011;11:763.
Little research has assessed the degree of severity and ordering of different types of sexual behaviors for HIV/STI infection in a measurement scale. The purpose of this study was to apply the Rasch model on psychometric assessment of an HIV/STI sexual risk scale among men who have sex with men (MSM).
A cross-sectional study using respondent driven sampling was conducted among 351 MSM in Shenzhen, China. The Rasch model was used to examine the psychometric properties of an HIV/STI sexual risk scale including nine types of sexual behaviors.
The Rasch analysis of the nine items met the unidimensionality and local independence assumption. Although the person reliability was low at 0.35, the item reliability was high at 0.99. The fit statistics provided acceptable infit and outfit values. Item difficulty invariance analysis showed that the item estimates of the risk behavior items were invariant (within error).
The findings suggest that the Rasch model can be utilized for measuring the level of sexual risk for HIV/STI infection as a single latent construct and for establishing the relative degree of severity of each type of sexual behavior in HIV/STI transmission and acquisition among MSM. The measurement scale provides a useful measurement tool to inform, design and evaluate behavioral interventions for HIV/STI infection among MSM.
PMCID: PMC3213074  PMID: 21970669
19.  Prevalence and association between obesity and metabolic syndrome among Chinese elementary school children: a school-based survey 
BMC Public Health  2010;10:780.
China has experienced an increase in the prevalence of childhood overweight/obesity over the last decades. The purpose of this study was to examine the prevalence of obesity and metabolic syndrome among Chinese school children and determine if there is a significant association between childhood obesity and metabolic syndrome.
A cross-sectional study was conducted among 1844 children (938 males and 906 females) in six elementary schools at Guangzhou city from April to June 2009. The body mass index (BMI), waist circumference, blood pressure, Tanner stage, lipids, insulin and glucose levels were determined. Criteria analogous to ATPIII were used for diagnosis of metabolic syndrome in children.
Among 1844 children aged 7-14 years, 205 (11.1%) were overweight, and 133 (7.2%) were obese. The prevalence of metabolic syndrome was 6.6% overall, 33.1% in obese, 20.5% in overweight and 2.3% in normal weight children. Multiple logistic regression analysis showed that BMI (3rd quartile)(OR 3.28; 95%CI 0.35-30.56), BMI (4th quartile)(OR 17.98; 95%CI 1.75-184.34), homeostasis model assessment (HOMA-IR) (2nd quartile) (OR2.36; 95% CI 0.46-12.09), HOMA-IR (3rd quartile) (OR 2.46; 95% CI 0.48-12.66), HOMA-IR (4th quartile) (OR3.87; 95% CI 0.72-20.71) were significantly associated with metabolic syndrome.
The current epidemic of obesity with subsequent increasing cardiovascular risk factors has constituted a threat to the health of school children in China. HOMA-IR and BMI were strong predictors of metabolic syndrome in children. Therefore, rigorous obesity prevention programs should be implemented among them.
PMCID: PMC3022853  PMID: 21176200
20.  Does Chinese culture influence psychosocial factors for heroin use among young adolescents in China? A cross-sectional study 
BMC Public Health  2010;10:563.
Little empirical research has examined how cultural factors influence psychosocial factors for heroin drug use. The objectives of the study were to investigate the levels of individualism and collectivism among young adolescents and how cultural differences were associated with the constructs of the Theory of Planned Behavior and other psychosocial factors for heroin drug use.
A cross-sectional study was conducted among young adolescents in an HIV and heroin-stricken area in China. The Individualism-Collectivism Interpersonal Assessment Inventory (ICIAI) was used to measure cultural norms and values in the context of three social groups: family members, close friends, and classmates.
A total of 220 boys and 241 girls were recruited and participated in an interview. Compared to boys, girls reported higher levels of the three specific-relationship ICIAIs, as well as higher levels of perceived behavioral control for heroin use, perceived peer control, and communication with parent about heroin use, but a lower level of favorable attitude towards heroin use. The levels of descriptive and subjective norms of heroin use were low in both girls and boys. Among boys, family ICIAI was positively associated with perceived behavioral control, and friend ICIAI was positively associated with perceived peer control and communication with parent. Among girls, family ICIAI was positively associated with perceived behavioral control and communication with parents about heroin use, but negatively with favorable attitudes to heroin use; friend ICIAI was positively associated with perceived peer control, and classmate ICIAI was negatively associated with favorable attitudes toward heroin use.
This study documents that collectivistic aspects of Chinese culture may influence psychosocial factors for heroin use, although the patterns are varied by gender. Findings provide an empirical basis for the development of culturally competent intervention programs for heroin use intervention and prevention.
PMCID: PMC2955002  PMID: 20858259
21.  Knowledge and risk behaviors related to HIV/AIDS, and their association with information resource among men who have sex with men in Heilongjiang province, China 
BMC Public Health  2010;10:250.
In Heilongjiang province, the HIV prevalence in men who have sex with men (MSM) is generally lower than other part of China. However, the official perception for their risk of HIV/AIDS infection has been increasing in the province over the years. Moreover, little information on HIV/AIDS was provided to the communities so that we have disadvantage of controlling HIV/AIDS epidemic in the region. The purpose of this study is to investigate the prevalence of HIV among MSM in Heilongjiang province, to assess their knowledge levels and risk behaviors related to HIV/AIDS, and to explore their associations with information resources.
A cross-sectional study using a standardized questionnaire and blood test was administered in 2008 by local interviewers to a sample (1353) of MSM in four cities in Heilongjiang province.
Among 1353 MSM, 2.3% were identified with HIV infection. About 48.7% of the subjects had multiple male sexual partners and only 37.3% of the subjects had consistent condom use (use every time) in the past 6 months. Most had a fair level of knowledge on HIV/AIDS, with the highest mean knowledge score among the MSM from Jiamusi, those with income 2000-3000 RMB/month, those searching sexual partners via internet and those performed HIV testing over 1 year ago). However, some myths regarding viral transmission (e.g., via mosquito bites or sharing kitchen utensils) also existed. Resources of information from which knowledge and risk behaviors related to HIV/AIDS was most available were television (58.6%) among MSM, followed by sexual partner (51.6%), publicity material (51.0%) and internet (48.7%). Significantly statistical differences of mean knowledge score were revealed in favor of book (P = 0.0002), medical staff (P = 0.0007), publicity material (P = 0.005) and sexual partner (P = 0.02). Press (P = 0.04) and book (P = 0.0003) were contributory to the most frequent condom use (condom use every time), while medical staff (P = 0.005) and publicity material (P = 0.04) is associated with moderate rate of condom use (condom use often).
Although the prevalence of HIV infection is low among MSM in Heilongjiang province, the situation that the risk behaviors were frequent in the population is alarming. The study suggests that some strategies like condom use and education intervention are practical approaches and need to be strengthened.
PMCID: PMC2885333  PMID: 20470385
22.  The effect of health and nutrition education intervention on women's postpartum beliefs and practices: a randomized controlled trial 
BMC Public Health  2009;9:45.
'Sitting month' is the Chinese tradition for postpartum customs. Available studies indicate that some of the traditional postpartum practices are potentially harmful for women's health. However, no intervention study aiming at postpartum practices has been performed. In this paper we evaluated the effect of a health and nutrition education intervention, which focused on improving postpartum dietary quality and optimal health behaviors.
The study design was a randomized controlled trial conducted in both urban and rural area of Hubei between August 2003 and June 2004. A total of 302 women who attended the antenatal clinic during the third trimester with an uncomplicated pregnancy were recruited. Women randomized to the education intervention group in both urban and rural area received two two-hour prenatal education sessions and four postpartum counseling visits. Control group women received usual health care during pregnancy and postpartum period. Women were followed up until 42 days postpartum. Outcome measures were nutrition and health knowledge, dietary behavior, health behavior and health problems during the postpartum period.
Women in the intervention groups exhibited significantly greater improvement in overall dietary behaviors such as consumption of fruits, vegetables, soybean and soybean products as well as nutrition and health knowledge than those in the control groups. Significantly more women in the intervention groups give up the traditional behavior taboos. The incidence of constipation, leg cramp or joint pain and prolonged lochia rubra was significantly lower in the intervention groups as compared with the control groups.
The study shows that health and nutrition education intervention enable the women take away some of the unhealthy traditional postpartum practices and decrease the prevalence of postpartum health problems. The intervention has potential for adaptation and development to large-scale implementation.
Trial registration number
PMCID: PMC2640472  PMID: 19183504
23.  Postpartum practices of puerperal women and their influencing factors in three regions of Hubei, China 
BMC Public Health  2006;6:274.
'Sitting month' is a Chinese tradition for women's postpartum custom. The present study aims to explore the postpartum dietary and health practices of puerperal women and identify their influential factors in three selected regions of Hubei, China.
A cross-sectional retrospective study was conducted in the selected urban, suburban and rural areas in the province of Hubei from 1 March to 30 May 2003. A total of 2100 women who had given birth to full-term singleton infants in the past two years were selected as the participants. Data regarding postpartum practices and potentially related factors were collected through questionnaire by trained investigators.
During the puerperium, 18% of the participants never ate vegetables, 78.8% never ate fruit and 75.7% never drank milk. Behaviour taboos such as no bathing, no hair washing or teeth brushing were still popular among the participants. About half of the women didn't get out of the bed two days after giving birth. The average time they stayed in bed during this period was 18.0 h. One third of them didn't have any outdoor activities in that time periods. The educational background of both women and their spouses, location of their residence, family income, postnatal visit, nutrition and health care educational courses were found to be the influencing factors of women's postpartum practices.
Traditional postpartum dietary and health behaviours were still popular among women in Hubei. Identifying the factors associated with traditional postpartum practices is critical to develop better targeting health education programs. Updated Information regarding postpartum dietary and health practices should be disseminated to women.
PMCID: PMC1636040  PMID: 17087836
24.  The effect of socioeconomic status on three-year mortality after first-ever ischemic stroke in Nanjing, China 
BMC Public Health  2006;6:227.
Low socioeconomic status (SES) is associated with increased mortality after stroke in developed countries. This study was performed to determine whether a similar association also exists in China.
A total of 806 patients with first-ever ischemic stroke were enrolled in our study. From August 1999 to August 2005, the three-year all-cause mortality following the stroke was determined. Level of education, occupation, taxable income and housing space were used as indicators for SES. Stepwise univariate and multivariate COX proportional hazards models were used to study the association between the SES measures and the three-year mortality.
Our analyses confirmed that occupation, taxable income and housing space were significantly associated with three-year mortality after first-ever stroke. Manual workers had a significant hazard ratio of 5.44 (95% CI 2.75 to 10.77) for death within three years when compared with non-manual workers. Those in the zero income group had a significant hazard ratio of 5.35 (95% CI 2.95 to 9.70) and those in the intermediate income group 2.10 (95% CI 1.24 to 3.58) when compared with those in the highest income group. Those in two of the three groups with the smallest housing space also had significant hazard ratios of 2.06 (95% CI 1.16 to 3.65) and 1.68 (95% CI 1.12 to 2.52) when compared with those in group with the largest housing space. These hazard ratios remained largely unchanged after multivariate adjustment for age, gender, baseline cardiovascular disease risk factors, and stroke severity. The analyses did not confirm an association with educational level.
Lower SES has a negative impact on the outcome of first-ever stroke in Nanjing, China. This confirms the need to improve preventive and secondary care for stroke among low SES groups.
PMCID: PMC1584410  PMID: 16961936
25.  Determinants of tobacco smoking among rural-to-urban migrant workers: a cross-sectional survey in Shanghai 
BMC Public Health  2015;15:131.
Although there are several studies to investigate the smoking behaviors among rural-to-urban Chinese migrants, no study has focused individually on this population in Shanghai. This study was performed to estimate the prevalence and identify the determinants of tobacco smoking among rural-to-urban migrants in Shanghai.
In this cross-sectional study, multi-stage quota sampling was used to select 5,856 rural-to-urban migrants aged 18 years or older from seven districts in Shanghai between July and October 2012. A structured questionnaire was administered to assess smoking knowledge, attitude, behavior and demographic characteristics. Mental health was assessed by the self-reported SCL-90. Multiple logistic regression analysis was used to determine the risk factors of smoking behavior.
A total of 5,380 of the 5,856 migrants enrolled completed the questionnaire, among whom 45.0% of male and 2.0% of female participants reported current smoking. Multivariate analysis revealed current smoking in female migrants to be significantly associated with working at construction (OR, 8.08; 95% CI, 1.80-36.28), hotels/restaurants (OR, 5.06; 95% CI, 1.68-15.27), entertainment sector (OR, 6.79; 95% CI, 2.51-18.42), with monthly income > 3500 yuan (OR, 2.69; 95% CI, 1.21-5.98), number of migratory cities of 2 (OR, 2.39; 95% CI, 1.23-4.65), and SCL-90 total score > 160 (OR, 2.03; 95% CI, 1.03-3.98), while the male migrants working at construction (OR, 1.30; 95% CI, 1.04-1.62), entertainment sector (OR, 1.86; 95% CI, 1.36-2.56), being divorced/widowed (OR, 2.20; 95% CI, 1.02-4.74), with duration of migration of 4 or more than 4 years (OR, 1.42; 95% CI, 1.06-1.91), number of migratory cities of 3 or more than 3 (OR, 1.42; 95% CI, 1.13-1.80), and SCL-90 total score > 160 (OR,1.39; 95% CI, 1.07-1.79) showed an excess smoking prevalence.
Migration lifestyle and mental status were associated with current smoking behaviors. The identifications of risk factors for current smoking may help to target health promotion interventions.
PMCID: PMC4334770
Rural-to-urban migrants; Smoking; Tobacco control; China

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