The conceptual definition,development dilemma,and path selection of a multi-level healthcare security system under the perspective of holistic governance / 中国卫生政策研究

The unclear connotation and fragmented governance of the multi-tiered medical security system pose challenges to its high-quality development.This article redefines the concept and connotation of the multi-tiered medical security system using holistic governance theory.It distinguishes the bottom layer,basic layer,and supplementary layer from the perspective of the essential attributes and direct functions of each system.Furthermore,from the perspective of holistic governance,the article analyzes the current reform practice and finds that fragmented management thinking,unclear positioning of sub-system functions,insufficient policy coordination,single participation subject,and lack of equal negotiation mechanisms are constraints on the overall effectiveness of the multi-tiered medical security system.Therefore,it is necessary to adopt systematic and targeted reform measures from the perspective of holistic governance to improve the system.

Construction and operation of the multi-level medical security system of the West China Women and Children Alliance / 中华医院管理杂志

Medical mutual aid is an important component of multi-level medical security system. West China Second University Hospital of Sichuan University led the establishment of the pediatric specialty alliance " West China Women and Children Alliance". Based on customized and inclusive mutual insurance product " Family Doctor Mutual Aid Plan", the alliance implemented key links such as mutual aid product forms, patient risk protection, institutional financing and hematopoiesis, and distribution of benefits to all parties, explored innovative mutual aid funding, payment, and incentive mechanisms, forming a closed-loop pediatric tiered diagnosis and treatment service system with the Mutual Aid Plan as the core. This system operated continuously under the " Four-in-One" framework, stimulating the integration of medical insurance and service supply systems while enhancing the synergistic effect between mutual insurance and social security. It has formed a distinctive health-centered multi-level medical security system within the alliance, and could provide reference for the construction and exploration of hierarchical diagnosis and treatment system.

Multi-level ranking classification algorithm for nuclear cataract based on AS-OCT image / 中华实验眼科杂志

Objective:To investigate the diagnostic value of an intelligent assisted grading algorithm for nuclear cataract using anterior segment optical coherence tomography (AS-OCT) images.Methods:A diagnostic test study was conducted.AS-OCT image data were collected from 939 cases of 1 608 eyes of nuclear cataract patients at the Shanghai Tenth People's Hospital of Tongji University from November 2020 to September 2021.The data were obtained from the electronic case system and met the requirements for clinical reading clarity.Among them, there were 398 cases of 664 male eyes and 541 cases of 944 female eyes.The ages of the patients ranged from 18 to 94 years, with a mean age of (65.7±18.6) years.The AS-OCT images were labelled manually from one to six levels according to the Lens Opacities Classification System Ⅲ (LOCS Ⅲ grading system) by three experienced clinicians.This study proposed a global-local cataract grading algorithm based on multi-level ranking, which contains five basic binary classification global local network (GL-Net).Each GL-Net aggregates multi-scale information, including the cataract nucleus region and original image, for nuclear cataract grading.Based on ablation test and model comparison test, the model's performance was evaluated using accuracy, precision, sensitivity, F1 and Kappa, and all results were cross-validated by five-fold.This study adhered to the Declaration of Helsinjki and was approrved by Shanghai Tenth People's Hospital of Tongji University (No.21K216).Results:The model achieved the results with an accuracy of 87.81%, precision of 88.88%, sensitivity of 88.33%, F1 of 88.51%, and Kappa of 85.22% on the cataract dataset.The ablation experiments demonstrated that ResNet18 combining local and global features for multi-level ranking classification improved the accuracy, recall, specificity, F1, and Kappa metrics.Compared with ResNet34, VGG16, Ranking-CNN, MRF-Net models, the performance index of this model were improved.Conclusions:The deep learning-based AS-OCT nuclear cataract image multi-level ranking classification algorithm demonstrates high accuracy in grading cataracts.This algorithm may help ophthalmologists in improving the diagnostic accuracy and efficiency of nuclear cataract.

Associação entre o contexto escolar e a ocorrência de múltiplos parceiros sexuais: um estudo transversal com análise multinível / Association between school context and occurrence of multiple sexual partners: cross-sectional study with multilevel analysis

Resumo O estudo investiga a associação entre o contexto escolar e a ocorrência de múltiplos parceiros entre adolescentes, considerando as variáveis individuais. Estudo transversal com análise multinível, realizado no período de fevereiro a junho de 2018 com estudantes de 14 a 19 anos. A variável desfecho (múltiplos parceiros sexuais) foi coletada com base no questionário Youth Risk Behavior Survey (YRBS). As variáveis do contexto escolar foram tempo na escola (escola regular vs escola integral/semi-integral) e índice de vulnerabilidade social (IVS) do bairro onde a escola está localizada. De 2.500 participantes, 1.044 foram analisados por serem sexualmente ativos. A maioria dos adolescentes (63,89%) teve dois ou mais parceiros. Estudantes de escola regular (mínimo de 4h diárias) tiveram mais chances (OR 1.47, IC 1.10-1.97) de terem múltiplos parceiros sexuais quando comparados àqueles de escola integral/semi-integral (mínimo de 7h diárias). Porém, não houve associação em relação ao IVS dos bairros das escolas (OR 1.18, IC 0.82-1.70). Maior tempo na escola esteve associado a menor chance de múltiplos parceiros sexuais, enquanto estudar em escolas localizadas em bairro de alta vulnerabilidade não esteve associado à ocorrência de múltiplos parceiros sexuais entre adolescentes.

Abstract The objective was to investigate the association between the school context and the occurrence of multiple partners among adolescents, considering individual variables (age, gender, Bolsa Família, LGB, early sexual initiation and use of alcohol or drugs in the last sex). Cross-sectional study with multilevel analysis carried out in 2018 with adolescent students from Olinda, Brazil. The variable (multiple partners) was collected based on the 'Youth Risk Behavior Survey' questionnaire. School context variables were time in school (regular school vs. full/semi-full school) and the Social Vulnerability Index of the school district. Of 2,500 participants, 1,044 were analyzed for being sexually active and most had two or more partners (63.89%). Regular school students were more likely (OR 1.47, CI 1.10-1.97) to have multiple sexual partners compared to those in full-day schools/half-day schools. However, no association was found in relation to the SVI of the schools' neighborhoods (OR 1.18, IC 0.82-1.70). More time spent at school was associated with fewer chances of multiple sexual partners, while studying in schools located in highly vulnerable neighborhoods was not associated with the occurrence of multiple sexual partners among adolescents.

Analysis of factors associated with admission to the intensive care unit of children and adolescents with COVID-19: application of a multilevel model / Análise dos fatores associados ao internamento na unidade de terapia intensiva de crianças e adolescentes com COVID-19: aplicação de um modelo multinível

ABSTRACT Objective To identify factors associated with hospitalization in the intensive care unit in children and adolescents with COVID-19. Methods This was a retrospective cohort study using secondary data of hospitalized children and adolescents (zero to 18 years old) with COVID-19 reported in Paraíba from April 2020 to July 2021, totaling 486 records. Descriptive analysis, logistic regression and multilevel regression were performed, utilizing a significance level of 5%. Results According to logistic regression without hierarchical levels, there was an increased chance of admission to the intensive care unit for male patients (OR = 1.98; 95%CI 1.18 - 3.32), patients with respiratory distress (OR = 2.43; 95%CI 1.29 - 4.56), patients with dyspnea (OR = 3.57; 95%CI 1.77 - 7.18) and patients living in large cities (OR = 2.70; 95%CI 1.07 - 6.77). The likelihood of requiring intensive care was observed to decrease with increasing age (OR = 0.94; 95%CI = 0.90 - 0.97), the presence of cough (OR = 0.32; 95%CI 0.18 - 0.59) or fever (OR = 0.42; 95%CI 0.23 - 0.74) and increasing Gini index (OR = 0.003; 95%CI 0.000 - 0.243). According to the multilevel analysis, the odds of admission to the intensive care unit increased in male patients (OR = 1.70; 95%CI = 1.68-1.71) and with increasing population size of the municipality per 100,000 inhabitants (OR = 1.01; 95%CI 1.01-1.03); additionally, the odds of admission to the intensive care unit decreased for mixed-race versus non-brown-skinned patients (OR = 0.981; 95%CI 0.97 - 0.99) and increasing Gini index (OR = 0.02; 95%CI 0.02 - 0.02). Conclusion The effects of patient characteristics and social context on the need for intensive care in children and adolescents with SARS-CoV-2 infection were better estimated with the inclusion of a multilevel regression model.

RESUMO Objetivo Identificar fatores associados ao internamento na unidade de terapia intensiva de crianças e adolescentes com COVID-19. Método Estudo de coorte retrospectiva, com dados secundários, de crianças e adolescentes hospitalizados (zero a 18 anos), notificados com COVID-19 na Paraíba, de abril de 2020 a julho de 2021, totalizando 486 registros. Foram realizadas análise descritiva, regressão logística e regressão multinível, considerando o nível de significância de 5%. Resultados Na regressão logística sem níveis hierárquicos, ocorreu aumento da chance de internamento na unidade de terapia intensiva em pacientes do sexo masculino (RC = 1,98; IC95% 1,18 - 3,32), com desconforto respiratório (RC = 2,43; IC95% 1,29 - 4,56), dispneia (RC = 3,57; IC95% 1,77 - 7,18) e residentes em cidades com grande porte populacional (RC = 2,70; IC95% 1,07 - 6,77). Foi observada diminuição da chance de cuidados intensivos com aumento da idade em anos (RC = 0,94; IC95%=0,90 - 0,97), presença de tosse (RC = 0,32; IC95% 0,18 - 0,59), febre (RC = 0,42; IC95% 0,23 - 0,74) e aumento no Índice de Gini (RC = 0,003; IC95% 0,000 - 0,243). Na análise multinível, a chance de internamento na unidade de terapia intensiva aumentou no sexo masculino (RC = 1,70; IC95%=1,68-1,71) e por conta do aumento no porte populacional do município a cada 100 mil habitantes (RC = 1,01; IC95% 1,01 - 1,03); a chance de internamento na unidade de terapia intensiva diminuiu em pacientes pardos versus não pardos (RC = 0,981; IC95% 0,97 - 0,99) e por conta do aumento a cada pontuação do Índice de Gini (RC = 0,02; IC95% 0,02 - 0,02). Conclusão Os efeitos das condições próprias do paciente e do contexto social na necessidade de cuidados intensivos em crianças e adolescentes com infecção pelo SARS-CoV-2 são mais bem estimados com a inclusão de um modelo de regressão multinível nas análises.

Contextual and individual determinants of oral health-related quality of life among adolescents

Abstract The aim of this study was to assess the factors associated with oral health-related quality of life in adolescents (OHRQoL). Individual data on adolescents were collected from a secondary database. OHRQoL was measured using the oral impact on daily performance (OIDP) scale. Individual- and city-level variables were selected to represent the structural and intermediate determinants of health. The individual covariates analyzed were sex, age, skin color, maternal education, household income, number of people per room in the housing unit, dental attendance, self-perception of dental needs, untreated dental caries, and gingival bleeding. The contextual variables included the allocation factor, the Human Development Index (HDI), Gini coefficient, illiteracy, unemployment, income, average number of emergency dental visits per inhabitant, access to a sanitary sewer system, garbage collection, primary health care coverage, oral health team coverage, and number of tooth extractions between selected dental procedures and supervised toothbrushing. Unadjusted and adjusted multilevel Poisson regression analyses were used to evaluate the relationship between contextual and individual variables with overall OIDP scores (STATA version 16.0) - rate ratio (RR) and 95%CI. The mean OIDP score was 0.72 and the prevalence was 31.8%. There was an association between supervised toothbrushing average and the outcome (RR 0.95; 95%CI 0.91-0.99). Moreover, adolescents who lived in municipalities with the highest average number of emergency dental visits per inhabitant showed a higher OIDP. Sex, maternal education, untreated dental caries, and gingival bleeding were associated with OIDP. In addition, intersectoral public policies focusing on the reduction of social inequalities should be on the agenda of policymakers and stakeholders.

Construção e validação de instrumento para avaliação socioestrutural e comportamental associado à infecção pelo HIV em jovensa / Construcción y validación de un instrumento de evaluación sociológica y comportamental asociado con la infección por VIH en jóvenes / Construction and validity of an instrument for sociological and behavioral assessment associated with HIV infection in young peoplea

RESUMO Objetivo construir e validar conteúdo de instrumento para avaliação socioestrutural e comportamental associado à infecção pelo HIV em jovens. Método estudo metodológico, desenvolvido em duas etapas: elaboração do instrumento; e validação de conteúdo. Os itens que compuseram o instrumento foram selecionados através de revisão literária, tendo como referencial os domínios multiníveis do Modelo Social Ecológico Modificado, categorizados em componentes socioestruturais e comportamentais. O conteúdo foi avaliado por especialistas em duas rodadas conduzidas pela técnica Delphi, admitindo-se um índice de concordância de, no mínimo, 80%. Resultados a primeira versão do instrumento continha 52 itens, distribuídos em três domínios. Na primeira rodada, 19 itens (36,5%) obtiveram Índice de Validade de Conteúdo inferior a 0,80, dois itens foram excluídos e os demais foram reformulados. Na segunda rodada, 2 itens foram excluídos e 3 foram incorporados como subitem, totalizando 45 itens. O Índice de Validade de Conteúdo do Instrumento foi de 95%. Conclusão e implicações para a prática as recomendações dos especialistas contribuíram para a qualificação do instrumento Avaliação Socioestrutural e Comportamental-HIV, possibilitando a reorganização do conteúdo. O instrumento é válido para a identificação de fatores socioestruturais e comportamentais associados à infecção pelo HIV em jovens, com potencial para constituir planejamento de cuidados preventivos.

RESUMEN Objetivo construir y validar el contenido de un instrumento de evaluación socioestructural y conductual asociada a la infección por VIH en jóvenes. Método estudio metodológico, desarrollado en dos etapas: elaboración del instrumento; y validación de contenido. Los ítems que conformaron el instrumento fueron seleccionados a través de una revisión literaria, tomando como referencia los dominios multinivel del Modelo Ecológico Social Modificado, categorizados en componentes socioestructurales y conductuales. El contenido fue evaluado por expertos en dos rondas realizadas mediante la técnica Delphi, suponiendo una tasa de acuerdo de al menos el 80%. Resultados la primera versión del instrumento contuvo 52 ítems, distribuidos en tres dominios. En la primera ronda, 19 ítems (36,5%) tuvieron un Índice de Validez de Contenido inferior a 0,80, dos ítems fueron excluidos y el resto fueron reformulados. En la segunda ronda, se excluyeron 2 ítems y se incorporaron 3 como subítems, totalizando 45 ítems. El Índice de Validez de Contenido del Instrumento fue del 95%. Conclusión e implicaciones para la práctica las recomendaciones de los expertos contribuyeron para la calificación del instrumento Evaluación Socioestructural y del Comportamiento-VIH, permitiendo la reorganización del contenido. El instrumento es válido para identificar factores socioestructurales y conductuales asociados a la infección por VIH en jóvenes, con potencial para constituir una planificación de atención preventiva.

ABSTRACT Objective to construct and validate the content of an instrument for sociostructural and behavioral assessment associated with HIV infection in young people. Method a methodological study developed in two steps: instrument elaboration; and content validity. The items that made up the instrument were selected through a literary review using the Modified Social Ecological Model multilevel domains as a reference, categorized into sociostructural and behavioral components. Content was assessed by experts in two rounds conducted using the Delphi technique, assuming an agreement rate of at least 80%. Results the first version of the instrument contained 52 items, distributed across three domains. In the first round, 19 items (36.5%) had a Content Validity Index lower than 0.80, two items were excluded and the rest were reformulated. In the second round, 2 items were excluded and 3 were incorporated as subitems, totaling 45 items. The Instrument Content Validity Index was 95%. Conclusion and implications for practice experts' recommendations contributed qualifying the Sociostructural and Behavioral Assessment-HIV instrument, enabling content reorganization. The instrument is valid for identifying socio-structural and behavioral factors associated with HIV infection in young people, with the potential to constitute preventive care planning.

Fundamento y generalidades de la construcción de modelos estadísticos multinivel en el ámbito de la investigación en salud / Construction of multilevel statistical models in health research: Foundations and generalities

Este trabajo tiene como objetivo presentar una mirada global de la aplicabilidad de los modelos de análisis multinivel en el ámbito de la investigación sanitaria. Ofrece información sobre los fundamentos teóricos, metodológicos y estadísticos y, además, menciona los pasos básicos para la construcción de estos modelos, y da ejemplos de su uso, según la estructura jerárquica de los datos. Cabe resaltar que, antes de utilizar estos modelos, se requiere contar con un soporte teórico sobre la necesidad de uso y una valoración estadística que dé cuenta del porcentaje de varianza explicada por el efecto de agrupación de las observaciones. Los requisitos para llevar a cabo este tipo de análisis dependen de condiciones especiales como el tipo de variables, la cantidad de unidades por nivel o el tipo de estructura jerárquica. Se concluye que los modelos de análisis multinivel son una herramienta útil para lograr la integración de información, dadas la complejidad de las relaciones y las interacciones que determinan la mayoría de las condiciones de salud, incluida la pérdida de independencia entre las unidades de observación.

This topic review aims to present a global vision of multilevel analysis models' applicability to health research, explaining its theoretical, methodological, and statistical foundations. We describe the basic steps to build these models and examples of their application according to the data hierarchical structure. It ir worth noticing that before using these models, researchers must have a rationale for needing them, and a statistical evaluation accounting for the variance percentage explained by the observations grouping effect. The requirements to conduct this type of analysis depends on special conditions such as the type of variables, the number of units per level, or the type of hierarchical structure. We conclude that multilevel analysis models are a useful tool to integrate information, considering the complexity of the relationships and interactions involved in most health conditions, including the loss of independence between observation units.

Spatial and temporal patterns of infant mortality and its components in Rio de Janeiro / Padrões espaciais e temporais da mortalidade infantil e seus componentes no Rio de Janeiro

ABSTRACT Objectives. The study aims to assess the trend of neonatal, post-neonatal, and infant mortality from 1996 to 2020 within the metropolitan region of the state of Rio de Janeiro and other regions. Methods. Ecological study using the region as analysis unity. Data were accessed from the Mortality Information System and Live Birth Information System in the capital Rio de Janeiro, in the neighboring areas of Niterói, São Gonçalo, Baixada Fluminense, and the remaining regions of the state of Rio de Janeiro State. We applied Poisson multilevel modeling, where the models' response variables were infant mortality and its neonatal and post neonatal components. Fixed effects of the adjusted models were region and death year variables. Results. During the 1996-2020 period, the Baixada Fluminense showed the highest infant mortality rate as to its neonatal and post neonatal components. All adjusted models showed that the more recent the year the lower the mortality risk. Niterói showed the lowest adjusted risk of infant mortality and its neonatal and post neonatal components. Conclusion. Baixada Fluminense showed the highest mortality risk for infant mortality and its neonatal and post-neonatal components in the metropolitan region. The stabilization in mortality rates in recent years was identified by the research.

RESUMO Objetivos. Avaliar a tendência da mortalidade neonatal, pós-neonatal e infantil de 1996 a 2020, na região metropolitana do estado do Rio de Janeiro e nas outras regiões. Métodos. Estudo ecológico utilizando regiões como unidade de análise. Os dados foram acessados no Sistema de Informações sobre Mortalidade e Sistema de Informações sobre Nascidos Vivos da Capital (Rio de Janeiro), dos territórios vizinhos (Niterói, São Gonçalo e Baixada Fluminense) e das outras regiões do Estado do Rio de Janeiro. Utilizamos a modelagem multinível de Poisson, onde as variáveis de resposta dos modelos foram mortalidade infantil e seus componentes neonatal e pós-neonatal. Os efeitos fixos dos modelos ajustados foram região e ano da morte. Resultados. No período 1996-2020, a Baixada Fluminense apresentou a maior taxa de mortalidade infantil de seus componentes neonatal e pós-natal na região metropolitana. Todos os modelos ajustados mostraram que quanto mais recente o ano, menor o risco de mortalidade. O risco ajustado da mortalidade infantil e seus componentes neonatal e pós-neonatal foi menor em Niterói. Conclusão. A Baixada Fluminense apresentou o maior risco de mortalidade infantil e de seus componentes neonatal e pós-neonatal na região metropolitana. Detectamos estabilização das taxas de mortalidade nos últimos anos.

Preventive role of community-level social capital in the need for long-term care and impairment in instrumental activities of daily living: a multilevel analysis

BACKGROUND@#Individual-level social capital is an important determinant of older adults' long-term care needs; however, there is scant evidence regarding community-level social capital. Therefore, we investigated the association between community-level social capital and the prevalence of the need for long-term care among older adults.@*METHODS@#Between January and February 2018, a cross-sectional survey was conducted among all older adults (n = 13,558) aged 65 to 74 years in a rural municipality in Japan (total population, n = 72,833). A self-reported questionnaire was used to identify community-level social capital, comprising civic participation, social cohesion, and reciprocity. A multilevel logistic regression analysis was performed to estimate the odds ratios of the need for long-term care and a decline in social activity competence as assessed by instrumental activities of daily living. For the analysis, the community levels were divided into 76 voting districts and adjusted for daily life, lifestyle, socioeconomic status, health conditions, and the three social capital subscale scores at the individual level.@*RESULTS@#After adjusting for the covariates, we observed a tendency that a higher community level of reciprocity was associated with a lower prevalence of long-term care needs (OR: 0.86, 95% confidence interval: 0.75-1.00), whereas a high community level of social cohesion was associated with a significantly reduced decline in instrumental activities of daily living (OR per standard deviation increase: 0.87, 95% confidence interval: 0.79-0.96). No significant association was found with civic participation. Similarly, individual-level social capital was associated with the need for long-term care and decline in instrumental activities of daily living.@*CONCLUSIONS@#Our findings suggest that good community-level reciprocity or social cohesion as well as good individual social capital status may help prevent the need for long-term care among older adults.

Visualization and analysis of the status of research on surgical treatment of multilevel cervical spondylotic myelopathy in the English literature of Web of Science database using Citespace soft-ware / 中国脊柱脊髓杂志

Objectives:To analyze visually the current research status,hot spots and trends of surgical treatment of multilevel cervical spondylotic myelopathy(MCSM)collected in Web of Science(WOS)core database by collecting relevant English literature via Citespace software and creating knowledge maps,in order to provide direction and reference for further research in this field.Methods:The literature related to re-search on surgical treatment of MCSM with the subject of"Cervical Spondylotic Myelopathy"OR"Cervical Myelopathy"AND"Multilevel"OR"MCSM"OR"CSM"AND"Surgery"OR"Operation",published from January 1,2000 to December 31,2022 was retrieved from Web of Science(WOS).The literature included was Article and Review,and duplicate literature was excluded with the Remove Duplicates function of Citespace(6.1.R6)software for bibliometric analysis.The authors,institutions and keywords of the included literature were analyzed and displayed visually.Results:A total of 372 literature was included in the study.The sta-tistical analysis of annual publication volume showed that overall foreign research in this field had been on the rise in the last 20 years or so,and there had been a surge in literature and a continuous popularity ever since 2016.The co-occurrence analysis of authors showed that there were 550 authors,including 23 core au-thors,and the top 3 in terms of number of publications were Ding Wenyuan,Fehlings Michael G,and Yuan Wen.The co-occurrence analysis of institutions showed that research institutions in this field were concentrat-ed in domestic and foreign universities and hospitals,and the top 3 in terms of publications were Soochow Univ,Second Mil Med Univ,and Sun Yat Sen Univ.The keyword analysis showed 7 major clusters were ob-tained,and the hot topic of research was the comparative evaluation of the efficacy and safety of different surgical procedures for MCSM.Conclusions:Surgical treatment of multilevel cervical spondylotic myelopathy is of increasing research concern year by year,and it remains a hot spot worthy of research in the future.Further in-depth research to optimize and improve existing surgical procedures and explore new procedures by combining new materials and technologies is a feasible path for future study.

Research on the social and commercial integration mode of Huimin Insurance from the perspective of holistic governance / 中华医院管理杂志

As an important part of China′s multi-level medical insurance system, commercial health insurance has developed rapidly in recent years, but its guarantee level is still limited, and its role in the multi-level medical insurance system is not fully played. Huimin Insurance, as a new public private partnership health insurance, takes into account the dual characteristics of commercial operation and inclusive protection, and provides an important supplement to meet the needs of the masses for multi-level protection, alleviate the economic burden of serious diseases, and promote the innovation and development of the pharmaceutical industry. The author systematically analyzed the characteristics of social and commercial integration in the development of Huimin Insurance in China from the aspects of value-oriented mechanism, policy complementary mechanism and operation support mechanism, and analyzed the problems of in the current development process of Huimin Insurance based on the holistic governance framework of multi-level medical security system in three dimensions of " hierarchy-institutional-tool". It is suggested that the functional positioning of multiple subjects should be clarified, the ability of information integration should be enhanced, and the product design and serviceshould be optimized, so as to fully enlarge the supplementary security efficiency of Huimin Insurance, and explore a new path for the formation of a multi-level medical insurance system with Chinese characteristics.

The status quo and demand analysis of multi-level pre-job training for clinical nursing teachers / 中华医学教育探索杂志

Objective:To investigate the status quo of multi-level pre-job training for clinical nursing teachers and analyze their training needs, so as to provide reference for the design of pre-job training for clinical nursing teachers.Methods:A cross-sectional survey method was used to investigate 172 clinical nursing teachers in a tertiary general hospital in Harbin from April 2020 to June 2020 with multi-level pre-job training mode. The status quo of pre-job training and the training needs of teachers were analyzed. SPSS 17.0 was used to process the original data statistically.Results:Among the 172 respondents, 138 teachers (80.2%) were under 35 years old, and 133 teachers (77.3%) had a bachelor's degree or less; 89 teachers (51.7%) confirmed that hospitals or departments would carry out pre-job training in a planned and organized way, 10 teachers (5.8%) said that hospitals or departments had never organized training, 41 teachers (23.8%) had never participated in pre-job training, and 80 teachers (46.5%) had participated in pre-job training 1-3 times. There were 5 duplicates in the first 8 training contents of in-hospital training and in-department training, including knowledge of common diseases, nursing procedures, communication skills, hospital rules and regulations, and teaching methods. The total score of training demand was (154.51± 40.35) points, and the overall demand rate was 81.3%, which was at the high level. The dimensions with the highest scoring rate were legal system and humanistic literacy, with a scoring rate of 83.0%. The dimension with the lowest score was teaching management, with a score of 74.9%. The scoring rate of training needs with the highest points won nine items respectively on students' basic quality (self-supervision, willingness to learn, professional quality, etc.) (84.7%), training of legal knowledge (84.4%), incompatibility of drugs commonly used in department (84.3%), nurse etiquette (83.3%), nursing risk prevention (83.1%), evaluation methods of student education (83.1%), nurse-patient communication skills (83.0%), nurses and patients medication observation points of commonly used drugs in the department (83.0%), and effects of commonly used drugs in department (82.9%). Among the top three training forms, 84 students (48.8%) received online learning, 74 students (43.0%) received lectures from experienced teachers in hospitals, and 72 students (41.9%) received experience exchange and sharing seminars.Conclusion:The talent structure of clinical nursing teachers in this hospital is relatively young, and the first education level is low. Therefore, the pre-job training of clinical nursing teachers should be strengthened vigorously. The awareness rate and participation rate of pre-job training are average, so we should strengthen the release of training information from various channels, improve the awareness rate of training activities, clarify the encouragement or reward measures to participate in pre-job training activities, and improve the participation rate of training activities. Pre-job training content is repeated at every level, with a gap between the training needs of teachers in clinical nursing teaching. It's suggested that the teaching hospitals combine with their training objects of training needs, take the online-offline mixed mode of training, reasonably plan training contents as a whole at all levels, avoid training content repetition and waste of teachers, and organize teachers to timely exchange and share experiences.

Construction of multi-level medical training platform system in clinical skills simulation training center / 中华医学教育探索杂志

This study mainly introduces the exploration of the construction and management of multi-level medical training platform in clinical skills center of the Affiliated Hospital of Yangzhou University. Through the construction of a multi-level clinical skills training platform, a reasonable hierarchical training program is formulated by taking the clinical basic skills training platform and the clinical specialist skills training platform as the basic core teaching content. This program adopts various ways to improve the teaching quality, effectively promote students' ability of clinical practice step by step, meet the needs of different levels of medical personnel in different stages, scientifically and effectively cultivate the high-quality medical personals, and give full play to the role of hospital clinical skills center in medical education, which lays a good foundation for the continuous improvement of teaching quality in hospitals.

Longitudinal study on growth of human immunodeficiency virus-exposed uninfected children from 2013 to 2019 in Chengdu City / 中华传染病杂志

Objective:To assess the early physical growth and development of human immunodeficiency virus-exposed uninfected (HEU) children by longitudinally comparing the differences of growth and development between HEU group and the healthy human immunodeficiency virus-unexposed uninfected (HUU) control group of children aged 0 to 18 months.Methods:A retrospective cohort study was designed.Maternal information of the human immunodeficiency virus (HIV) infected mothers and follow-up information at 0, 1, 3, 6, 9, 12, and 18 months postpartum of their children (born between January 2013 and December 2019 in Chengdu City) were collected from the Information System of Prevention of Mother-to-Child Transmission of Human Immunodeficiency Virus Management. The HUU control group was matched with HEU group by maternal age, gestational age at birth, and infant gender at a ratio of 1∶1. There were 385 children each included in the HEU and HUU groups. Matched samples t-test and the multilevel models were used to compared the physical developmental differences between the two groups. Results:Weight for age Z scores (WAZ) at 0, 3, 6 months of HEU group were -0.72±1.03, -0.09±1.18 and 0.05±1.09, respectively, which were all lower than WAZ of HUU group (-0.21±1.04, 0.42±1.19 and 0.41±1.16, respectively), which were all significantly different ( t=8.41, 7.47 and 5.18, respectively, all P<0.001). Length for age Z scores (LAZ) at 3, 6, 12, 18 months of HEU group were -0.23±1.36, -0.01±1.48, -0.18±1.20 and -0.32±1.13, respectively, which were all lower than LAZ of HUU group (0.24±1.26, 0.30±1.26, 0.07±1.11 and 0.04±1.05, respectively), which were all significantly different ( t=6.14, 4.04, 2.72 and 4.30, respectively, all P<0.01). Weight for length Z scores (WLZ) at 0, 3, 6 months of HEU group were -1.05±1.18, 0.23±1.03 and 0.22±0.95, respectively, which were all lower than WLZ of HUU group (-0.20±0.98, 0.44±1.03 and 0.45±1.00, respectively), which were all significantly different ( t=10.90, 2.95 and 2.96, respectively, all P<0.01). After possible confounding factors were corrected, the WAZ of HEU children at 0, 3, 6 months were still lower than those of HUU children, the LAZ of 3, 6, 12, 18 months were still lower than those of HUU children, and the WLZ of 0, 3, 6 months were still lower than those of HUU children. Conclusions:The differences between HEU and HUU children in Chengdu City mainly occur within six months of age, but the differences of body length persist until 18 months of age.Prenatal exposure to HIV infection affects both fetal and postnatal body growth and development.

Current status and future prospects of the model integrating medicine with health regimens for elderly care under the multilevel referral healthcare system / 中华老年医学杂志

Along with population aging in China, the spectrum of chronic diseases in the elderly is constantly evolving, and the demand for different types of elderly care is increasing steadily.The healthcare infrastructure constitutes the cornerstone of elderly care.In order to further improve the elderly care system and the medical service model, this paper analyzes the current status of the model integrating medicine with health regimens for elderly care under the multilevel referral healthcare system and puts forward suggestions for future development.

Multilevel model in the identification of behavioral and structural risk factors for HIV: integrative review / Modelo multinivel para la identificación de factores de riesgo comportamentales y estructurales del VIH: revisión integradora / Modelo multinível na identificação de fatores de risco comportamentais e estruturais ao HIV: revisão integrativa

ABSTRACT Objectives: to investigate studies that adopted the multilevel analysis model to identify behavioral and structural risk factors associated with HIV infection. Methods: an integrative review of the literature with studies available in full, obtained from EMBASE, CINAHL, Pubmed, and Scopus, whose selected descriptors were the indexed terms: "HIV", "multilevel analysis" and "behavior". Results: the search resulted in 236 studies. Out of these, ten studies comprised the sample. Economic disadvantage, neighborhood characteristics, housing instability, incarceration, transactional sex, multiple partners, substance abuse, and age at first intercourse were classified as structural and behavioral risk factors for HIV. Reduced socioeconomic disadvantage, provision of housing stability, and condom use were associated with protective factors for HIV exposure. Conclusions: by applying the multilevel model in risk factor research studies, it was possible to identify the structural and behavioral elements of HIV risk.

RESUMEN Objetivos: investigar estudios que adoptaron el modelo del análisis multinivel para identificar los factores de riesgo comportamentales y estructurales asociados al VIH. Método: es una revisión bibliográfica integradora con estudios disponibles en su totalidad, obtenidos de las bases de datos EMBASE, CINAHL, Pubmed y Scopus, cuyos descriptores fueron los términos: "HIV", "multilevel analysis", "behavior". Resultados: diez artículos, de los 236 encontrados, formaron parte de la muestra. Desventajas económicas, características del vecindario, inestabilidad habitacional, encarcelamiento, sexo transaccional, parejas múltiples, abuso de sustancias y edad de la primera relación sexual se destacaron como factores de riesgo estructurales y comportamentales del VIH. La reducción de desventajas socioeconómicas, la provisión de estabilidad habitacional y el uso de preservativos están asociados a la protección contra el VIH. Conclusiones: al aplicar el modelo multinivel en los estudios de investigación de los factores de riesgo, fue posible identificar los elementos estructurales y comportamentales del riesgo del VIH.

RESUMO Objetivos: investigar estudos que adotaram o modelo de análise multinível na identificação de fatores de risco comportamentais e estruturais, que estão associados a infecção pelo HIV. Métodos: revisão integrativa da literatura com estudos disponíveis na íntegra, obtidos nas bases EMBASE, CINAHL, Pubmed e Scopus, cujos descritores selecionados foram os termos constantes: "HIV", "multilevel analysis", "behavior". Resultados: a pesquisa resultou em 236 artigos. Destes, dez artigos compuseram a amostra. Desvantagem econômica, características de vizinhança, instabilidade habitacional, encarceramento, sexo transacional, múltiplos parceiros, abuso de substâncias e idade da primeira relação sexual foram classificados como fatores de risco estruturais e comportamentais ao HIV. Redução da desvantagem socioeconômica, fornecimento de estabilidade habitacional e uso de preservativos foram associados a fatores de proteção à exposição ao HIV. Conclusões: com a aplicabilidade do modelo multinível nos estudos de investigação de fatores de risco, foi possível identificar os elementos estruturais e comportamentais de risco ao HIV.

Economic fluctuations and educational inequalities in premature ischemic heart disease mortality in Argentina / Variaciones económicas y desigualdades educativas en la mortalidad prematura por enfermedad isquémica en Argentina / Flutuações econômicas e desigualdades educacionais na mortalidade prematura por doença isquêmica na Argentina

Abstract: Although mortality from ischemic heart disease has declined over the past decades in Argentina, ischemic heart disease remains one of the most frequent causes of death. This study aimed to describe the role of individual and contextual factors on premature ischemic heart disease mortality and to analyze how educational differentials in premature ischemic heart disease mortality changed during economic fluctuations in two provinces of Argentina from 1990 to 2018. To test the relationship between individual (age, sex, and educational level) and contextual (urbanization, poverty, and macroeconomic variations) factors, a multilevel Poisson model was estimated. When controlling for the level of poverty at the departmental level, we observed inequalities in premature ischemic heart disease mortality according to the educational level of individuals, affecting population of low educational level. Moreover, economic expansion was related to an increase in ischemic heart disease mortality, however, expansion years were not associated with increasing educational inequalities in ischemic heart disease mortality. At the departmental level, we found no contextual association beween area-related socioeconomic level and the risk of ischemic heart disease mortality. Despite the continuing decline in ischemic heart disease mortality in Argentina, this study highlighted that social inequalities in mortality risk increased over time. Therefore, prevention policies should be more focused on populations of lower socioeconomic status in Argentina.

Resumen: Si bien la mortalidad por cardiopatía isquémica ha disminuido en las últimas décadas en Argentina, la cardiopatía isquémica sigue siendo una de las causas más frecuentes de muerte. Los objetivos de este estudio fueron describir el papel de los factores individuales y contextuales en la mortalidad prematura por cardiopatía isquémica y analizar cómo estos cambiaron las diferencias educativas en la mortalidad prematura por cardiopatía isquémica durante las variaciones económicas en dos provincias de Argentina durante el periodo 1990-2018. Para probar la relación entre los factores individuales (edad, género y nivel de educación) y contextuales (urbanización, pobreza y variaciones macroeconómicas), se estimó un modelo de Poisson multinivel. Controlando el nivel de pobreza en el ámbito departamental, se observaron desigualdades en la mortalidad prematura por cardiopatía isquémica según el nivel de educación de los individuos, lo que afecta a la población con bajo nivel de educación; la expansión económica se relacionó con el aumento de la mortalidad por cardiopatía isquémica; sin embargo, el periodo de expansión no estuvo asociado a aumentos de las desigualdades educativas en la mortalidad por cardiopatía isquémica. En el ámbito departamental no se detectó asociación entre el nivel socioeconómico de la área y el riesgo de mortalidad por cardiopatía isquémica. A pesar de la disminución continua de la mortalidad por cardiopatía isquémica en Argentina, este estudio destaca que las desigualdades sociales con relación al riesgo de mortalidad tuvieron un aumento con el tiempo. Por lo tanto, las políticas de prevención deberán dirigirse más a las poblaciones de menor nivel socioeconómico en Argentina.

Resumo: Embora a mortalidade por doença isquêmica do coração tenha diminuído nas últimas décadas na Argentina, a doença isquêmica do coração continua sendo uma das causas mais frequentes de morte. Os objetivos deste estudo foram descrever o papel de fatores individuais e contextuais na mortalidade prematura por doença isquêmica do coração e analisar como as diferenças educacionais na mortalidade prematura por doença isquêmica do coração mudaram durante as flutuações econômicas em duas províncias da Argentina durante o período 1990-2018. Para testar a relação entre fatores individuais (idade, sexo e escolaridade) e contextuais (urbanização, pobreza e variações macroeconômicas), estimou-se um modelo de Poisson multinível. Controlando o nível de pobreza no nível departamental, observaram-se desigualdades na mortalidade prematura por doença isquêmica do coração de acordo com o nível educacional dos indivíduos, afetando a população de baixa escolaridade; a expansão econômica esteve relacionada ao aumento da mortalidade por doença isquêmica do coração; no entanto, os anos de expansão não foram associados a aumentos nas desigualdades educacionais na mortalidade por doença isquêmica do coração. No nível departamental, não foi detectada uma associação contextual entre nível socioeconômico da área e risco de mortalidade por doença isquêmica do coração. Apesar do contínuo declínio da mortalidade por doença isquêmica do coração na Argentina, este estudo destaca que as desigualdades sociais em relação ao risco de mortalidade aumentaram ao longo do tempo. Portanto, as políticas de prevenção devem ser mais focadas nas populações de menor nível socioeconômico na Argentina.

Climas empowering y disempowering, necesidades psicológicas e intención de práctica deportiva futura en jóvenes deportistas / Empowering and disempowering climates, psychological needs and future sports practice intention in young athletes

Resumen Introducción: El objetivo principal de este trabajo es conocer la interrelación entre la percepción de los climas empowering y disempowering generados por los entrenadores (nivel equipo) con la satisfacción y frustración de las necesidades psicológicas básicas, y estas, a su vez, con las intenciones de continuar y abandonar la práctica deportiva (nivel individual) en jóvenes deportistas. Método: Participaron 251 deportistas mexicanos (M = 13.22, DT = 1.28) pertenecientes a 19 equipos. Se les aplicó una batería de cuestionarios para la recolección de datos y se realizó un análisis multinivel de ecuaciones estructuradas. Resultados: El modelo de ecuaciones estructurales reveló asociaciones positivas entre las percepciones de climas empowering desde una perspectiva grupal sobre la satisfacción de necesidades psicológicas básicas y de estas sobre las intenciones de continuar la práctica deportiva desde una perspectiva individual, así como entre las percepciones de un clima disempowering sobre la frustración de las necesidades psicológicas básicas y de estas sobre las intenciones de abandono. Conclusión: Los hallazgos de este estudio sugieren en un nivel aplicado que el clima empowering actúa como catalizador del bienestar psicológico y como protector de la aparición de frustración, mientras que el clima disempowering facilita el desarrollo de respuestas psicológicas desadaptativas en el deporte.

Abstract Introduction: The main objective of this work is to know the interrelation between the perception of empowering and disempowering climates generated by coaches (team level) with basic psychological needs satisfaction and frustration, and these in turn, with the intentions to continue and abandon sports practice (individual level) in young athletes. Method: 251 Mexican athletes participated (M = 13. 22, SD = 1.28) belonging to 19 teams. A battery of questionnaires was applied for data collection and a multilevel structured equation analysis was performed. Results: The structural equation model revealed positive associations between perceptions of empowering climates from a group perspective on the satisfaction of basic psychological needs and of these on intentions to continue practicing sports from an individual perspective; as well as between perceptions of a disempowering climate on the frustration of basic psychological needs and of these on intentions to drop out. Conclusion: The findings of this study suggest at an applied level that the empowering climate acts as a catalyst of psychological well-being and as a protector against the occurrence of frustration, while the disempowering climate facilitates the development of maladaptive psychological responses in sport.

Inequidad en el ingreso y caries de la infancia temprana en Colombia: un análisis multinivel / Income inequality and early childhood caries in Colombia: a multilevel analysis

Resumen Evaluamos la asociación entre inequidad en los ingresos y caries de la infancia temprana en Colombia, utilizando un análisis multinivel. Analizamos datos del último estudio nacional de salud bucal (2014) e información sobre ingresos en términos absolutos y relativos a nivel departamental. Los desenlaces fueron experiencia de caries y caries no tratada. Se utilizó un modelo de regresión logística multinivel con dos niveles: niños/familias (nivel 1) anidados en departamentos (nivel 2). En el nivel 1 se consideraron variables de edad, sexo, posición socioeconómica (PSE) de la vivienda, ingresos del hogar y régimen de aseguramiento en salud. Para el nivel 2 las variables fueron coeficiente Gini, Necesidades Básicas Insatisfechas (NBI) y Producto Interno Bruto (PIB). Se evaluaron datos de 5.250 niños de 1, 3 y 5 años, 36.9% tenían experiencia de caries y 33.0% caries no tratada. Los desenlaces mostraron asociaciones significativas con edad, PSE baja del hogar y pertenecer al régimen subsidiado de salud. Para caries no tratada se encontraron asociaciones con PSE baja o muy baja (OR: 1.72; IC95% 1.42, 2.07 y OR: 1.69; IC95% 1.36, 2.09 respectivamente) y régimen subsidiado de salud (OR: 1.58; IC95% 1.11, 2.24). No se encontraron asociaciones significativas con indicadores de coeficiente Gini, PIB y NBI.

Abstract The association between income inequality and dental caries on early childhood in Colombia was evaluated using a multi-level analysis. We analyzed data from the latest national oral survey (2014) and information about income in absolute and relative terms on a state-level. The outcomes were caries experience, and untreated caries. A multilevel logistic regression model was used (2 levels) with children/households nested within states. Age, gender, area-level socioeconomic position (SEP), household income and health insurance regime were the level 1 explanatory variables. For level 2, variables were the Gini coefficient, Unsatisfied Basic Needs (UBN) and Gross Domestic Product (GDP). Data from 5.250 children, aged 1, 3 and 5 years were evaluated. Prevalence of caries experience and untreated caries was 36.9% and 33.0% respectively. Both outcomes showed significant associations with age, low SEP and belonging to the subsidized health insurance regime: untreated dental caries was associated with living in low and very low SEP (OR: 1.72; 95%CI 1.42, 2.07 and OR: 1.69; 95%CI 1.36, 2.09 respectively), and subsidized health insurance scheme (OR: 1.58; 95%CI 1.11, 2.24). When the Gini, GDP and UBN indicators were included in the models, no significant associations were found.