Coping with COVID: Performance of China's hierarchical medical system during the COVID-19 pandemic.

Objective: The COVID-19 pandemic has challenged the health system worldwide. This study aimed to assess how China's hierarchical medical system (HMS) coped with COVID-19 in the short-and medium-term. We mainly measured the number and distribution of hospital visits and healthcare expenditure between primary and high-level hospitals during Beijing's 2020-2021 pandemic relative to the 2017-2019 pre-COVID-19 benchmark period. Methods: Hospital operational data were extracted from Municipal Health Statistics Information Platform. The COVID-19 period in Beijing was divided into five phases, corresponding to different characteristics, from January 2020 to October 2021. The main outcome measures in this study include the percentage change in inpatient and outpatient emergency visits, and surgeries, and changing distribution of patients between different hospital levels across Beijing's HMS. In addition, the corresponding health expenditure in each of the 5 phases of COVID-19 was also included. Results: In the outbreak phase of the pandemic, the total visits of Beijing hospitals declined dramatically, where outpatient visits fell 44.6%, inpatients visits fell 47.9%; emergency visits fell 35.6%, and surgery inpatients fell 44.5%. Correspondingly, health expenditures declined 30.5% for outpatients and 43.0% for inpatients. The primary hospitals absorbed a 9.51% higher proportion of outpatients than the pre-COVID-19 level in phase 1. In phase 4, the number of patients, including non-local outpatients reached pre-pandemic 2017-2019 benchmark levels. The proportion of outpatients in primary hospitals was only 1.74% above pre-COVID-19 levels in phases 4 and 5. Health expenditure for both outpatients and inpatients reached the baseline level in phase 3 and increased nearly 10% above pre-COVID-19 levels in phases 4 and 5. Conclusion: The HMS in Beijing coped with the COVID-19 pandemic in a relatively short time, the early stage of the pandemic reflected an enhanced role for primary hospitals in the HMS, but did not permanently change patient preferences for high-level hospitals. Relative to the pre-COVID-19 benchmark, the elevated hospital expenditure in phase 4 and phase 5 pointed to hospital over-treatment or patient excess treatment demand. We suggest improving the service capacity of primary hospitals and changing the preferences of patients through health education in the post-COVID-19 world.

Student COVID-19 vaccination preferences in China: A discrete choice experiment

Objective This study uses a discrete choice experiment (DCE) questionnaire to investigate student vaccination preferences for both intrinsic and extrinsic attributes. Methods A two-part DCE questionnaire was distributed to 1,138 students through face-to-face interviews at vaccination centers in Qingdao, China. Conditional logit models were used to understand student preference trade-offs. Mixed logit models (MLM) and sub-group analysis were conducted to understanding student preference heterogeneity. Results We found that students preferred vaccines with fewer side effects (β = 0.845;95% CI, 0.779–0.911), administered through third level health facilities (β = 0.170;95% CI, 0.110–0.230), and had at least 1 year duration of protection (β = 0.396;95% CI, 0.332–0.461. Higher perception of COVID-19 risks (β = 0.492;95% CI, 0.432–0.552) increased the likelihood of student vaccination uptake. Surprisingly, vaccine effectiveness (60%) and percentages of acquaintances vaccinated (60%) reduced vaccination utility, which points to free-rider problems. In addition, we find that student study majors did not contribute to preference heterogeneity, and the main disparities in preferences were attributed to student risk tolerances. Conclusion Both intrinsic and extrinsic attributes were influential factors shaping student preferences for COVID-19 vaccines. Our results inform universities and local governments across China on targeting their vaccination programs.

Individual Preferences for COVID-19 Vaccination under the China's 2021 National Vaccination Policy: A Discrete Choice Experiment Study.

(1) Background: Since China's national vaccination policy announcement in January 2021, individual vaccination preferences related to vaccine characteristics, social relationships, sociodemographic characteristics and cognition remain opaque. This study aims to investigate vaccination preferences regarding these attributes, and to assess changes in individual vaccine preferences since the pre-2021 emergency vaccination phase. (2) Methods: The two-part questionnaire surveyed 849 individuals between May and June 2021 in Qingdao, China. The survey contained eight binary choice tasks that investigated preference trade-offs. Respondents' sociodemographic characteristics, including age, sex, urban/rural residence, income, education and whether living with the young or old, were also collected. Conditional logit, mixed logit and latent class models were used to quantify preference utility and identify preference heterogeneity. (3) Results: Vaccine effectiveness, vaccine side effects, duration of protection and probability of infection all significantly affected vaccination utility. Preference heterogeneity based on individual social relationships and sociodemographic characteristics were also established. Marginal analysis showed that compared to the pre-2021 phase, individuals' preferences had shifted towards vaccines with longer protection periods and better accessibility. (4) Conclusion: This study will inform the full rollout of China's 2021 national vaccination program and provide valuable information for future vaccination policy design to meet resurgent COVID-19 risks.

Parents' Decisions to Vaccinate Children against COVID-19: A Scoping Review.

Since 2019, the COVID-19 pandemic has resulted in sickness, hospitalizations, and deaths of the old and young and impacted global social and economy activities. Vaccination is one of the most important and efficient ways to protect against the COVID-19 virus. In a review of the literature on parents' decisions to vaccinate their children, we found that widespread vaccination was hampered by vaccine hesitancy, especially for children who play an important role in the coronavirus transmission in both family and school. To analyze parent vaccination decision-making for children, our review of the literature on parent attitudes to vaccinating children, identified the objective and subjective influencing factors in their vaccination decision. We found that the median rate of parents vaccinating their children against COVID-19 was 59.3% (IQR 48.60~73.90%). The factors influencing parents' attitudes towards child vaccination were heterogeneous, reflecting country-specific factors, but also displaying some similar trends across countries, such as the education level of parents. The leading reason in the child vaccination decision was to protect children, family and others; and the fear of side effects and safety was the most important reason in not vaccinating children. Our study informs government and health officials about appropriate vaccination policies and measures to improve the vaccination rate of children and makes specific recommendations on enhancing child vaccinate rates.

The COVID-19 Run on Medical Resources in Wuhan China: Causes, Consequences and Lessons.

The COVID-19 run on medical resources crashed Wuhan's medical care system, a medical disaster duplicated in many countries facing the COVID-19 pandemic. In a novel approach to understanding the run on Wuhan's medical resources, we draw from bank run theory to analyze the causes and consequences of the COVID-19 run on Wuhan's medical resources and recommend policy changes and government actions to attenuate runs on medical resources in the future. Like bank runs, the cause of the COVID-19 medical resource run was rooted in China's local medical resource context and a sudden realignment of expectations, reflecting shortages and misallocations of hospital resources (inadequate liquidity and portfolio composition); high level hospitals siphoning-off patients from lower level health providers (bank moral hazard and adverse selection problem); patients selecting high-level hospitals over lower-level health care (depositor moral hazard problem); inadequate government oversight and uncontrolled risky hospital behavior (inadequate bank regulatory control); biased medical insurance schemes (inadequate depositor insurance); and failure to provide medical resource reserves (failure as lender of last resort). From Wuhan's COVID-19 run on medical resources, we recommend that control and reform by government enlarge medical resource supply, improve the capacity of primary medical care, ensure timely virus information, formulate principles for the allocation of medical resources that suit a country's national conditions, optimize the medical insurance schemes and public health fund allocations and enhance the emergency support of medical resources.

The influencing factors of discrimination against recovered Coronavirus disease 2019 (COVID-19) patients in China: a national study.

BACKGROUND: Over 26 million recovered COVID-19 patients will suffer from discrimination in work, education and social interactions. We analyzed the determinants of discrimination against recovered COVID-19 patients and suggest policy recommendations to reduce such discrimination. METHODS: Twenty-seven Chinese cities were selected randomly based on their geographical location and GDP rank. One hundred adults were interviewed in each city with an equal number of men and women and three urban residents for every two rural residents. A multiple ordered logistic regression model was used to assess the associations between potential determinants and the COVID-19 discrimination level. RESULTS: Of 2377 participants, 79.76% displayed discrimination toward recovered COVID-19 patients. The female discrimination level was 1.25 times that of males; the discrimination level increased with age; and was occupation-specific, with physicians' (OR = 0.352) and students' (OR = 0.553) discrimination level lower than that of farmers. The discrimination level of participants from the central regions was 1.828 times, and the eastern region 1.504 times, that of participants from western region. The participants' discrimination level was lower when they scored higher in transmission knowledge, prevention knowledge and other COVID-19 knowledge, treatment methods and quarantine time. CONCLUSION: Sex, age, occupation, infections of relatives and friends, regions and scores on COVID-19 knowledge were determinants of discrimination level against recovered COVID-19 patients. In contrast with qualitative studies, our quantitative study recommends targeted education campaigns, focusing on physicians, women, older people and certain occupations. Only the COVID-19 vaccination program for the whole population will resolve the COVID-19 discrimination problem.

Development, Status Quo, and Challenges to China's Health Informatization During COVID-19: Evaluation and Recommendations.

By applying advanced health information technology to the health care field, health informatization helps optimize health resource allocation, improve health care services, and realize universal health coverage. COVID-19 has tested the status quo of China's health informatization, revealing challenges to the health care system. This viewpoint evaluates the development, status quo, and practice of China's health informatization, especially during COVID-19, and makes recommendations to address the health informatization challenges. We collected, assessed, and evaluated data on the development of China's health informatization from five perspectives-health information infrastructure, information technology (IT) applications, financial and intellectual investment, health resource allocation, and standard system-and discussed the status quo of the internet plus health care service pattern during COVID-19. The main data sources included China's policy documents and national plans on health informatization, commercial and public welfare sources and websites, public reports, institutional reports, and academic papers. In particular, we extracted data from the 2019 National Health Informatization Survey released by the National Health Commission in China. We found that China developed its health information infrastructure and IT applications, made significant financial and intellectual informatization investments, and improved health resource allocations. Tested during COVID-19, China's current health informatization system, especially the internet plus health care system, has played a crucial role in monitoring and controlling the pandemic and allocating medical resources. However, an uneven distribution of health resources and insufficient financial and intellectual investment continue to challenge China's health informatization. China's rapid development of health informatization played a crucial role during COVID-19, providing a reference point for global pandemic prevention and control. To further promote health informatization, China's health informatization needs to strengthen top-level design, increase investment and training, upgrade the health infrastructure and IT applications, and improve internet plus health care services.

Will COVID-19 Vaccinations End Discrimination against COVID-19 Patients in China? New Evidence on Recovered COVID-19 Patients.

(1) Background: By April 2021, over 160 million Chinese have been vaccinated against coronavirus disease 2019 (COVID-19). This study analyzed the impact of vaccination on discrimination against recovered COVID-19 patients and the determinants of discrimination among intended vaccinated people. (2) Methods: A self-designed questionnaire was used to collect data on COVID-19 associated discrimination from nine provinces in China. Pearson chi-square tests and a multivariate ordered logistic regression analyzed the determinants of COVID-19-related discrimination. (3) Results: People who intended to be COVID-19 vaccinated displayed a high level of discrimination against recovered COVID-19 patients, with only 37.74% of the intended vaccinated without any prejudice and 34.11% displaying severe discrimination. However, vaccinations reduced COVID-19-related discrimination against recovered COVID-19 patients from 79.76% to 62.26%. Sex, age, education level, occupation, geographical region, respondents' awareness of vaccine effectiveness and infection risk, and COVID-19 knowledge score had a significant influence on the COVID-19 related discrimination (p < 0.05). (4) Conclusions: Vaccination significantly reduced COVID-19 associated discrimination, but discrimination rates remained high. Among the intended vaccinated respondents, females, the older aged, people with high school and above education level, retirees, migrant workers, and residents in central China were identified as key targets for information campaigns to reduce COVID-19 related discrimination.

The Intention to Receive the COVID-19 Vaccine in China: Insights from Protection Motivation Theory.

(1) Background: More coronavirus disease 2019 (COVID-19) vaccines are gradually being developed and marketed. Improving the vaccination intention will be the key to increasing the vaccination rate in the future; (2) Methods: A self-designed questionnaire was used to collect data on COVID-19 vaccination intentions, protection motivation and control variables. Pearson Chi-square test and multivariate ordered logistic regression models were specified to analyze the determinants of intention to receive COVID-19 vaccine; (3) Results: Although the vaccine was free, 17.75% of the 2377 respondents did not want, or were hesitant, to receive the COVID-19 vaccine. Respondents' cognition of vaccine safety, external reward and response efficacy were positively related to COVID-19 vaccination intention, while age, income and response cost were negatively related to the intention to receive the COVID-19 vaccine. Professionals and people without medical insurance had the lowest intention to vaccinate; (4) Conclusions: The older aged, people without health insurance, those with higher incomes and professionals should be treated as the key intervention targets. Strengthening publicity and education about the safety and efficacy of COVID-19 vaccines, training vaccinated people and community leaders as propagandists for the vaccine, and improving the accessibility to the COVID-19 vaccine are recommended to improve COVID-19 vaccination intention.

COVID-19 Vaccination Willingness among Chinese Adults under the Free Vaccination Policy.

(1) Background: China will provide free coronavirus disease 2019 (COVID-19) vaccinations for the entire population. This study analyzed the COVID-19 vaccination willingness rate (VWR) and its determinants under China's free vaccination policy compared to a paid vaccine. (2) Methods: Data on 2377 respondents were collected through a nationwide questionnaire survey. Multivariate ordered logistic regression models were specified to explore the correlation between the VWR and its determinants. (3) Results: China's free vaccination policy for COVID-19 increased the VWR from 73.62% to 82.25% of the respondents. Concerns about the safety and side-effects were the primary reason for participants' unwillingness to be vaccinated against COVID-19. Age, medical insurance and vaccine safety were significant determinants of the COVID-19 VWR for both the paid and free vaccine. Income, occupation and vaccine effectiveness were significant determinants of the COVID-19 VWR for the free vaccine. (4) Conclusions: Free vaccinations increased the COVID-19 VWR significantly. People over the age of 58 and without medical insurance should be treated as the target intervention population for improving the COVID-19 VWR. Contrary to previous research, high-income groups and professional workers should be intervention targets to improve the COVID-19 VWR. Strengthening nationwide publicity and education on COVID-19 vaccine safety and effectiveness are recommended policies for decision-makers.

Application of Big Data Technology for COVID-19 Prevention and Control in China: Lessons and Recommendations.

BACKGROUND: In the prevention and control of infectious diseases, previous research on the application of big data technology has mainly focused on the early warning and early monitoring of infectious diseases. Although the application of big data technology for COVID-19 warning and monitoring remain important tasks, prevention of the disease's rapid spread and reduction of its impact on society are currently the most pressing challenges for the application of big data technology during the COVID-19 pandemic. After the outbreak of COVID-19 in Wuhan, the Chinese government and nongovernmental organizations actively used big data technology to prevent, contain, and control the spread of COVID-19. OBJECTIVE: The aim of this study is to discuss the application of big data technology to prevent, contain, and control COVID-19 in China; draw lessons; and make recommendations. METHODS: We discuss the data collection methods and key data information that existed in China before the outbreak of COVID-19 and how these data contributed to the prevention and control of COVID-19. Next, we discuss China's new data collection methods and new information assembled after the outbreak of COVID-19. Based on the data and information collected in China, we analyzed the application of big data technology from the perspectives of data sources, data application logic, data application level, and application results. In addition, we analyzed the issues, challenges, and responses encountered by China in the application of big data technology from four perspectives: data access, data use, data sharing, and data protection. Suggestions for improvements are made for data collection, data circulation, data innovation, and data security to help understand China's response to the epidemic and to provide lessons for other countries' prevention and control of COVID-19. RESULTS: In the process of the prevention and control of COVID-19 in China, big data technology has played an important role in personal tracking, surveillance and early warning, tracking of the virus's sources, drug screening, medical treatment, resource allocation, and production recovery. The data used included location and travel data, medical and health data, news media data, government data, online consumption data, data collected by intelligent equipment, and epidemic prevention data. We identified a number of big data problems including low efficiency of data collection, difficulty in guaranteeing data quality, low efficiency of data use, lack of timely data sharing, and data privacy protection issues. To address these problems, we suggest unified data collection standards, innovative use of data, accelerated exchange and circulation of data, and a detailed and rigorous data protection system. CONCLUSIONS: China has used big data technology to prevent and control COVID-19 in a timely manner. To prevent and control infectious diseases, countries must collect, clean, and integrate data from a wide range of sources; use big data technology to analyze a wide range of big data; create platforms for data analyses and sharing; and address privacy issues in the collection and use of big data.

Individual preferences for COVID-19 vaccination in China.

BACKGROUND: Vaccinations are an effective choice to stop disease outbreaks, including COVID-19. There is little research on individuals' COVID-19 vaccination decision-making. OBJECTIVE: We aimed to determine individual preferences for COVID-19 vaccinations in China, and to assess the factors influencing vaccination decision-making to facilitate vaccination coverage. METHODS: A D-efficient discrete choice experiment was conducted across six Chinese provinces selected by the stratified random sampling method. Vaccine choice sets were constructed using seven attributes: vaccine effectiveness, side-effects, accessibility, number of doses, vaccination sites, duration of vaccine protection, and proportion of acquaintances vaccinated. Conditional logit and latent class models were used to identify preferences. RESULTS: Although all seven attributes were proved to significantly influence respondents' vaccination decision, vaccine effectiveness, side-effects and proportion of acquaintances vaccinated were the most important. We also found a higher probability of vaccinating when the vaccine was more effective; risks of serious side effects were small; vaccinations were free and voluntary; the fewer the number of doses; the longer the protection duration; and the higher the proportion of acquaintances vaccinated. Higher local vaccine coverage created altruistic herd incentives to vaccinate rather than free-rider problems. The predicted vaccination uptake of the optimal vaccination scenario in our study was 84.77%. Preference heterogeneity was substantial. Individuals who were older, had a lower education level, lower income, higher trust in the vaccine and higher perceived risk of infection, displayed a higher probability to vaccinate. CONCLUSIONS: Preference heterogeneity among individuals should lead health authorities to address the diversity of expectations about COVID-19 vaccinations. To maximize COVID-19 vaccine uptake, health authorities should promote vaccine effectiveness; pro-actively communicate the absence or presence of vaccine side effects; and ensure rapid and wide media communication about local vaccine coverage.