Anxiety disorders and depression are frequent conditions in childhood and adolescence. eMental healthcare technologies may improve access to services, but their uptake within health systems is limited.The objective of this review was to examine and describe how the implementation of eMental healthcare technologies for anxiety disorders and depression in children and adolescents has been studied.We conducted a search of 5 electronic databases and gray literature. Eligible studies were those that assessed an eMental healthcare technology for treating or preventing anxiety or depression, included children or adolescents (<18 years), or their parents or healthcare providers and reported findings on technology implementation. The methodological quality of studies was evaluated using the Mixed Methods Appraisal Tool. Outcomes of interest were based on 8 implementation outcomes: acceptability (satisfaction with a technology), adoption (technology uptake and utilization), appropriateness (“fitness for purpose”), cost , feasibility (extent to which a technology was successfully used), fidelity (implementation as intended), penetration (“spread” or “reach” of the technology), and sustainability . For extracted implementation outcome data, we coded favorable ratings on measurement scales as “positive results” and unfavorable ratings on measurement scales as “negative results.” Those studies that reported both positive and negative findings were coded as having “mixed results.”A total of 46 studies met the inclusion criteria, the majority of which were rated as very good to excellent in methodological quality. These studies investigated eMental healthcare technologies for anxiety (n=23), depression (n=18), or both anxiety and depression (n=5). Studies of technologies for anxiety evaluated the following: (1) acceptability (78%) reported high levels of satisfaction, (2) adoption (43%) commonly reported positive results, and (3) feasibility (43%) reported mixed results. Studies of technologies for depression evaluated the following: (1) appropriateness (56%) reported moderate helpfulness and (2) acceptability (50%) described a mix of both positive and negative findings. Studies of technologies designed to aid anxiety and depression commonly reported mixed experiences with acceptability and adoption and positive findings for appropriateness of the technologies for treatment. Across all studies, cost, fidelity, and penetration and sustainability were the least measured implementation outcomes.Acceptability of eMental healthcare technology is high among users and is the most commonly investigated implementation outcome. Perceptions of the appropriateness and adoption of eMental healthcare technology were varied. Implementation research that identifies, evaluates, and reports on costs, sustainability, and fidelity to clinical guidelines is crucial for making high-quality eMental healthcare available to children and adolescents. Worldwide, at least 6.5% and 2.6% of children and adolescents meet the criteria for anxiety and depressive disorders, respectively . The burUnderdiagnosis and undertreatment of childhood and adolescent depression and anxiety are well-documented concerns ,10. The Distinguishing implementation effectiveness from the viewpoint of treatment effectiveness is critical for integrating eMental healthcare technologies. When uptake efforts fail, it is important to know if the failure occurred because the intervention was ineffective in the new setting , or if an effective intervention was deployed ineffectively . Current research on eMental healthcare technologies lack implementation frameworks , and theA protocol for the review was developed and registered with PROSPERO (Registration #CRD42016049884). Reporting of the review adheres to the Preferred Reporting Items of Systematic Reviews and Meta-Analyses statement checklist . FundingA research librarian developed the search strategies for 5 databases: MEDLINE, EMBASE, PsycINFO, CINAHL, and the Cochrane Database of Systematic Reviews using date (2000-2016) restrictions. No restriction was placed on the study design or language to capture a broad range of evidence. The strategy was peer reviewed prior to implementation. The searches included literature published until December 5, 2016. Grey literature was searched using Google Scholar and ProQuest Dissertations & Theses Global. Clinical trials were searched using clinicialtrials.gov. Conference proceedings of the last 2 years (2014-2016) of the International Society for Research on Internet Interventions were searched as well. Reference lists of included studies were also searched. acceptability ; adoption ; appropriateness ; cost, ; feasibility, ; fidelity, ; penetration, ; and sustainability,  [Studies were included if they met the following criteria: (1) assessed an eMental healthcare technology for treating or preventing anxiety or depression; (2) the technology under investigation involved children or adolescents (<18 years), or their parents or healthcare providers. Studies that included both adolescents <18 and young adults were included if the mean age of the study sample was ≤19 years to ensure that the results largely reflected implementation with children and adolescents; (3) the technology needed to be an internet-, computer-, tablet-, or mobile-based program or mobile app; (4) the technology was used within the primary or secondary healthcare system (as opposed to the school system); (5) reported on an implementation outcome as a primary or secondary measure. The 8 outcomes of interest were drawn from Proctor and colleagues’ implementation framework . These crations) . We exclReferences were organized and screened using EndNote X7.2.1. Three reviewers  independently screened the titles and abstracts in the EndNote library and calculated the interrater agreement with the kappa statistic for every 100 articles screened . Once a Data were extracted by one reviewer , and reviewed for accuracy and completeness by another. After verifying all of the extracted data, discrepancies were resolved by discussion or adjudication by another party (ASN). Extracted data included information on study characteristics  and implementation objectives, characteristics of the technology, study population, study setting, and implementation results. We coded statistically significant favorable ratings on measurement scales as “positive results”  and statistically significant unfavorable ratings on measurement scales as “negative results” . Those studies that reported both positive and negative findings were coded as having “mixed results” .Methodological quality was assessed independently by 2 of the 3 assessors . Disagreements were resolved through discussion. ASN participated when consensus could not be reached. The quality of studies was assessed using the Mixed Methods Appraisal Tool (MMAT) . The scoA codebook approach  was usedThe search strategy identified 6269 citations after removal of duplicates. Of these, 727 studies were considered potentially relevant based on their title and abstract . After fDetails on the quality of the studies are provided in Complimentary to recent reviews ,82, thisThe vast majority of studies included in the review examined some dimension of acceptability, signifying that this construct is important as an indicator of effective implementation, but its measurement varied. Satisfaction, a frequent acceptability metric, was reported as high among participants , but was largely derived from self-reports of parents and adolescents taken at a single time-point . This means we still know little about satisfaction/dissatisfaction among those who fail to complete the treatment, or how early perceptions of satisfaction might impact effort and adherence during the later stages of treatment. More than half of the studies used nonvalidated measures of acceptability, which are problematic for assessing reliability and psychometric sensitivity. Given that almost all validated psychiatric patient satisfaction measures are validated for adults (not children and adolescents) and that developmental age affects perceptions of satisfaction with healthcare , our finReframing Adoption as Process not ProductWhile reporting on adoption (namely adherence) was fairly common in studies we reviewed, authors reported mixed findings. Moreover, none of the studies in our review formatively examined adolescent, parent, or clinician adoption in terms of readiness for eMental health, intent-to-use, or ongoing decision-making. All of these factors play a central role in behavior change associated with effective mental health treatments ,88,89. AA little less than half of the studies testing depression interventions and a third of those focused on anxiety measured some dimension of “appropriateness,” with many reporting overall mixed results. Perceptions about the suitability of a given healthcare service in a particular setting, for a particular purpose, with a particular provider and clientele can be a function of organizational culture and climate, as well as a public opinion. In practice, eMental healthcare is still considered outside standard practice by most youth mental health service providers ; yet, inFindings from this review also make an important contribution to expanding our understanding of feasibility. The feasibility results observed in our review were most frequently related to provider-level concerns . This suggests that the workflow impacts of eMental health services are a vital area for future implementation research. Given that most of the eMental healthcare technologies in our review included some form of healthcare provider interaction before or during the treatment, their role cannot be underappreciated. Many of the studies described atypical interactions for providers trained in traditional psychotherapy, including use of SMS text messages, frequent short emails, and bidirectional electronic exchanges, technical support, etc. Our review echoes recent calls to move beyond the simplistic analyses of barriers and facilitators to models of feasibility that allow researchers to test how eHealth modalities disrupt established professional roles, responsibilities, and working styles . We recoFinally, this review highlights persistent gaps in the measurement of fidelity, penetration, and sustainability constructs. These implementation facets are important macro-level determinants of policies and strategies for technology integration ,101. HowAlthough this review was rigorous, carefully executed, and employed a robust methodological approach, it is not without limitations. Technologies being deployed in healthcare systems that have not been scientifically investigated and without reported implementation data were not available for our review. We did not search databases such as the NIH Reporter, which may have yielded additional eMental healthcare technology studies. While some of the studies in the NIH Reporter may have been additionally registered in the clinicaltrials.gov registry after our search, some may not have been. Given that eMental healthcare technologies are constantly appearing and disappearing from the behavioral health service landscape, published accounts of the state of this field will likely always be slightly outdated. This is true for all eHealth-related research syntheses, and it only underscores the need to promote an “evergreen” mentality for research that acknowledges that the evidence base is always evolving. The inclusion of multiple study designs created a challenge for summarizing study features and generalizing study findings. Nonetheless, this approach allowed for the comparison of different kinds of evidences that shape real-world policy and service delivery. By not limiting our search based on study design, but rather reporting on quality via a validated appraisal tool, we established a starting point for broad critical appraisal. Finally, the inconsistent use of eHealth terminology -107 acroAcceptability of eMental healthcare technology appears to be high among users, and it is the most commonly investigated implementation outcome. Perceptions of the appropriateness of eMental healthcare technology for use in healthcare varied, as did the adoption of technologies in healthcare practice. These findings suggest that the implementation science of eMental health for adolescent anxiety and depression needs to mature. Validated implementation measures as well as research designs and analytic techniques that model complex interactions and implementation contexts should be pursued in earnest. Future studies should help bridge gaps in knowledge about the fidelity of eMental health interventions over time and how eMental health technologies spread through the healthcare system, direct and indirect costs, and sustainability models. Closing these knowledge gaps has the potential to make treatments more accessible and reduce the burden of anxiety and depression on affected children and adolescents.


Antimicrobial resistance (AMR) driven by antibiotic consumption is a growing global health threat. However, data on antimicrobial consumption patterns in low- and middle-income countries (LMICs) is sparse. Here, we investigate the patterns of antibiotic sales in humans and livestock in urban Nairobi, Kenya, and evaluate the level of awareness and common behaviours related to antibiotic use and AMR amongst human and veterinary pharmacists.A total of 40 human and 19 veterinary drug store pharmacists were interviewed in Nairobi in 2018 using a standard questionnaire. Data recorded included demographic variables, types of antibiotics sold, antibiotic customers, antibiotic prescribing practices and knowledge of antibiotic use and AMR.Our study shows that at the retail level, there is a considerable overlap between antibiotic classes (10/15) sold for use in both human and veterinary medicine. Whilst in our study, clinical training significantly influenced knowledge on issues related to antibiotic use and AMR and respondents had a relatively adequate level of knowledge about AMR, several inappropriate prescribing practices were identified. For example, we found that most veterinary and human drug stores (100% and 52% respectively) sold antibiotics without a prescription and noted that customer preference was an important factor when prescribing antibiotics in half of the drug stores.Although more research is needed to understand the drivers of antibiotic consumption in both human and animal populations, these findings highlight the need for immediate strategies to improve prescribing practices across the pharmacists in Nairobi and by extension other low- and middle-income country settings. Antibiotic resistance (AMR) has been described as one of the most serious public health threats of this century -3. AntimAs in most cities in low and middle income countries (LMICs), in urban Nairobi the high incidence of bacterial diseases and antimicrobial resistance in clinical medicine is a major public health challenge . In bothPharmacists (both human and veterinary) play a pivotal role in enhancing antimicrobial stewardship initiatives, not just by highlighting the AMR problem, but also by influencing crucial prescribing decisions ,9. To fuA cross-sectional study targeting human and veterinary drug stores in urban Nairobi, Kenya was carried out in January 2018 as part of the UrbanZoo project . BrieflyA draft of the questionnaire was pre-tested with five drug stores (three human and two veterinary), and refined on basis of the feedback from the pre-testing sessions before final dissemination. In each drug store a detailed questionnaire was used to collect data on socio-demographic variables, training on antibiotic use, types of antibiotics sold (by class), the four antibiotic classes most commonly sold, variation in antibiotic sales, antibiotic sources, antibiotic customer characteristics, and antibiotic prescribing practices. A summary of the collected data are presented in Table S1 in 2 or Fisher exact test using R package stats [Descriptive statistics were prepared for all data including frequencies and percentages for categorical variables  and means, medians, standard deviations (SDs), quartiles, and ranges for quantitative variables  depending on the distribution of the data. We used a χge stats  to descrP < 0.05 to be statistically significant.Next, we aimed to describe practices and evaluate the factors associated with drug prescribing amongst human and veterinary pharmacists. To achieve this, we collected data on information provided to customers after purchasing antibiotics as an indicator of good prescribing practices. This included: whether pharmacists provided customers with information on dosage, directions for use , storage instructions, side effects, expiry date and contra-indications . The datIn order to assess the internal consistency of the ten statements evaluating the level of knowledge on AMR, Cronbach’s alpha coefficients were calculated for each statement. Internal consistency is a measure of item-total correlations and reliability of the scale, thus describing the extent to which all items in a test measure the same concept or construct . An unstPrincipal Component Analysis (PCA) using polychoric correlation  was usedThe scores of the first PCA component were used as measure of knowledge of AMR, and the higher the knowledge score, the higher the implied knowledge of AMR of that respondent. A generalised linear model was used to investigate the possible influence of type of drug store (human or veterinary), clinical training (present or absent), education level (high or low), and range of antibiotics sold in the drug store (proxy for store size) on the level of knowledge of AMR.Ethical approval for this study was obtained from the International Livestock Research Institute (ILRI) Institutional Research Ethics Committee (ILRI IREC) (project reference: ILRI-IREC2017-35).P = 0.01, Fisher exact test). Additionally, for participants who underwent clinical training, professional development programmes/trainings aimed at continuing education in AMR were an important source of information on antibiotic stewardship .A total of 59 participants were interviewed – 40 from human drug stores and 19 from veterinary drug stores   were reported as the main provider of antibiotics to human drug stores (78%). On the other hand, distribution companies  were reported as the main provider of antibiotics to veterinary drug stores (58%).P = 0.20; Mann-Whitney U test) between human drug stores  and veterinary drug stores .The average daily number of customers purchasing antibiotics was not significantly different  believed that AMR occurs when their body becomes resistant to antibiotics rather than the bacteria themselves that develop resistance. Similarly, 40% and 53% of human and veterinary respondents respectively suggested that AMR is only a problem for regular consumers of antibiotics. More than half (52%) of the respondents interviewed responded neutrally or disagreed with the statement that antibiotic resistant bacteria could be spread from person to person , meaning respondents with clinical training had a higher knowledge about AMR than those who had not undergone such training. The level of knowledge about AMR did not differ by store type, education level or range of antibiotics available in the store (P > 0.05)  (Table S5 in the Fifty-two per-cent (21/40) of the human drug stores reported that they sold antibiotics without a prescription while all veterinary drug stores sold antibiotics without a prescription. Multivariable logistic regression analysis revealed prescribing practices did not vary significantly by clinical training, store type, range of antibiotics sold and/or education level , followed by price of the antibiotic (in >50% of the stores). Of note, 28% and 31% of human and veterinary pharmacists respectively considered customer preference as an important factor when prescribing an antibiotic.In this study, we aimed to investigate the patterns of antibiotic sales in humans and animals in a large and rapidly developing city in a LMIC: Nairobi, Kenya. We also evaluated the level of awareness and common behaviours related to antibiotic use and AMR amongst human and veterinary pharmacists. Our study was based on gathering antibiotic sales data from human and veterinary drug stores across the city, where sales data were interpreted as representing antibiotic usage.Our study shows considerable overlap in the antibiotic classes (10/15) sold for human and animal use in urban Nairobi, with marked variations in the sale of some antibiotic classes such as cephalosporins and fluoroquinolones – mostly found in human drug stores. This overlap in antibiotic classes, including of critically important antimicrobials , highligThe most common symptoms prompting antibiotic purchase in humans were similar to those reported in other studies, respiratory tract infections and diarrhoeal disease ,26,27. BIn the current study, tetracyclines, sulphonamides, penicillins, and macrolides were the most commonly purchased veterinary antibiotics and poultry farmers were the major consumers of antibiotics. Further, our findings indicate that colistin – a drug considered of last resort in human medicine  – was anKnowledge about antimicrobial resistance among pharmacists has only been studied to a limited extent in LMICs . ConsistWhilst the majority of the pharmacists we interviewed have an understanding of the threat posed by AMR to public health, our data highlight the poor quality of community pharmacy practice, most notably the dispensing of antibiotics without prescriptions and the inclusion of customer preference as an important factor when selling antibiotics. Antibiotics were dispensed without prescription in 53% and 100% of the human and veterinary drug stores respectively; a finding consistent with similar studies in Tanzania (92.3%) , Serbia Restating the particular relevance of training to antibiotic stewardship measures, the role of enhanced training in antimicrobial prescribing and AMR has been identified in surveys of both medical personnel and the public, both in Kenya and globally . ResultsSimilar to other studies ,52, our This is the first study designed to capture the overlapping patterns of antibiotic sales in humans and livestock in a developing city via an epidemiologically-structured approach. A variety of approaches are available for assessing patterns of antibiotic use in humans and animals . ConsideMonitoring and surveillance of antibiotic use in LMICs is challenging, but vital, as it provides valuable information for public health policy. Our study shows that at the retail level in urban Nairobi, there is a considerable overlap between antibiotic classes available for use in both human and veterinary medicine. Whilst the majority of human and veterinary pharmacists showed high knowledge about antibiotic use and antimicrobial resistance, inappropriate prescribing practices were noted, highlighting the need for continued education to the pharmacists and the public, about prudent antibiotic prescribing and use. Although further research is necessary to understand the drivers of antibiotic consumption in both populations, it is clear that interventions are urgently required to improve prescribing practices across the pharmacists.


This review aims to summarize the progress of patient evaluation studies focusing on primary health care (PHC) in China, specifically in relation to survey instruments and implementation issues. Eligible studies published in English or Chinese were obtained through online searches of PubMed and China National Knowledge Infrastructure. A descriptive reporting approach was used due to variations in the measurements and administration methods between studies. A total of 471 articles were identified and of these articles; of those 91 full-text articles were included in the final analysis. Most studies used author-developed measurements with five-point Likert response scales and many used the Chinese translations of validated tools from other countries. Most instruments assessed the physical environment, medical equipment, clinical competency and convenience aspects of PHC using a satisfaction rating instead of care experience reporting. Many studies did not report the sampling approach, patient recruitment procedures and survey administration modes. The patient exit survey was the most commonly used survey implementation method. The focus on the structural dimensions of PHC, inconsistent wording, categories of response options that use satisfaction rating, and unclear survey implementation processes are common problems in patient evaluation studies of PHC in China. Further studies are necessary to identify population preferences of PHC in China in order to move towards developing Chinese value-based patient experience measurements. In China, the primary health care (PHC) system set up in the 1950s has contributed to a dramatic reduction in maternal and infant mortality, a significant improvement in general population health and the development of the Declaration of Alma-Ata in 1978 . InsteadTo address these issues, China launched a national health reform in 2009 with the aim of providing its citizens with essential public health and basic medical services that are safe, effective, accessible and affordable through a strong PHC based health system ,4. To dePatient experience has been studied extensively in developed countries. It is recognized as one of the pillars of health care quality alongside clinical effectiveness and patient safety . PatientSome of the widely used patient experience instruments in developed countries include the Primary Care Assessment Survey (PCAS) ; the ConThese lessons provide practical information for patient survey design and implementation in developing countries, including China, where there is growing interest in measuring PHC performance from a user perspective. This literature review aims to summarize the progress and issues with patient evaluation studies of PHC in China in relation to three aspects: the choice of domains and items, the choice of response scales, and survey administration methods. The results will lay a solid foundation for further development of patient experience measurement methods in China. PubMed and China National Knowledge Infrastructure (CNKI) were searched to identify relevant articles. The PubMed and CNKI searches were conducted in February 2018. The following key search terms and their synonyms were used: China, primary health care, primary care, community health, township health center, village clinic, assessment, evaluation, measurement and patient. An iterative approach was used to identify search terms. The final search strategy can be found in A total of 169 articles in English and 302 articles in Chinese were identified. The following inclusion criteria were used: (1) the study is part of original research in China; (2) the study design is a patient survey; (3) the study reports the information on the measurement and administration of patient surveys. The screening process was conducted by one researcher. After screening the titles and abstracts, 37 articles in English and 92 articles in Chinese were included for full-text review. After full-text review, nine English and 29 Chinese articles were excluded because they did not report any information on measurement and survey administration. This resulted in a total of 28 articles in English and 63 articles in Chinese that were included in the final analysis. Among them, nine articles include two sub-studies each. One article includes three sub-studies. Therefore, 102 studies were included in the current analysis. A total of 81 studies focus on community health centers, 17 studies - on township health centers and four studies—on village clinics. The description of each study is provided in A data extraction form in Excel was developed to collect the following information: author, published date, the year when the study was conducted, study setting, domains measuring PHC, items measuring PHC, response options and survey administration methods. Due to the variations in measurements and administration methods between studies, a descriptive reporting approach was used. A total of 102 studies were included for data analysis. More than 80% (84) of the studies were published after 2009 when China launched its national health reform. Most studies were conducted in eastern (more developed) provinces in China. Guangdong (29), Shanghai (9) and Shandong (8) contributed to nearly half of the studies.The measurements adapted from the instruments developed in other countries were used in over one-third (37 of 102) of the studies . The PCAThe original PCAT developed by Barbara Starfield at the Johns Hopkins Primary Care Policy Center is the most widely used instrument in China, including Guangdong ,36,37,38There are various Chinese versions of PCAT. Among 18 PCAT studies, 12 included all seven domains ,37,38,41The Health System Responsiveness Survey was developed by the WHO to measure the users’ interaction with health services in eight domains: Dignity, Autonomy, Confidentiality, Communication, Prompt Attention, Quality of Basic Amenities, Social Support and Choice of health care providers. Questions measuring health system responsiveness cover ambulatory (22 items) and inpatient (11 items) visits. All questions used similarly ordered four-point  or five-point  Likert response options . Among tTwo-thirds (65 of 102) of the studies used measurements developed by the authors themselves. Most did not report the development process for these measurements. The frequency of PHC aspects, number of items and response options included in these measurements are summarized in More than 40 care aspects were evaluated in the 65 studies. The care aspects most frequently evaluated, in decreasing order, were: service attitude of health professionals (92%); medical cost (82%); physical environment (78%); technical skill of health professionals (68%); and medical equipment (66%). Convenience and waiting times were evaluated in more than 50% of the studies. There are fewer studies that include interpersonal care aspects, such as privacy protection (25%), respect (12%), shared decision making (9%) and the doctor’s listening skills and patience (6%). The number of items reported in the studies ranged from 3 to 35, with the majority ranging from 5 to 15. A five-point-Likert response scale was used most often (50 out of 65) although some studies used three, four or six response options. The wording of five-point response options also varied. For example, some studies used “always, usually, sometimes, occasionally, never” or “completely agree, agree, not sure, disagree, completely disagree”. Other studies used “very good, good, neutral, bad, very bad” or “very satisfied, satisfied, neutral, dissatisfied, very dissatisfied”. Depending on the types of questions  measuring patient perception, further research could explore appropriate evaluative language and response scales among Chinese people. Only six out of the 65 studies reported the psychometric properties of measurements ,59,60,61The on-site survey was used by 99 studies while only three out of the 102 studies used a telephone survey. For the location of the on-site survey, the exit of primary care institutions is the most common place and was used by 63% of the studies. For the administration of the on-site survey, a face-to-face interview was reported by 29 studies and self-administration was reported by 14 studies, while this information was missing in the remaining 56 studies . Based on our previous research, we captured two major points relating to patient evaluation studies of PHC in China: the inconsistency of survey instruments and implementation approaches. Through a thorough discussion with PHC researchers in China and Canada, we agreed that a narrative review was an efficient approach to produce an overall picture about what measurements have been used and how they have been implemented among the patient evaluation studies of PHC in China. The advantage of this approach is that it offers breadth of literature coverage and the flexibility to deal with evolving knowledge and concepts, without requiring more time and resources to prepare and update the records as in a systematic review . To inclThrough the analysis of 102 patient evaluation studies of PHC in China, we found that most studies used author-developed instruments with commonly used five-point Likert response options and many used Chinese translations of the instruments developed in other countries. Furthermore, most author-developed instruments measure the structural dimensions of PHC, and most measures focus on satisfaction to rate subjective perception rather than on care experience to report objective problems. The studies included in our review used a similar approach to adapting instruments but the results varied even in the same context. This calls for national collaboration to address these issues. For example, three studies reported the adaptation process and validation results of PCAT in China ,43,63. EThe principles of First Contact, Continuity, Coordination and Comprehensiveness that are included in PCAT are recognized and shared internationally. However, service delivery and financing systems vary significantly between countries. The tools developed in one context may not be appropriate in another. For the same domain of primary care, the patients in different countries may have a different understanding and expectations. For example, First Contact items from the original PCAT may not be appropriate in countries with a different health system organization and patient expectations. Making appointments in advance and gatekeeping by primary care workers may not be applicable in some countries ,65. GeogMost author-developed measures focus on the structural dimensions of PHC, such as the physical environment, medical equipment and convenience (distance from home to facility). The interest in predominantly evaluating the structural dimensions is based on the assumption that adequately trained doctors and nurses with access to infrastructure (such as well-equipped facilities and medicines) will be sufficient for guaranteeing adequate quality . HoweverAlthough the technical skills of doctors are also often evaluated by patients in China, there is a weak correlation between the patient-perceived technical quality of care and technical quality measures extracted from medical records . HoweverMost patient survey measures of PHC in China focus on satisfaction to rate subjective perception rather than on patients’ care experience to report objective problems. In addition, there is increasing interest in patient satisfaction studies in hospital settings in China ,73,74,75The patient exit survey in primary care institutions is the most commonly used survey implementation method in China. The popularity of the patient exit survey is due to its operational efficiency as it is more convenient to identify patients at clinics than through population-based surveys . HoweverThe two most popular survey administration methods in patient exit surveys in China are: face-to-face verbal interviews using paper and pencil; and the traditional paper and self-administration method involving handing paper questionnaires to people in person and asking them to complete them by hand and return them to the researcher. Some studies used both methods. Face-to-face interviews have the advantage of a high response rate and low cognitive burden for the respondents although this method leads to a high social desirability bias and interviewer bias . The visThe patient experience measurements and survey implementation approaches are two major issues in patient evaluation studies of PHC in China. Most studies evaluate the structural dimensions of PHC, of which patients are not the best evaluators. Various wordings and categories of response options are used but it is unclear which one is optimal among Chinese people. Many studies do not report a detailed sampling approach or patient recruitment procedures and the effect of different survey administration methods on participants’ responses is unclear. The lack of consistency in survey instruments and administration methods indicates that more coordinated efforts are needed in order to develop valid instruments to evaluate patient perceptions of PHC performance in China. This study is only the first step to map out the current situation and propose future direction towards developing Chinese value-based patient experience measurements. As a starting point, explicit information about what matters most to patients in China should be investigated. Patient experience measurements should reflect patients’ needs and preferences in their cultural and health system contexts. Patient preferences or priorities have been studied extensively in Europe and North America. These efforts consistently demonstrate that in addition to clinical competency or technical quality, interpersonal care aspects, such as interpersonal communication, shared decision-making, respectfulness and relational continuity, are also very important for patients ,89,90,91Subsequently, the operational definitions and optimal response scales should be explored and identified. For each PHC care aspect prioritized by patients, we need to capture the measurable terms or phrases that they use when reporting their care experience. We also need to capture the evaluative language and categories that they use when they make judgement of “good” or “bad” health care. This type of work could generate the elements included in each PHC care aspect and the optimal response scale among Chinese patients, which will guide the selection of items and survey development. Based on these achievements, a research agenda of developing patient experience measurements could be envisioned. In general, this includes setting up a research team, selecting the domains and items, consensus process around finalizing the initial survey, pilot testing and refinement, examination of psychometric properties and knowledge translation. At the same time, a standardized survey implementation strategy could be developed, including determining the sample size for each institution, outlining the sampling approach, data collection approach, data entry and management, data analysis format and guidelines on data reporting. As China is moving towards building a people-centered integrated health system, measuring patient experience is an important approach to better understand patients’ needs and preferences and to ensure that people-centered care is delivered. Action plans are needed in order to promote the development of a patient experience measurement and the application of patient experience information. First, a national patient experience measurement strategy could be developed, which might be incorporated into the functions of the National Medical Service Management Center. This national strategy would aim to coordinate all efforts to measure patient experience, which would allow the government and health care providers to produce compelling data on which decisions can be based. The UK and the USA are world leaders in this field. Supervised by Care Quality Commission (CQC), England’s health care regulator, national patient experience surveys are conducted annually since 1998 through the National Health Service’s (NHS) Patient Survey Program. In the USA, patient experience surveys are mainly conducted through the Consumer Assessment of Healthcare Providers and Systems (CAHPS) program, which was established in 1995 by the Agency for Healthcare Research and Quality (AHRQ), the government agency responsible for health care quality and research. Recently, Canada has also initiated the process of developing a federal and provincial strategy for patient experience measurement. Similar work could be conducted in China through strong collaboration between health authorities, care providers and researchers, while considering the experiences from the above-mentioned countries. Second, more clarity is required around what information health authorities and health care providers need from patient experience surveys, including the format and how this information will be used by them in health policy making and quality improvement. International experiences have shown that managers and clinicians often struggle to link patient experience data to concrete transformations that could lead to an improved care experience . These oThird, an effective public reporting program may also be established in order to inform patients of the care experience performance of different providers to guide their health care seeking behavior. Recognizing the value of transparency and accountability, publicly released performance information is not only viewed as a fundamental patient right but is also essential for improving the functioning of health care markets. There is evidence that consumers would use reports to support their decision making if the information was better designed and more relevant . As Chin


The purpose of this case report is to describe the diagnosis and treatment of unerupted canine teeth in a maned wolf. After physical examination, complete blood count, and serum biochemical profile, the animal underwent general anesthesia and head radiography was performed to confirm the diagnosis. The treatment consisted of the extraction of both maxillary canine teeth and clinical and radiographic follow-up of the right mandibular canine tooth. Chrysocyon brachyurus) is a characteristic canid of the cerrado biome and its existence area includes Central Brazil, Paraguay, and small areas of Argentina, Bolivia, Peru, and possibly Uruguay. Although the conservation of this species is fundamental, mainly to the equilibrium of the cerrado biome, the maned wolf has been listed as “near threatened” on the IUCN Red List [The maned wolf  and food was withheld for 12 hours prior to anesthesia. The anesthetic protocol was as follows: sedation and analgesia, ketamine , midazolam , and meperidine ; induction, propofol ; maintenance, inalatory isoflurane and oxygen. Lactated Ringer's solution (10 mL/kg IV) was administered throughout anesthesia [Based on the clinical and radiological findings, the maxillary canine teeth were extracted. Labial mucoperiosteal flap was raised to expose the bone overlying the unerupted teeth. A burr on a slow-speed handpiece under irrigation with sterile saline was used to perform alveolectomy . A dentaThe authors found no studies or reports about unerupted teeth in maned wolves. A study involving eighty specimens of maned wolf  suggested that the most common oral diseases include tooth wear (83.7%) and tooth fracture (54.4%) [Injuries or systemic diseases occurring during dental development can have an impact on tooth eruption and dental occlusion , 8. The The results of this report show that we can use the diagnostic and therapeutic approach in maned wolf just like those used in dogs and provide marked improvement in the quality of life of the animal. Further studies are necessary to elucidate the distribution of oral diseases in wild canids.