Health providers' perspectives on delivering public health services under the contract service policy in rural China: evidence from Xinjian County

Policy perception, job satisfaction and intentions to remain in rural area: evidence from the National Compulsory Service Programme in China

BACKGROUND

Exploring factors that may influence general practitioners (GPs)' intentions to remain in rural area is necessary to inform the training and placement of future medical workforce in rural area. However, little is known about how GPs' perception towards the National Compulsory Service Programme (NCSP) and job satisfaction impact their turnover intention. This paper explores GPs' intentions to remain in rural China and how their policy perception and job satisfaction predict the intentions.

METHODS

We conducted a cross-sectional, online survey from December 2021 to February 2022 to investigate GPs' perception towards NCSP, job satisfaction, and intentions to remain in rural area. Eligible participants were GPs who were required to provide health services as part of NCSP at township health centres of 9 provinces which could represent all NCSP GPs in China. Multinomial logistic regression analyses were performed to explore the associations between policy perceptions, job satisfaction, and intentions to remain.

RESULTS

Of 3615 GPs included in the analysis, 442 (12.2%) would like to remain in rural area and 1266 (35.0%) were unsure. Results of the multinomial logistic regression analyses showed that compared with GPs who would leave, GPs with higher perception scores for the restriction on taking postgraduate exam (RRR: 1.93, 95% CI 1.72, 2.16) and the commitment to work for six years (RRR: 1.53, 95% CI 1.31, 1.78) were more likely to remain. In contrast, GPs who had higher perception scores for completing standardised residency training (RRR: 0.75, 95% CI 0.64, 0.88) and passing National Medical Licensing Examinations (RRR: 0.74, 95% CI 0.62, 0.87) were more likely to leave. GPs who were satisfied with the freedom of choosing work methods (RRR: 1.52, 95% CI 1.25, 1.84) and chances of promotion (RRR: 1.60, 95% CI 1.32, 1.94) were more likely to remain.

CONCLUSIONS

This study highlights the significance of policy perception and job satisfaction on GPs' intentions to remain in rural area. Factors such as career advancement and the empowerment of GPs to build on and use their skills and abilities should be taken into account when designing rural placement programmes.

The association of family doctor contract service and patient trust in doctor: evidence from twenty-five village clinics of three counties in rural China

BACKGROUND

China is implementing the family doctor (FD) system to reform the primary healthcare (PHC). The family doctor contract service (FDCS) policy plays a crucial role in this system implementation, aiming to transform the doctor-patient relationship and enhance PHC quality. This study aims to investigate the impact of FDCS on the doctor-patient relationship in PHCs using field research methodology.

METHOD

The field research methodology was employed to address the research questions. Quantitative methods were utilized for data collection and analysis. A structure questionnaire was used to collect data based on the research questions. Our investigation encompassed twenty-five village clinics across three counties in China. A total of 574 subjects helped us to finish this investigation in the study. The collected data was analyzed using statistical analysis including ordinary least squares (OLS) model and propensity scores matching model (PSM) to estimate the relationship.

RESULT

The findings from ordinary least squares (OLS) regression revealed that FDCS had a positive influence on patient trust in doctors within PHCs, with patients who participated the FDCS exhibiting higher levels of trust compared to those who did not participate. Propensity score matching (PSM) analysis further confirmed these results by accounting for selection bias.

CONCLUSIONS

The implementation of family doctor contract service has brought about significant transformation in the doctor-patient relationship within rural Chinese PHCs. In essence, it has revolutionized the service model of doctor in PHC, playing a pivotal role in improving primary health quality and enhance the service capability of doctors in PHC. This transformative process has been crucial for carrying out hierarchical diagnosis and treatment policy, which aims to adjust the medical service structure and optimizing the health service system. Therefore, it is imperative for government authorities and health administration departments to ensure continuous support for this essential service through appropriate formulation.

Trends in output of hypertension management and associated factors in primary care facilities: a latent trajectory analysis in China from 2009 to 2017

BACKGROUND

The prevalence of hypertension is high (25.2% in 2012) and there were a large number of patients with hypertension (more than 200 million) in China. Township health centres in rural areas and community health centres in urban areas are responsible for hypertension management. This study aims to identify trends in hypertension management output and related facility-level, geographical and economic factors in primary care facilities and to assess the effect of the national project of basic public health services in China from 2009 to 2017.

METHODS

A cross-sectional survey (2018) was combined with retrospective data collection (2009-2017) from 685 primary care facilities in six provinces in China. The hypertension management output was indicated by the number of patients with hypertension under management per 10,000 population. Latent class growth analysis and group-based trajectory models were applied to classify trajectories and determine associations with facility-level, geographic and economic characteristics.

RESULTS

The trend in the output increased rapidly from 2009 to 2012 with an average growth rate of 54.58% and slowed down from 2012 to 2017 (growth rate of 5.94%). Five trajectories of the output were identified and labelled according to baseline status and increase rates: low-gradually increasing (16.9%), middle-slightly increasing (16.2%), low-sharply increasing (7.9%), middle-sharply increasing (34.2%) and persistently high (24.9%). The time-stable characteristics, including region (eastern, central or western), district (urban or rural), landform, were associated with hypertension management output of the facilities. Number of public health physicians was a significant time-dependent characteristic influencing management output.

CONCLUSIONS

Five latent trajectories of hypertension management output were identified. The output was still at a low level compared with the prevalence of hypertension. Hypertension screening in young people need to be emphasized. Facilities are recommended to establish good relationships with residents for better hypertension management outcomes especially in urban areas.

How does people-centered integrated care in medical alliance in China promote the continuity of healthcare for internal migrants: The moderating role of respect

Background

Continuity is crucial to the health care of the internal migrant population and urgently needs improvements in China. Chinese government is committed to promoting healthcare continuity by improving the people-centered integrated care (PCIC) model in medical alliances. However, little is known about the driving mechanisms for continuity.

Methods

We created the questionnaire for this study by processes of a literature research, telephone interviews, two rounds of Delphi consultation. Based on the combination of quota sampling and judgment sampling, we collected 765 valid questionnaires from developed region and developing region in Zhejiang Province. Structural equation models were used to examined whether the attributes of PCIC (namely coordination, comprehensiveness, and accessibility of health care) associated with continuity, and explored the moderated mediating role of respect.

Results

The result of SEM indicated that coordination had direct effect on continuity, and also had mediating effect on continuity via comprehensiveness and accessibility. The hierarchical linear regression analysis showed that the interactive items of coordination and respect had a positive effect on the comprehensiveness (β = 0.132), indicating that respect has positive moderating effect on the relationship between coordination and comprehensiveness. The simple slope test indicated that in the developed region, coordination had a significant effect on comprehensiveness for both high respect group(β = 0.678) and low respect group (β = 0.508). The moderated mediation index was statistically significant in developed areas(β = 0.091), indicating that respect had moderated mediating effect on the relationship between coordination and continuity via comprehensiveness of healthcare in the developed region; however, the moderated mediation effect was not significant in the developing region.

Conclusion

Such regional differences of the continuity promoting mechanism deserve the attention of policy-makers. Governments and health authorities should encourage continuity of healthcare for migrants through improving the elements of PCIC-coordination, comprehensiveness and accessibility of healthcare, shaping medical professionalism of indiscriminate respect, and empowering migrants to have more autonomy over selection of services and decisions about their health.

Incentives Promoting Contracted Family Doctor Service Policy to Improve Continuity and Coordination in Diabetes Patient Management Care in China

Background

As the first step toward building a gatekeeping system in China, the governments have introduced a contracted family doctor service (CFDS) policy in primary healthcare (PHC) facilities. This study was to examine the association between apply of incentive to improve the implementation of CFDS and the performance on diabetes management care.

Methods

We conducted a cross-sectional study in 72 PHC facilities in 6 cities that piloted the CFDS. Multivariate regression models were applied, based on a sample of 827 PHC providers and 420 diabetic patients.

Results

PHC providers who reported the performance being linked with increased income were 168.1 and 78.0% more likely to have good continuity and coordination of diabetes patient management care, respectively. Additional one-point percentage of PHC providers whose performance on CFDS was assessed was associated with 7.192 times higher probability of patients with control of blood glucose.

Discussion

Inclusion of incentives rewarding better performance on CFDS were associated with better delivery process and outcome performance on diabetes management care.

Conclusion

Design and implementation of the incentive should be accompanied with the policy of CFDS, in order to increase the proportion of performance-related income of PHC providers, thereby improving the quality of diabetes management care.

Roles and Challenges for Village Doctors in COVID-19 Pandemic Prevention and Control in Rural Beijing, China: A Qualitative Study

Objectives

Rural areas in China are more vulnerable to COVID-19 pandemic than urban areas, due to their far fewer health care resources. Village doctors, as rural grassroots health workers in China, have been actively engaged in the pandemic prevention and control. This study aims to describe the roles of village doctors in rural China, and the challenges they have faced during the prevention and control of the COVID-19 pandemic.

Setting

This study was conducted in three towns in Huairou District, Beijing, China.

Design

We carried out semi-structured interviews with 75 key informants. All the interviews were audio-recorded and transcribed verbatim. We employed thematic analysis to define themes and sub-themes from the qualitative data.

Results

We reported four themes. First, the village doctor guided the village committee to carry out decontamination, monitored home-isolated residents, and disseminated knowledge on prevention of the COVID-19 pandemic during the rural pandemic prevention and control. Second, they took pandemic prevention measures in village clinics, distributed pandemic prevention materials, and undertook pre-screening triage. Third, village doctors provided basic medical care, including treatment of common diseases as well as the purchase and delivery of medicines to villagers. Fourth, village doctors faced difficulties and challenges, such as inadequate medical skills, aging staff structure, and lack of pandemic prevention materials.

Conclusions

Despite many difficulties and challenges, village doctors have actively participated in rural pandemic prevention and control, and made outstanding contributions to curbing spread of COVID-19 pandemic in rural areas. Village doctors provide basic health care while participating in various non-medical tasks.

Health Promotion Capacity Among Chinese Healthcare Professionals and Its Influence on Preventive Health Service Practices

Background

This study evaluated the current health promotion capacity level of Chinese healthcare professionals and explored the association between health promotion capacity and preventive health service practices.

Methods

A total of 124 doctors and 72 nurses were recruited from 6 county hospitals and 12 community health centers from June to August 2019 in Zhejiang Province, China. Health promotion capacity was measured using the revised Chinese version of the Health Promotion Professionals Core Competency Scale.

Results

The mean total score on the health promotion capacity scale was 45.04 (SD = 7.30). Total health promotion capacity score was negatively associated with county hospitals (β = −0.32, p < 0.001; Ref: community health center) and positively associated with a monthly income of more than 5001 RMB ($786.39) (β = 0.25, p = 0.004; Ref: less than 5000 RMB ($786.24)). All domain scores of the health promotion capacity scale were positively related to preventive health service practices.

Conclusion

Health promotion capacity is one of the most important capacities among healthcare professionals, and there is a particular need to improve nurses’ capacity. A higher level of health promotion capacity is beneficial for implementing preventive health services.

The Awareness and Attitude of Contracted Service Among General Medical Practitioners in Community Health Service Centers in Urban China: A Cross-Sectional Study

This study aims to explore the attitude, willingness, and satisfaction with contracted service (CS) among staff in community health service (CHS) centers in urban China and to explore the associated factors of satisfaction with CS. From August 2016 to July 2017, five CHS centers in three provinces of China were selected. Setting-level information was collected by official document review; and personal information on demographic characteristics, awareness, willingness, and attitude of CS among staff was collected by questionnaire survey. Univariate and multivariable logistic regression models were fitted to explore the associated factors of satisfaction with CS. Multiple correspondence analysis (MCA) was used to visually demonstrate the correlations among category data related with satisfaction with CS. The CS signing rates were 30.78, 12.72, 22.20, 14.32, and 21.19% in the five CHS centers. A total of 286 staff included family doctors (40.91%), nurses (31.12%), and others (27.97%) completed the survey. For the sense of self-worth, 86.01% (246/286) participants hold a positive attitude. The predominant barrier of CS signing was caused by the work pressure due to CS performance assessment (48.60%, 139/286). About 30% of family doctors and nurses reported a heavy work pressure, and more than 30% of doctors had great feeling of fatigue. Notably, 51.69% family doctors would like to change their job in the future. Compared with other staff, family doctors were more likely to be unsatisfied with CS (OR: 2.793, 95% CI: 1.155–6.754, p = 0.022). Participants in Sichuan province have lower satisfaction than other places. The MCA yielded similar factors consistent with multivariable results of clustering with different levels of CS satisfaction. Our study revealed that the CS coverage and satisfaction among staff from the primary healthcare system varied geographically and are associated with professional field, workload, and pressure. Measures that aim to promote the stability of primary care human resource should be considered in the future.

Model to assess workload of village doctors in the National Essential Public Health Services Program in six provinces of China

BACKGROUND

No studies, particularly quantitative analyses, have been conducted regarding the workload of village doctors in the National Essential Public Health Services (NEPHS) program and differences in service delivery by village doctors, according to region and services. In this study, we developed a quantitative analysis approach to measure the workload of NEPHS provided by village doctors in six provinces of China in 2016. We aimed to identify areas and services of the NEPHS needing improvement, so as to implement targeted measures to ensure adequate delivery of NEPHSs in rural remote underserved areas.

METHODS

Based on survey data from 300 town hospital centers (THCs) located in 60 counties in the six selected provinces, we calculated village doctors' share of workload under the NEPHS using the equivalent value (EV) model. To define the workload and corresponding EV of each NEPHS, a series of five meetings was held with THC managers, public health workers, family physicians, nurses and village doctors. Field observations were conducted to verify the workload and EV of each service.

RESULTS

Village doctors' share of the workload under the NEPHS program was 43.71% across the 300 sampled THCs in six provinces. The village doctors' workload shares for different NEPHS ranged from 17.14 to 57.00%. The percentage workload undertaken by village doctors under the NEPHS program varied across different provinces, with the highest proportion 63.4% and the lowest 28.5%.

CONCLUSIONS

The total NEPHS workload assigned to village doctors by THCs in the six sampled provinces exceeded the Chinese government's requirement of 40%, but the workload proportion in some provinces was less than 40%. In addition, the percentage workload for some NEPHS undertaken by village doctors was lower than others. We suggest conducting district-level analysis of the workload among village doctors under the NEPHS program using the EV method, to identify areas and services needing improvement, to implement targeted measures to expand and promote health service provision in China's rural underserved areas.

Factors Associated with Rural Residents' Contract Behavior with Village Doctors in Three Counties: A Cross-Sectional Study from China

Historically, cooperative medical insurance and village doctors are considered two powerful factors in protecting rural residents' health. However, with the central government of China's implementation of new economic policies in the 1980s, cooperative medical insurance collapsed and rural residents fell into poverty because of sickness. In 2009, the New Rural Cooperative Medical Insurance (NRCMI) was implemented to provide healthcare for rural residents. Moreover, the National Basic Drug System was implemented in the same year to protect rural residents' right to basic drugs. In 2013, a village doctor contract service was implemented after the publication of the Guidance on Pilot Contract Services for Rural Doctors. This contract service aimed to retain patients in rural primary healthcare systems and change private practice village doctors into general practitioners (GPs) under government management.

OBJECTIVES

This study investigates the factors associated with rural residents' contract behavior toward village doctors. Further, we explore the relationships between trust, NRCMI reimbursement rate, and drug treatment effect. We used a qualitative approach, and twenty-five village clinics were chosen from three counties as our study sites using a random sampling method. A total of 625 villagers participated in the investigation. Descriptive analysis, chi-squared test, t-test, and hierarchical logistic analyses were used to analyze the data.

RESULTS

The chi-squared test showed no significant difference in demographic characteristics, and the t-test showed a significant difference between signed and unsigned contract services. The results of the hierarchical logistic analysis showed that trust significantly influenced patients' willingness to contract services, and the drug treatment effect and NRCMI reimbursement rate moderated the influence of trust.

CONCLUSION

Our findings suggest that the government should aim to strengthen trust in the doctor-patient relationship in rural areas and increase the NRCMI reimbursement rate. Moreover, health officers should perfect the contract service package by offering tailored contract services or expanding service packages.

Could the connectedness of primary health care workers involved in social networks affect their job burnout? A cross-sectional study in six counties, Central China

Background

This study aimed to reveal the effects of the connectedness of primary health care (PHC) workers in social networks on their job burnout.

Methods

Cross-sectional survey data of rural PHC workers in China were analyzed. A total of 663 respondents were enrolled. Chi-square and cumulative logistic regression were used to determine the effects of the connectedness of PHC workers in social networks on their job burnout.

Results

PHC workers in rural China had high levels of emotional exhaustion (24.1%), depersonalization (15.7%), and lack of personal accomplishment (34.7%). More than half of the participants were in the middle connectedness level in terms of their advisory (70.4%) and friendship (70.3%) networks. The degree of emotional exhaustion seemed to increase when participants had a low connectedness in their friendship networks (β = 0.769, 95% CI = 0.080–1.458, P = 0.029). Respondents with the middle level of connectedness in advisory networks had higher levels of depersonalization (β = 0.739, 95% CI = 0.130–1.348, P = 0.017) and lack of personal accomplishment (β = 0.583, 95% CI = 0.111–1.055, P = 0.015) than those with the high degree of connectedness in advisory networks.

Conclusions

The connectedness of PHC workers in social networks influenced their job burnout. Thus, organizations should establish an informal communication platform and information feedback mechanism, promote and manage friendship networks, and help PHC workers overcome emotional exhaustion. Managers should also encourage individuals with a high level of connectedness in advisory networks play the role of “opinion leader” so that they can help others mitigate burnout.

Evolution of the Output-Workforce Relationship in Primary Care Facilities in China from 2009 to 2017

This study evaluates trends in workforce supply compared with those in the volume of service delivery (output) for basic clinical care (CC) and public health (PH) services from 2009 to 2017 in China. A cross-sectional survey (2018) was combined with retrospective data (2009–2017) from 785 primary care (PC) facilities in six provinces. Measures for the output of clinical care and of public health services were aggregated into a single (weighted) index for both service profiles. The output–workforce relationship was measured by its ratio. Latent class growth analysis and logistic regression analysis were applied to classify trajectories and determine associations with facility-level, geographic, and economic characteristics. From 2009 to 2017, the proportion of PC to overall healthcare workforce decreased from 24.25% to 18.57%; the proportion of PH to PC providers at PC facilities increased from 23.6% to 29.5%, while the proportion of PH output increased from 44.3% to 65.9%. Four trajectories of the output–workforce relationship were identified for CC, and five trajectories for PH services of which 85.3% of the facilities showed initially increasing and then slightly decreasing trends. Geographic characteristics impacted different trajectories. The PC workforce falls behind hospital workforce. The expansion in workload of PH services is unbalanced with that of workforce.

Rural Resident Experience on National Basic Public Health Services: A Cross-Sectional Survey in 10 Western Provinces of China

National basic public health services (BPHSs) are important for promoting the health of rural populations. A better understanding of rural BPHSs from the viewpoint of residents utilizing the services can help health-related departments and primary health care (PHC) centers further improve rural BPHSs. By conducting a large-scale cross-sectional survey in 10 western provinces of China, the study depicts rural resident experiences with rural BPHSs. Of the 9019 participants, 59.33% and 66.48% did not receive services related to health examinations or health education in the six months prior to the survey, respectively. A total of 56.90% were satisfied with the rural BPHSs, and the mean overall satisfaction score was 3.61 ± 0.908 (out of a maximum of 5). The most satisfying domain for rural residents with BPHSs was the attitude of PHC workers, whereas rural residents with chronic diseases were the least satisfied with the health management. Satisfaction with the attitude of PHC workers was identified as the strongest determinant of rural residents’ overall satisfaction with BPHSs. This study could enlighten rural BPHSs management in China.

Motivating factors on performance of primary care workers in China: a systematic review and meta-analysis

OBJECTIVE

Although China has made remarkable progress in strengthening its primary healthcare system, lack of well-performed primary health workforce is still the bottleneck of deepening the reform. The objective of this review is to understand the current profile of Chinese primary care workers (PCWs) and their motivating factors of performance and propose targeted policy suggestions on improving their work performance.

DESIGN

Systematic review.

METHODS

A systematic search of PubMed and MEDLINE was conducted to identify articles published from January 1, 2000, to June 2, 2018. Quality assessment and data extraction for the studies closely relevant to performance of PCWs in China were conducted by two reviewers independently. A preliminary framework containing different levels of factors influencing PCWs' motivation based on existence, growth and relatedness (ERG) theory guided the synthesis analysis. In addition, we used a random-effects model to pool individual studies on job satisfaction and estimate the overall job satisfaction of PCWs.

RESULTS

A total of 36 articles were included; 16 (23 882 participants) in the meta-analysis. Regarding the individual level of motivation, 3 overarching themes and 12 subthemes were developed. The subthemes of financial incentives, career advancement and work itself were frequently mentioned and have more influences on PCWs' performance. Moreover, the healthcare system reform policies have inevitable and complex impacts on different levels of human needs, and then influences on the motivation and performance of PCWs. Meta-analysis showed that the overall job satisfaction score among PCWs was 3.30, just reaching a satisfied rating and varied in different regions.

CONCLUSIONS

This study suggests low work satisfaction among PCWs in China, with financial incentives and career advancement being two most important motivating factors. Efforts to improve the work performance in PCWs should give priority to these motivating factors and systematically take into account the health policy's impacts on performance of PCWs.

Factors influencing the quality of clinical trials on traditional Chinese medicine-Qualitative interviews with trial auditors, clinicians and academic researchers

BACKGROUND

As clinical trials evaluating the efficacy of traditional Chinese medicine (TCM) therapies have increased, several empirical studies have shown that the quality of TCM trials is generally low in terms of risk of bias. This qualitative study aimed to investigate the factors influencing the quality of TCM clinical trials to provide strategic advice on trial quality improvement.

METHODS

One focus group with clinical trial auditors (n = 4) and six in-depth semi-structured interviews with clinical research organization managers (n = 2), lecturers and researchers in TCM academic institutions (n = 2), a chief physician in a TCM oncology department and a PhD candidate specialized in non-pharmaceutical TCM interventions were conducted. The interviews were audio-recorded, transcribed verbatim and thematically analyzed.

RESULTS

Factors that influenced the quality of TCM clinical trials emerged with the following 6 themes: trial design; trialists/participants; trial conducting; TCM specified problems; trial monitoring, and finally societal influences. The lack of expertise and time inputs of the trialists were repeatedly mentioned. Methodological difficulties experienced when conducting TCM trials including calculating sample size, analyzing the efficacy of TCM decoctions with multiple ingredients, blinding in trials investigating non-pharmaceutical TCM interventions were highlighted. Interviewees agreed that third-party monitoring can help improving trial quality and improve participant welfare, may accelerate recruiting processes and increase compliance; however more comprehensive regulations and funding requirements would be needed.

CONCLUSIONS

This study identified real-life issues influencing the quality of TCM clinical trials from design to reporting. In addition to mandatory training for TCM trial designers and coordinators, more effective institutional oversight is required. Future studies should explore specific measures to address the methodological problems in TCM trials and explore how the quality of TCM trials can affect further evidence synthesis and clinical practice.

Job satisfaction of the primary healthcare providers with expanded roles in the context of health service integration in rural China: a cross-sectional mixed methods study

OBJECTIVE

Against the backdrop of integrating public health services and clinical services at primary healthcare (PHC) institutions, primary healthcare providers (PCPs) have taken on expanded roles. This posed a potential challenge to China as it may directly impact PCPs' workload, income, and perceived work autonomy, thus affecting their job satisfaction. This study aimed to explore the association between the expanded roles and job satisfaction of the PCPs in township healthcare centers (THCs), the rural PHC institutions in China.

METHODS

A cross-sectional study using mixed methods was conducted in 47 THCs in China's Shandong province. Based on a sample of 1146 PCPs, the association between the proportion of PCPs' working time spent on public health services and PCPs' self-reported job satisfaction was estimated using the logistic regression. Qualitative data were also collected and analyzed to explore the mechanism of how the expanded roles impacted PCPs' job satisfaction.

RESULTS

One hundred eighty-four physicians and 146 nurses undertook increased work responsibilities, accounting for 15.91% and 12.61% of the total sample. For those spending 40-60%, 60-80%, and more than 80% of the working time providing public health services, the time spent on public health was negatively associated with job satisfaction, with the odds ratio being 0.199 [0.067-0.587], 0.083 [0.025-0.276], and 0.030 [0.007-0.130], respectively. Qualitative analysis illustrated that a majority of the PCPs with expanded roles were dissatisfied with their jobs due to the heavy workload, the mismatch between the income and the workload, and the low level of work autonomy. PCPs' heavier work burden was mainly caused by the current public health service delivery policy and the separation of public health service delivery and regular clinical services delivery, a significant challenge undermining the efforts to better integrate public health services and clinical services at PHC institutions.

CONCLUSION

The current policies of adding public health service delivery to the PHC system have negative impacts on PCPs' job satisfaction through increased work responsibilities for PCPs, which have led to low work autonomy and the mismatch between the income and the workload. The fundamental reason lies in the fragmented incentives and external supervision for public health service delivery and clinical service delivery. Policy-makers should balance the development of clinic and public health departments at the institutional level and integrate their financing and supervision at the system level so as to strengthen the synergy of public health service provision and routine clinical service provision.

Competency building for lay health workers is an intangible force driving basic public health services in Southwest China

BACKGROUND

Providing universal basic public health services (BPHS) for residents is the main goal of the new health reform in China. Lay health workers (LHWs) in primary health care (PHC) sectors play key roles in BPHS delivery. The competency of LHWs is critical to quality BPHS. This study assessed LHWs' competency to deliver BPHS and related training in resource-limited Southwest China.

METHODS

A mixed research method combining in-depth interviews with secondary data collection was used to collect data in this cross-sectional study. Fifty-four LHWs and 16 leaders in 16 PHC sectors were recruited for in-depth interviews. Secondary data on 198 LHWs were collected through standard forms.

RESULTS

Both the interviews and secondary data suggested that all PHC sectors did not have sufficient LHWs and lacked qualified LHWs to deliver BPHS overall, particularly in relatively low economic rural areas in Guizhou province. Furthermore, PHC sectors had difficulties retaining existing LHWs due to low incomes and fewer opportunities for self-development. In-depth interviews discovered that, although numerous training opportunities have been provided for LHWs since 2009, the trainings did not achieve the expected outcome in LHW competency building, as LHWs actually did not have access to the trainings and the training design was unresponsive to the actual needs of LHWs. Both LHWs and leaders expressed an urgent need for effective training for LHWs based on systematic needs assessments and the use of qualified trainers and materials.

CONCLUSIONS

The shortage of qualified LHWs in PHC sectors became the bottleneck for BPHS delivery in Southwest China. Recent trainings for LHWs were less effective with regard to LHW competency building. A need-based professional training programme for LHWs by qualified trainers was expected by both LHWs and leaders in PHC sectors.

Strengthening public health services to achieve universal health coverage in China

Better integration of public health and medical services and greater focus on quality of services are needed to make further progress on health outcomes, say Beibei Yuan and colleagues

The impact of contract service policy and doctor communication skills on rural patient-doctor trust relationship in the village clinics of three counties

Background

Trust is regarded as the cornerstone of the doctor-patient relationship in the world of medicine; it determines the decisions patients make when choosing doctors and influences patients’ compliance with recommended treatments. In China, patient-doctor trust acts as a thermometer measuring harmony in the doctor-patient relationship. The objective of this study is to explore the relationship between the contract service and patient-doctor trust-building in 25 village clinics of rural China.

Method

The research was carried out in village clinics in rural China. A simple random sampling method was used to choose clinics and subjects. Based on feasibility and financial support, we chose three counties as our study settings: Dafeng District, Jiangsu Province; Yinan County, Shandong Province; and Wufeng Tujia Autonomous County, Hubei Province. Twenty-five village clinics and 574 subjects were selected in the three areas from the contract service and patient list. Descriptive statistics, t-tests, MANOVA, SEM, and multiple regression statistical analysis were employed to analyze the data.

Result

Statistical analysis showed that contract service directly and indirectly influenced patient-doctor trust-building in village clinics. The patient perception of doctor communication skills was a mediator in the relationship between contract service policy and patient-doctor trust-building.

Conclusions

Building patient-doctor trust is important in developing and enhancing rural health. The policy of contract service plays a significant role in building relationships. Well-developed communication skills of doctors contribute to the implementation of the contract service policy and to establishing patient-doctor trust.

Self-reported environmental health risks of nurses working in hospital surgical units

AIM

This study investigated the occupational health risk factors among nurses who work in public hospital surgical units.

BACKGROUND

Nursing has a significant place in healthcare systems around the world. Surgical units are environments with certain risks, especially because of the possibility of exposure to various chemical, biologic or physical hazards.

METHODS

This study was conducted with 229 nurses who were working in the 11 surgery units of a big university hospital. In this cross-sectional study, a personal information form and an occupational risk factors scale were administered to respondents. We performed factor and reliability analyses for the scale; the overall reliability of the 41 items was α = 0.924, and the factor analysis found the scale was feasible.

RESULTS

Biologic and psychological risk factor levels were found to be high. Physical, chemical, ergonomic and radiation risk factor levels were moderate. The general occupational risk factor score was moderate. Nurses working night duty were confronted with physical and psychological risk factors at a higher rate compared with those working in the daytime.

CONCLUSION

Reported occupational health problems by nurses were correlated with the descriptive properties of the nurses including age, sex, marital status, education level, working hours, mode of working and status of occupational health and safety training.

IMPLICATIONS FOR NURSING

Nurses experience different occupational risks. If these risks are identified, healthier working environments can be provided to the nurses by taking necessary precautions.

IMPLICATIONS FOR SOCIAL POLICY

The health care provided by nurses who work in a healthy environment would be more efficient and of better quality, which will result in better economic and social outcomes for individual and communities.

Determinants of village doctors' job satisfaction under China's health sector reform: a cross-sectional mixed methods study

Background

To strengthen rural health workforce, the Chinese government has launched a series of policies to promote the job satisfaction of village doctors since the health sector reform. The purpose of this mixed-method study is to describe village doctors’ job satisfaction under the context of health sector reform and investigate the associated factors.

Methods

Data was obtained from a survey of village doctors across three Chinese provinces in 2014. Using a multistage sampling process, quantitative data was collected from village doctors through the self-administered questionnaire and analyzed by multilevel logistic regression models. Qualitative data was collected through face-to-face semi-structured interviews on both village doctors and health managers. Theoretical coding was then conducted to analyze qualitative data.

Results

Among the 1221 respondents, 48.6% felt satisfied with their job. Older village doctors with less of a workload and under high-level integrated management were more likely to feel satisfied with their job. Village doctors who earned the top level of monthly income felt more satisfied, while on the county level, those who lived in counties with the highest GDP felt less satisfied. However, enrollment in a pension plan showed no significant difference in regards to village doctors’ job satisfaction.

Among 34 participants of qualitative interviews, most believed that age, income, and integrated management had a positive influence on the job satisfaction, while pension plan and basic public health care policies exhibited negative effects. Also, the increasing in availability of healthcare and health resources along with local economic development had negative effects on village doctors’ job satisfaction.

Conclusion

Village doctors’ job satisfaction was quite low in regards to several determinants including age, income, workload, enrollment in a pension plan, integrated management, and county economic and medical availability development.

Financing strategies to improve essential public health equalization and its effects in China

BACKGROUND

In 2009, China launched a health reform to promote the equalization of national essential public health services package (NEPHSP). The present study aimed to describe the financing strategies and mechanisms to improve access to public health for all, identify the strengths and weaknesses of the different approaches, and showed evidence on equity improvement among different regions.

METHODS

We reviewed the relevant literatures and identified 208 articles after screening and quality assessment and conducted six key informants' interviews. Secondary data on national and local government health expenditures, NEPHSP coverage and health indicators in 2003-2014 were collected, descriptive and equity analyses were used.

RESULTS

Before 2009, the government subsidy to primary care institutions (PCIs) were mainly used for basic construction and a small part of personnel expenses. Since 2009, the new funds for NEPHSP have significantly expanded service coverage and population coverage. These funds have been allocated by central, provincial, municipal and county governments at different proportions in China's tax distribution system. Due to the fiscal transfer payment, the Central Government allocated more subsides to less-developed western regions and all the funds were managed in a specific account. Several types of payment methods have been adopted including capitation, pay for performance (P4P), pay for service items, global budget and public health voucher, to address issues from both the supply and demand sides. The equalization of NEPHSP did well through the establishment of health records, systematic care of children and maternal women, etc. Our data showed that the gap between the eastern, central and western regions narrowed. However the coverage for migrants was still low and performance was needed improving in effectiveness of managing patients with chronic diseases.

CONCLUSIONS

The delivery of essential public health services was highly influenced by public fiscal policy, and the implementation of health reform since 2009 has led the public health development towards the right direction. However China still needs to increase the fiscal investments to expand service coverage as well as promote the quality of public health services and equality among regions. Independent scientific monitoring and evaluation are also needed.

Sustained Implementation of Evidence-based Programs in Disadvantaged Communities: A Conceptual Framework of Supporting Factors

This paper presents a review of the empirical literature for studies evaluating factors that facilitate and create barriers to sustained program implementation in disadvantaged communities. It outlines study methodology and sustainment outcomes and proposes a conceptual model that involves implementation sustainment support for providers delivering evidence-based health and family services in disadvantaged communities. Sustained program implementation in the community setting is a significant issue as only 43% of studies reported successfully sustained programs. The review identified 18 factors that facilitate success and create barriers to program sustainment. The factors are synthesized into three themes; program characteristics, workplace capacity, and process and interaction factors. The majority of factors map onto commonly cited sustainability influences in implementation science. However, there was an additional focus for studies included in this review on the importance of factors such as program burden, program familiarity and perceived competence in program skills, workplace support for the program, staff mobility and turnover, supervision and peer support, and ongoing technical assistance. The need to use a conceptual framework and develop measures to guide and evaluate capacity building in EBP implementation and sustainment in low-resource community settings is highlighted.

Determinants of basic public health services provision by village doctors in China: using non-communicable diseases management as an example

BACKGROUND

To ensure equity and accessibility of public health care in rural areas, the Chinese central government has launched a series of policies to motivate village doctors to provide basic public health services. Using chronic disease management and prevention as an example, this study aims to identify factors associated with village doctors' basic public health services provision and to formulate targeted interventions in rural China.

METHODS

Data was obtained from a survey of village doctors in three provinces in China in 2014. Using a multistage sampling process, data was collected through the self-administered questionnaire. The data was then analyzed using multilevel logistic regression models.

RESULTS

The high-level basic public health services for chronic diseases (BPHS) provision rate was 85.2% among the 1149 village doctors whom were included in the analysis. Among individual level variables, more education, more training opportunities, receiving more public health care subsidy (OR = 3.856, 95 % CI: 1.937-7.678, and OR = 4.027, 95% CI: 1.722-9.420), being under integrated management (OR = 1.978, 95% CI: 1.132-3.458), and being a New Cooperative Medical Scheme insurance program-contracted provider (OR = 2.099, 95% CI: 1.187-3.712) were associated with the higher BPHS provision by village doctors. Among county level factors, Foreign Direct Investment Index showed a significant negative correlation with BPHS provision, while the government funding for BPHS showed no correlation (P > 0.100).

CONCLUSION

Increasing public health care subsidies received by individual village doctors, availability and attendance of training opportunities, and integrated management and NCMS contracting of village clinics are important factors in increasing BPHS provision in rural areas.

Factors Associated with the Competencies of Public Health Workers in Township Hospitals: A Cross-Sectional Survey in Chongqing Municipality, China

Purpose: This study aimed to explore the competencies of public health workers (PHWs) of township hospitals in Chongqing Municipality (China), and determine the related impact factors of the competencies of PHWs; Methods: A cross-sectional research was conducted on 314 PHWs from 27 township hospitals in three districts in Chongqing Municipality (China), from June to August 2014. A self-assessment questionnaire was established on the basis of literature reviews and a competency dictionary. The differences in competencies among the three districts were determined by adopting the chi-square test, t-test, analysis of variance (ANOVA) method, and the impact factors of the competencies of PHWs were determined by adopting stepwise regression analysis. Results: (1) Results of the demographic characteristics of PHWs in three sample districts of Chongqing Municipality showed that a significant difference in age of PHWs (p = 0.021 < 0.05) and the majors of PHWs (p = 0.045 < 0.05); (2) In terms of the self-evaluation competency results of PHWs in township hospitals, seven among the 11 aspects were found to have significant differences in the three districts by the ANOVA test; (3) By adopting the t-test and ANOVA method, results of the relationship between the characteristics of PHWs and their competency scores showed that significant differences were found in the economic level (p = 0.000 < 0.05), age (p = 0.000 < 0.05), years of working (p = 0.000 < 0.05) and title of PHWs (p = 0.000 < 0.05); (4) Stepwise regression analysis was used to determine the impact factors of the competencies of PHWs in township hospitals, including the economic level (p = 0.000 < 0.001), years of working (p = 0.000 < 0.001), title (p = 0.001 < 0.005), and public health major (p = 0.007 < 0.01). Conclusions: The competencies of the township hospital staff in Chongqing Municipality (China), are generally insufficient, therefore, regulating the medical education and training skills of PHWs is crucial to improve the competencies of PHWs in the township hospitals of Chongqing Municipality. The results of this study can be mirrored in other areas of China.

Rural-to-Urban Migrants' Experiences with Primary Care under Different Types of Medical Institutions in Guangzhou, China

Objectives

China is facing the unprecedented challenge of rapidly increasing rural-to-urban migration. Migrants are in a vulnerable state when they attempt to access to primary care services. This study was designed to explore rural-to-urban migrants’ experiences in primary care, comparing their quality of primary care experiences under different types of medical institutions in Guangzhou, China.

Methods

The study employed a cross-sectional survey of 736 rural-to-urban migrants in Guangzhou, China in 2014. A validated Chinese version of Primary Care Assessment Tool—Adult Short Version (PCAT-AS), representing 10 primary care domains was used to collect information on migrants’ quality of primary care experiences. These domains include first contact (utilization), first contact (accessibility), ongoing care, coordination (referrals), coordination (information systems), comprehensiveness (services available), comprehensiveness (services provided), family-centeredness, community orientation and culturally competent. These measures were used to assess the quality of primary care performance as reported from patients’ perspective. Analysis of covariance was conducted for comparison on PCAT scores among migrants accessing primary care in tertiary hospitals, municipal hospitals, community health centers/community health stations, and township health centers/rural health stations. Multiple linear regression models were used to explore factors associated with PCAT total scores.

Results

After adjustments were made, migrants accessing primary care in tertiary hospitals (25.49) reported the highest PCAT total scores, followed by municipal hospitals (25.02), community health centers/community health stations (24.24), and township health centers/rural health stations (24.18). Tertiary hospital users reported significantly better performance in first contact (utilization), first contact (accessibility), coordination (information system), comprehensiveness (service available), and cultural competence. Community health center/community health station users reported significantly better experience in the community orientation domain. Township health center/rural health station users expressed significantly better experience in the ongoing care domain. There were no statistically significant differences across settings in the ongoing care, comprehensiveness (services provided), and family-centeredness domains. Multiple linear regression models showed that factors positively associated with higher PCAT total scores also included insurance covering parts of healthcare payment (P<0.001).

Conclusions

This study highlights the need for improvement in primary care provided by primary care institutions for rural-to-urban migrants. Relevant policies related to medical insurance should be implemented for providing affordable healthcare services for migrants accessing primary care.