Chinese primary care physicians and work attitudes

The effect of family doctor policy practice on primary health-care workers' health in Hongkou District of Shanghai, China: varied by occupational divisions?

BACKGROUND

A key component of the 2009 medical reform in China was the change to family doctor (FD) policy practice. However, this led to an increased workload for primary health-care workers (PHCWs) at community health service centres. Their increasing workload may play a significant role in affecting PHCWs' health.

METHODS

A questionnaire survey was conducted in Hongkou district of Shanghai amongst PHCWs including family doctors (FDs), family nurses (FNs), public health doctors (PHDs), and other PHCWs in early 2019. Ordered logistic regression models (Models 1 to 3) were performed to explore the differing health status amongst PHCWs, and their respective influential factors were also tested (Models 4 to 7).

RESULTS

Five hundred sixty-two valid questionnaires were collected with a response rate of 96.4%. Other PHCWs' (OR = 2.03; 95% CI: 1.163-3.560) and FNs' (OR = 1.98; 95% CI: 1.136-3.452) self-rated health (SRH) were significantly better than that of FDs. In terms of FNs, the OR of SRH for those who strongly perceived the extra workload brought by FD-contracted services was only 12.0% (95% CI: 0.018-0.815) of that of the no-pressure group. Similarly, FNs with stronger work pressure had worse SRH, i.e., compared with "no" pressure, the SRH ORs for "neutral," "strong," and "very strong" evaluations of work pressure were 0.002 (95% CI: 0.000-0.055), 0.001 (95% CI: 0.000-0.033), and 0.000 (95% CI: 0.000-0.006), respectively. Information technology (IT) systems and performance incentives were suggested to improve SRH for FNs, while the former was found to be negatively correlated with other PHCWs. After one unit increase in the PHDs' team/department support, their OR was 10.7 times (95% CI: 1.700-67.352) higher. In addition, policy support had a negative effect on SRH for PHDs. The OR of "good" assessments of cultural environments was 25.98 times (95% CI: 1.391-485.186) higher than that of "very poor" for Other PHCWs.

CONCLUSIONS

The influences of FD policy practice on FNs' SRH were the most significant amongst PHCWs, rather than FDs' as expected. The significant factors of SRH were varied over different occupational categories, that is team/department support and policy support (though negative) for PHDs, IT system and incentive for FNs, facility and equipment for FDs, and culture environment for other PHCWs respectively.

A Smart and Multifaceted Mobile Health System for Delivering Evidence-Based Secondary Prevention of Stroke in Rural China: Design, Development, and Feasibility Study

BACKGROUND

Mobile health (mHealth) technologies hold great promise in improving the delivery of high-quality health care services. Yet, there has been little research so far applying mHealth technologies in the context of delivering stroke care in resource-limited rural regions.

OBJECTIVE

This study aimed to introduce the design and development of an mHealth system targeting primary health care providers and to ascertain its feasibility in supporting the delivery of a System-Integrated techNology-Enabled Model of cAre (SINEMA) service for strengthening secondary prevention of stroke in rural China.

METHODS

The SINEMA mHealth system was designed by a multidisciplinary team comprising public health researchers, neurologists, and information and communication technology experts. The iterative co-design and development of the mHealth system involved the following 5 steps: (1) assessing the needs of relevant end users through in-depth interviews of stakeholders, (2) designing the functional modules and evidence-based care content, (3) designing and building the system and user interface, (4) improving and enhancing the system through a 3-month pilot test in 4 villages, and (5) finalizing the system and deploying it in field trial, and finally, evaluating its feasibility through a survey of the dominant user group.

RESULTS

From the in-depth interviews of 49 relevant stakeholders, we found that village doctors had limited capacity in caring for village-dwelling stroke patients in rural areas. Primary health care workers demonstrated real needs in receiving appropriate training and support from the mHealth system as well as great interests in using the mHealth technologies and tools. Using these findings, we designed a multifaceted mHealth system with 7 functional modules by following the iterative user-centered design and software development approach. The mHealth system, aimed at 3 different types of users (village doctors, town physicians, and county managers), was developed and utilized in a cluster-randomized controlled trial by 25 village doctors in a resource-limited county in rural China to manage 637 stroke patients between July 2017 and July 2018. In the end, a survey on the usability and functions of the mHealth system among village doctors (the dominant group of users, response rate=96%, 24/25) revealed that most of them were satisfied with the essential functions provided (71%) and were keen to continue using it (92%) after the study.

CONCLUSIONS

The mHealth system was feasible for assisting primary health care providers in rural China in delivering the SINEMA service on the secondary prevention of stroke. Further research and initiatives in scaling up the SINEMA approach and this mHealth system to other resource-limited regions in China and beyond will likely enhance the quality and accessibility of essential secondary prevention among stroke patients.

CLINICALTRIAL

ClinicalTrials.gov NCT03185858; https://clinicaltrials.gov/ct2/show/NCT03185858.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.1016/j.ahj.2018.08.015.

A qualitative study of two management models of community health centres in two Chinese megacities

Two common public models of community health centres (CHCs) exist in China, i.e. the 'government-owned and government-managed' CHCs (G-CHCs) and the 'government-owned and hospital-managed' CHCs (H-CHCs). Shanghai and Shenzhen are two Chinese megacities that lead the primary care development on the G-CHC and H-CHC models, respectively. Using a qualitative case study design, this study compares the management of the G-CHC model in Shanghai and H-CHC model in Shenzhen, through perspectives of a range of health providers. In each city, we randomly selected four CHCs and in total conducted 31 interviews with officers from the municipal health authorities, directors, GPs, nurses and public health doctors of the CHCs. When comparing with the H-CHC model in Shenzhen, the G-CHC model in Shanghai, a model with more simplified but accountable structure tended to present better management conditions, in terms of financial transparency, recruitment autonomy, community health workforce development (CHC staffing and family medicine training), funding and priority for public health. However, regardless of the models, staff retention remained a challenge. While our study tends to suggest that the G-CHC model in Shanghai presents better management conditions, future study can test whether and to what extent the model itself can lead to such differences.

Satisfaction of village doctors with the township and village health services integration policy in the western minority-inhabited areas of China

Township and Village Health Services Integration Management (TVHSIM) is an essential form of China's two-tiered health service integration plan at the township and village level. Its main purpose, also one of the target goals in China's new healthcare reform, is to gradually integrate rural health services and appropriately allocate rural health resources. This study aims to assess the village doctors' satisfaction with the TVHSIM and provide scientific base to further improve TVHSIM. A cross-sectional study was carried out in which 162 village doctors from Qinghai, Inner Mongolia and Xinjiang in western China were interviewed. Descriptive analysis, independent t-test, one-way ANOVA, Spearman rank correlation and multiple linear regression were used to analyze the difference and relevance between village doctors' personal characteristics and their satisfaction with TVHSIM and six subscales. Village doctors with different years of practice, social insurance status and essential medical knowledge level showed statistically significant differences in their satisfaction levels (all P<0.05). Age (P<0.05) and years of practice (P<0.01) were negatively correlated with Drug and Medical Device Management and Financing Management. Essential medical knowledge level (P<0.05) was negatively correlated with Operations Management as well. However, social insurance status (P<0.05) was positively correlated with Human Resources Management and Drug and Medical Device management. Gender, age and years of practice respectively had significant influence on village doctors' satisfaction with TVHSIM (P<0.01). In conclusion, in order to further promote TVHSIM policy in rural China, a well-rounded social insurance model for village doctors is urgently needed. In addition, the development of TVHSIM is regionally imbalanced. Efficient and effective measures aiming at rationalizing gender and age structure and enhancing essential medical training should be carefully considered.

Antibiotic prescribing for upper respiratory infections among children in rural China: a cross-sectional study of outpatient prescriptions

BACKGROUND

Overuse of antibiotics contributes to the development of antimicrobial resistance.

OBJECTIVE

This study aims to assess the condition of antibiotic use at health facilities at county, township and village levels in rural Guangxi, China.

METHODS

We conducted a cross-sectional study of outpatient antibiotic prescriptions in 2014 for children aged 2-14 years with upper respiratory infections (URI). Twenty health facilities were randomly selected, including four county hospitals, eight township hospitals and eight village clinics. Prescriptions were extracted from the electronic records in the county hospitals and paper copies in the township hospitals and village clinics.

RESULTS

The antibiotic prescription rate was higher in township hospitals (593/877, 68%) compared to county hospitals (2736/8166, 34%) and village clinics (96/297, 32%) (p < 0.001). Among prescriptions containing antibiotics, county hospitals were found to have the highest use rate of broad-spectrum antibiotics (82 vs 57% [township], vs 54% [village], p < 0.001), injectable antibiotics (65 vs 43% [township], vs 33% [village], p < 0.001) and multiple antibiotics (47 vs 15% [township], vs 0% [village], p < 0.001). Logistic regression showed that the likelihood of prescribing an antibiotic was significantly associated with patients being 6-14 years old compared with being 2-5 years old (adjusted odds ratio [aOR] = 1.3, 95% CI 1.2-1.5), and receiving care at township hospitals compared with county hospitals (aOR = 5.0, 95% CI 4.1-6.0). Prescriptions with insurance copayment appeared to lower the risk of prescribing antibiotics compared with those without (aOR = 0.8, 95% CI 0.7-0.9).

CONCLUSIONS

Inappropriate use of antibiotics was high for outpatient childhood URI in the four counties of Guangxi, China, with the highest rate found in township hospitals. A significant high proportion of prescriptions containing antibiotics were broad-spectrum, by intravenous infusion or with multiple antibiotics, especially at county hospitals. Urgent attention is needed to address this challenge.

Factors that influence the turnover intention of Chinese village doctors based on the investigation results of Xiangyang City in Hubei Province

INTRODUCTION

This study analyzes the factors that influence the turnover intention of village doctors by investigating village clinic workers in rural areas, particularly in Xiangyang City, Hubei Province.

METHODS

A total of 1184 village clinics were sampled randomly in Xiangyang City. The research assistants distributed 1930 questionnaires to village doctors. This study had a response rate of 97.88%. A total of 1889 village doctors completed the questionnaires.

RESULTS

The results of the investigation conducted in Xiangyang City indicated that 63.2% of the village doctors did not plan to leave the organization where they were currently employed. However, more than one-third (36.8%) of the village doctors considered leaving their posts voluntarily. Some job satisfaction indexes affect their intention to resign. The results showed that income satisfaction and the way organization policies are put into practice, in addition, my pay and the amount of work I do, the chances for advancement on this job and the work conditions are significant factors that contribute to the turnover intention of village doctors.

CONCLUSIONS

This study may interest heath care management administrator and highlight the influence of job satisfaction on turnover intention of village doctors. Our findings outline some issues that contribute to these problems and suggest an approach for health care policy maker to implement a broader national process and organizational strategies to improve the job satisfaction and stability of the village doctors.

Work stress, work motivation and their effects on job satisfaction in community health workers: a cross-sectional survey in China

OBJECTIVE

It is well documented that both work stress and work motivation are key determinants of job satisfaction. The aim of this study was to examine levels of work stress and motivation and their contribution to job satisfaction among community health workers in Heilongjiang Province, China.

DESIGN

Cross-sectional survey.

SETTING

Heilongjiang Province, China.

PARTICIPANTS

The participants were 930 community health workers from six cities in Heilongjiang Province.

PRIMARY AND SECONDARY OUTCOME MEASURES

Multistage sampling procedures were used to measure socioeconomic and demographic status, work stress, work motivation and job satisfaction. Logistic regression analysis was performed to assess key determinants of job satisfaction.

RESULTS

There were significant differences in some subscales of work stress and work motivation by some of the socioeconomic characteristics. Levels of overall stress perception and scores on all five work stress subscales were higher in dissatisfied workers relative to satisfied workers. However, levels of overall motivation perception and scores on the career development, responsibility and recognition motivation subscales were higher in satisfied respondents relative to dissatisfied respondents. The main determinants of job satisfaction were occupation; age; title; income; the career development, and wages and benefits subscales of work stress; and the recognition, responsibility and financial subscales of work motivation.

CONCLUSIONS

The findings indicated considerable room for improvement in job satisfaction among community health workers in Heilongjiang Province in China. Healthcare managers and policymakers should take both work stress and motivation into consideration, as two subscales of work stress and one subscale of work motivation negatively influenced job satisfaction and two subscales of work motivation positively influenced job satisfaction.

Coverage, quality of and barriers to postnatal care in rural Hebei, China: a mixed method study

BACKGROUND

Postnatal care is an important link in the continuum of care for maternal and child health. However, coverage and quality of postnatal care are poor in low- and middle-income countries. In 2009, the Chinese government set a policy providing free postnatal care services to all mothers and their newborns in China. Our study aimed at exploring coverage, quality of care, reasons for not receiving and barriers to providing postnatal care after introduction of this new policy.

METHODS

We carried out a mixed method study in Zhao County, Hebei Province, China from July to August 2011. To quantify the coverage, quality of care and reasons for not using postnatal care, we conducted a household survey with 1601 caregivers of children younger than two years of age. We also conducted semi-structured interviews with 24 township maternal and child healthcare workers to evaluate their views on workload, in-service training and barriers to postnatal home visits.

RESULTS

Of 1442 (90% of surveyed caregivers) women who completed the postnatal care survey module, 8% received a timely postnatal home visit (within one week after delivery) and 24% of women received postnatal care within 42 days after delivery. Among women who received postnatal care, 37% received counseling or guidance on infant feeding and 32% on cord care. 24% of women reported that the service provider checked jaundice of their newborns and 18% were consulted on danger signs and thermal care of their newborns. Of 991 mothers who did not seek postnatal care within 42 days after birth, 65% of them said that they did not knew about postnatal care and 24% of them thought it was unnecessary. Qualitative findings revealed that staff shortages and inconvenient transportation limited maternal and child healthcare workers in reaching out to women at home. In addition, maternal and child healthcare workers said that in-service training was inadequate and more training on postnatal care, hands-on practice, and supervision were needed.

CONCLUSIONS

Coverage and quality of postnatal care were low in rural Hebei Province and far below the targets set by Chinese government. We identified barriers both from the supply and demand side.