Health Workers In China Research Articles

Work-family conflict among primary health workers during the COVID-19 pandemic: Its mediating role in the relationship between workload and job burnout.

This study explores the situation of workload, work-family conflict and job burnout among primary health workers in China in the context of COVID-19 and identifies the mediating effect of work-family conflict between workload and job burnout. Since the breakout of the COVID-19 pandemic, primary health workers have been working on the frontline of the epidemic and may experience increasing workload, work-family conflict and job burnout. It is important to focus on the issue of how to alleviate job burnout of primary health workers. A cross-sectional study (STROBE) was used. Data were collected from 785 primary health workers in China. Multiple regression analysis was used to examine the mediating effect of work-family conflict between workload and job burnout. 18.7%, 10.4% and 39.5% of respondents had high job burnout in the dimensions of emotional exhaustion, depersonalization and personal accomplishment, respectively. 34.6% of the respondents had high or very high workload, and 12.8% of the respondents had high or very high work-family conflict. Results of multiple regression analysis indicated that work-family conflict mediated the relationship between workload and job burnout. Workload (β = .163, CI = .207-.549) and work-family conflict (β = .211, CI = .311-.640) positively influenced job burnout, and workload (β = .428, CI = .375-.508) positively influenced work-family conflict. The study indicated that primary health workers experienced a high level of job burnout, especially in the personal accomplishment dimension. Furthermore, this study verified the mediating effect of work-family conflict between workload and job burnout. Some interventions for alleviating workload, work-family conflict and job burnout should be taken, including workplace assistance programmes, family-friendly policies and a well-integrated healthcare system. This study does not involve patient or public contribution in any part. Nurses and other primary health workers are health gatekeepers of residents and play a vital role in the healthcare system. Due to the breakout of COVID-19, they have taken more work and are more vulnerable to work overload, work-family conflict and the consequent job burnout. Some interventions should be taken to effectively alleviate their job burnout and improve their health and performance.

Factors associated with recommendation behaviors of four non-National Immunization Program vaccines: a cross-sectional survey among public health workers in China

BackgroundImmunization is a crucial preventive measure to safeguard children under five years old against a range of diseases. In China, the coverage rate of non-National Immunization Program (non-NIP) vaccines can be improved by leveraging the recommendation from public health workers. Hence, understanding the influencing factors of recommendation behaviors assume paramount importance. This study aims to investigate influencing factors of public health workers' recommendation behaviors towards non-NIP vaccines, with a particular emphasis on financial incentives.MethodsA cross-sectional survey was conducted using a multi-stage sampling method in 2019 from August to October. 627 public health workers were recruited from 148 community healthcare centers in ten provincial-level administrative divisions in China. An anonymous questionnaire was used to collect demographic information, attitudes towards vaccination, and recommendation behaviors towards non-NIP vaccines, including Haemophilus influenzae type b (Hib) vaccine, pneumococcal conjugate vaccine, varicella vaccine, and rotavirus vaccine. Descriptive analysis and multivariate logistic regression analysis were adopted in this study.ResultsOf the 610 public health workers with complete survey data, 53.8%, 57.4%, 84.1%, and 54.1% often recommended Hib vaccine, pneumococcal pneumonia vaccine (PCV), varicella vaccine, and rotavirus vaccine, respectively. Logistic regression revealed that gender (Hib vaccine: OR = 0.4, 95% CI: 0.2–0.8; PCV: OR = 0.4, 95% CI: 0.2–0.8; rotavirus vaccine: OR = 0.3, 95% CI: 0.2–0.6), financial incentives for non-NIP vaccination (Hib vaccine: OR = 1.9, 95% CI: 1.1–3.6; PCV: OR = 2.1, 95% CI: 1.1–3.9; rotavirus vaccine: OR = 2.0, 95% CI: 1.1–3.8) and perception of vaccine safety (Hib vaccine: OR = 2.7, 95% CI: 1.1–7.0; PCV: OR = 3.2, 95% CI: 1.2–8.0; rotavirus vaccine: OR = 3.0, 95% CI: 1.2–7.7) were associated with public health workers’ recommendation towards Hib vaccine, PCV and rotavirus vaccine.ConclusionsThe findings highlighted public health workers’ recommendation behaviors of non-NIP vaccines in China and revealed strong association between vaccine recommendation and financial incentives. This highlights the importance of financial incentives in public health workers’ recommendation toward non-NIP vaccines in China. Proper incentives are recommended for public health workers to encourage effective health promotion in immunization practices.Graphical

The need for digital health education among next-generation health workers in China: a cross-sectional survey on digital health education

BackgroundDigital health is important for sustainable health systems and universal health coverage. Since the outbreak of COVID-19, many countries, including China, have promoted the introduction of digital health in their medical services. Developing the next generation of physicians with digital health knowledge and skills is a prerequisite for maximizing the potential of digital health.ObjectiveWe aimed to understand the perception of digital health among Chinese medical students, the current implementation of digital health education in China, and the urgent need of medical students.MethodsOur cross-sectional survey was conducted online and anonymously among current medical students in China. We used descriptive statistical analysis to examine participant demographic characteristics and the demand for digital health education. Additional analysis was conducted by grouping responses by current participation in a digital health course.ResultsA total of 2122 valid responses were received from 467 medical schools. Most medical students had positive expectations that digital health will change the future of medicine. Compared with wearable devices (85.53%), telemedicine (84.16%), and medical big data (86.38%), fewer respondents believed in the benefits of clinical decision support systems (CDSS) (63.81%). Most respondents said they urgently needed digital health knowledge and skills, and the teaching method of practical training and internship (78.02%) was more popular than the traditional lecture (10.54%). However, only 41.45% wanted to learn about the ethical and legal issues surrounding digital health.ConclusionsOur study shows that the current needs of Chinese medical students for digital health education remain unmet. A national initiative on digital health education, is necessary and attention should be paid to digital health equity and education globally, focusing on CDSS and artificial intelligence. Ethics knowledge must also be included in medical curriculum. Students as Partners (SAP) is a promising approach for designing digital health courses.

Effects of infection prevention and control measures on patient and visitor violence against health workers in China during COVID-19 pandemic.

To examine trends in patient and visitor violence (PVV) among large public hospitals from 2016 to 2020 in China, and investigate the effects of infection prevention and control (IPC) measures on PVV during the COVID-19 pandemic. The hospital-level data of PVV used in this study from 2016 to 2020 in three cities in northern China were extracted from the database of the Medical Quality and Safety Notification System from 41 public hospitals. The difference-in-difference (DID) method was used to estimate the effects of IPC measures on PVV. The empirical strategy was to compare changes in the incidence rate of PVV in public hospitals where IPC measures were stricter to relatively weaker hospitals. From 2019 to 2020, the incidence rate of PVV decreases from 4.59 to 2.15% for high-IPC measure level hospitals and increases from 4.42 to 4.56% for medium-IPC measure level hospitals. The results from the DID models showed that as the IPC measure level increased, the incidence rate of PVV (β = -3.12, 95% CI = -5.74 ~ -0.50) decreased more significantly based on controlling for hospital fixed effects and time trends. The multi-dimensional and comprehensive IPC measures throughout the pandemic in China have not only controlled the pandemic, but also directly or indirectly reduced the incidence rate of PVV by alleviating the stress of health workers and the crowded working environment, creating a good order of admission, and reducing patient waiting time.

Correlation between input on public health services and work motivation among primary health workers in China

BackgroundThe integration of public health services into primary health care has been advocated and practiced worldwide for better management of preventable diseases. Health policy makers in China have started the reforms to better integrate public health services and clinical services, but public health services in China still remained neglected in primary health system. This study aimed to explore the input of Chinese primary health workers on delivering public health services and its association with their intrinsic working motivation in China.MethodsData were collected from a cross-sectional survey conducted in 2019. Participants in this survey included 803 primary health workers in 75 primary health institutions in China. Questions about the input on clinical and public health services delivery and intrinsic working motivation were asked. A multiple linear regression model was adopted to investigate the correlation between intrinsic working motivation and the time input on public health service. The robustness of this model was checked with a generalized linear model.ResultsIntrinsic motivation was found to have negative association with health workers’ input on public health (β: -1.01, p < 0.05), with the robustness checked with a generalized linear model. The significance of this association differed in the group of urban community health centers and rural township health center. Other factors that had significant relationship with the input on public health services include the being nurses instead of doctors (p < 0.01), being a member of family doctor team (p < 0.01), recognition on relative importance of clinical services (p < 0.01), and perception on better exterior support (p < 0.01).ConclusionWith higher intrinsic working motivation, primary health workers tended to spend less time on public health services. It reflected that doctors and nurses in primary healthcare institutions still perceived clinical treatment services as their main work responsibility and source of career recognition. Organizational level supports and system level policies should guide the primary health workers to increase their awareness on the importance of public health services and to cultivate their internal interests on public health services, in order to ensure sustainable input and performance improvement on public health services in primary health system in China.

Work Motivation of Primary Health Workers in China: The Translation of a Measurement Scale and Its Correlation with Turnover Intention.

BackgroundHigh turnover intention, as a manifestation of low work motivation, is a crucial barrier to strengthening primary health systems worldwide, including in China. Targeting those being less motivated will be a realistic choice to retain primary health workers. This study translate, adapt, and validate the Work Motivation Scale for Health Workers (WMSHW) scale to directly measure and rate health workers’ motivation composition based on Self-Determination Theory, and assessed how health workers with different levels of motivation being associated with the turnover intention.MethodsThe process of translation and cross-cultural adaptation followed the recommendations of international guidelines. Participants include 1341 health workers within 75 primary health institutions from 6 provinces in China. The reliability and validity of the scale was analyzed. Cluster analysis in a person-centered approach and logistic regression analysis was used to understand how different combinations of motivations related to intention to leave.ResultsConfirmatory factor analysis indicated that the modified five-factor model had a better fit than the other models in accordance with the original English version. The factor loads were high and ranged from 0.70 to 0.9. Cronbach’s alpha coefficients for five dimensions of the Chinese WMSHW ranged from 0.81 to 0.94, indicating the scale’s high internal consistency. Four distinct clusters of work motivation were found in this study, representing low motivated, highly controlled, highly autonomous and highly motivated primary health workers. Compared with low motivation group, both controlled and autonomous motivation groups were more likely to have lower turnover intention. The negative relationship between motivation and intention to leave became stronger with the level of motivation increasing: highly controlled cluster (OR: 0.47; 95% CI: 0.35–0.63), highly autonomous (OR: 0.27; 95% CI: 0.18–0.41) and highly motivated (OR: 0.20; 95% CI: 0.15–0.27).ConclusionThe Chinese version of WMSHW showed satisfactory reliability and validity and can be used as an instrument for measuring and rating the work motivation of Chinese health workers. The primary health workers were grouped into four motivation levels based on this scale. Both controlled and autonomous motivation could work in reduce the turnover intention, and the influence of autonomous motivation on retaining was stronger.

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

ObjectivesRural 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.SettingThis study was conducted in three towns in Huairou District, Beijing, China.DesignWe 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.ResultsWe 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.ConclusionsDespite 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.

Skin diseases of frontline health workers in China: from perspectives of occupational protection against COVID-19

Skin diseases of frontline health workers in China: from perspectives of occupational protection against COVID-19

Evaluation of the correlation between effort-reward imbalance and sleep quality among community health workers

BackgroundA chronic state of imbalance between effort and reward can affect sleep quality. However, few studies have explored the relationship between variables in the work-related stress (the effort-reward imbalance model, ERI model) and sleep quality in community health workers in mainland China. We investigated the relationship between ERI and sleep quality in community health workers.MethodsThis cross-sectional study was conducted from September to November 2018 and involved 249 registered doctors and 223 registered nurses. The Pittsburgh Sleep Quality Index (PSQI) was used to evaluate the sleep problems status of the participants. The ERI questionnaire was administered to evaluate job-related stress. Multivariate logistic regression was performed to evaluate the factors related to sleep quality.ResultsThe ERI ratio of the 472 health workers was 1.17 ± 0.22, and 273 health workers (57.84%) had PSQI scores > 7.There were statistically significant differences in the effort scores, overcommitment scores and ERI ratio between the health workers with and without sleep problems. The ERI ratio was an independent risk factor for sleep quality; sleep quality, race, type of work, shift work,job title, and personal monthly income were related to the ERI ratio among community health workers.ConclusionsWe found that sleep problems were prevalent, work effort was greater than reward and a positive correlation between effort-reward and sleep quality among community health workers in China. Managers should focus on the factors that influence sleep problems among community health workers, balance the efforts and rewards of work, and reduce the incidence of sleep problems.

Occupational Health Protection for Health Workers in China With Lessons Learned From the UK: Qualitative Interview and Policy Analysis.

BackgroundHealthcare settings have been recognized among the most hazardous places to work. Based on the five categories of occupational hazards that were identified by the ILO and WHO, this study aimed to analyze policy framework relevant to occupational health protection of health workers (HWs) in public health service in China, then discussed how to share the experience of the National Health Service (NHS) England for improvement.MethodsBased on policy learning theories, policy analysis and qualitative interview were used in this study.ResultsIn the Chinese public health service, at least five laws related to the regulation of occupational health protection for HWs; however, enforcement of relevant laws was separated and multi-centered; the national monitoring system, which targeted to occupational hazards and health outcome for HWs in China, had yet to be developed; the top three priorities were workplace violence, bloodborne pathogens, and musculoskeletal disorders; national strategies included Security Hospital, and Healthy China 2030. In NHS England, three laws were fundamental; several monitoring systems had been set up, including NHS Staff Survey, Commissioning for Quality and Innovation incentive scheme; mental health, musculoskeletal problem, and nutrition disorder and overweight were raised great concern; Health and Safety, and NHS Healthy Workforce Program were critical nationwide strategies.ConclusionThere were several similarities as well as differences between the Chinese public health system and NHS England, which laid foundation of learning by China. Recommendations of improving occupational health policies in China were provided, based on the lessons learned from the NHS England.

Working conditions and health status of 6,317 front line public health workers across five provinces in China during the COVID-19 epidemic: a cross-sectional study

ABSTRACTBackgroundPublic health workers at the Chinese Centre for Disease Control and Prevention (China CDC) and primary health care institutes (PHIs) were among the main workers who implemented prevention, control, and containment measures. However, their efforts and health status have not been well documented. We aimed to investigate the working conditions and health status of front line public health workers in China during the COVID-19 epidemic.MethodsBetween 18 February and 1 March 2020, we conducted an online cross-sectional survey of 2,313 CDC workers and 4,004 PHI workers in five provinces across China experiencing different scales of COVID-19 epidemic. We surveyed all participants about their work conditions, roles, burdens, perceptions, mental health, and self-rated health using a self-constructed questionnaire and standardised measurements (i.e., Patient Health Questionnaire and General Anxiety Disorder scale). To examine the independent associations between working conditions and health outcomes, we used multivariate regression models controlling for potential confounders.ResultsThe prevalence of depression, anxiety, and poor self-rated health was 21.3, 19.0, and 9.8%, respectively, among public health workers (27.1, 20.6, and 15.0% among CDC workers and 17.5, 17.9, and 6.8% among PHI workers). The majority (71.6%) made immense efforts in both field and non-field work. Nearly 20.0% have worked all night for more than 3 days, and 45.3% had worked throughout the Chinese New Year holiday. Three risk factors and two protective factors were found to be independently associated with all three health outcomes in our final multivariate models: working all night for >3 days (multivariate odds ratio [ORm]=1.67~1.75, p<0.001), concerns about infection at work (ORm=1.46~1.89, p<0.001), perceived troubles at work (ORm=1.10~1.28, p<0.001), initiating COVID-19 prevention work after January 23 (ORm=0.78~0.82, p=0.002~0.008), and ability to persist for > 1 month at the current work intensity (ORm=0.44~0.55, p<0.001).ConclusionsChinese public health workers made immense efforts and personal sacrifices to control the COVID-19 epidemic and faced the risk of mental health problems. Efforts are needed to improve the working conditions and health status of public health workers and thus maintain their morale and effectiveness during the fight against COVID-19.

Turnover intention among primary health workers in China: a systematic review and meta-analysis

ObjectivesTo analyse the prevalence and determinants of turnover intention (TI) among primary health workers (PHWs) in China to provide evidence for improving retention measures.DesignSystemic review and meta-analysis.Data sourcesFour English-language databases...

Seasonal Influenza Vaccination and Recommendation: The Difference between General Practitioners and Public Health Workers in China.

Seasonal influenza vaccination for healthcare workers (HCWs) is critical to the protection of HCWs and their patients. This study examined whether the separation of public health workers and general practitioners could affect the influenza vaccine uptake and recommendation behaviors among HCWs in China. A survey was conducted from August to October 2019, and HCWs from 10 provinces in China were recruited. A self-administered and anonymous questionnaire was used to assess HCWs’ demographic information, knowledge, and attitudes toward influenza vaccination, as well as vaccine uptake and recommendation behaviors. The primary outcome was HCWs’ vaccination and recommendation status of seasonal influenza vaccine. Multivariate logistic regression models were used to identify the influence factors of influenza vaccine uptake and recommendation among HCWs. Of the 1159 HCWs in this study, 25.3% were vaccinated against influenza in the previous season. “No need to get vaccinated” was the primary reason for both unvaccinated public health workers and general practitioners. Multivariate logistic regression showed that public health workers were more likely to get vaccinated against influenza (OR = 2.20, 95% CI 1.59–3.05) and recommend influenza vaccination to children (OR = 2.10, 95% CI 1.57–2.80) and the elderly (OR = 1.69, 95% CI 1.26–2.25) than general practitioners. Besides, the knowledge and perceived risk of influenza can give rise to HCWs’ vaccination and recommendation behaviors, and HCWs who got vaccinated in the past year were more likely to recommend it to children and the elderly in their work. The influenza vaccine coverage and recommendation among HCWs are still relatively low in China, especially for general practitioners. Further efforts are needed to improve the knowledge and attitudes toward influenza and influenza vaccination among HCWs, and coherent training on immunization for both public health workers and general practitioners might be effective in the face of separated public health and clinical services in China.

Job burnout and correlated factors of three-tiered public health workers: A cross-sectional study in China.

This study aimed to reveal burnout levels and its potential influencing factors among three-tiered public health workers in China. A total of 1,328 public health workers from cities, counties and townships in Henan and Hubei provinces participated. Cumulative logistic regressions were used to determine job burnout predictors. Township workers (β=0.276, p=.046) showed higher levels of emotional exhaustion (EE) than city workers. Municipal workers showed higher levels of depersonalisation (DP) (β=-0.439, p=.004) and lack of personal accomplishment (LPA) (β=-0.343, p=.005) than township workers. Compared with those who had better results, township workers with average levels of interpersonal relationships (β=0.703, p=.014) exhibited higher EE degrees. Municipal (β=1.050, p<.001) and county (β=1.359, p<.001) workers with moderate training satisfaction had higher levels of burnout than those with a high degree of training satisfaction. Municipal (β=3.933, p<.001) and county (β=1.218, p=.018) workers earning 2,000 RMB and below every month were more likely to have higher burnout levels than those earning 4,001 RMB and above. Township respondents exhibited high EE levels, given the low-level education of their services' target audience. Similarly affected by interpersonal relationships, township workers require interpersonal and emotional intervention programmes. City respondents showed a high level of DP and LPA, which was attributed to considerable differences between public health workers and medical workers in cities. Hence, apart from narrowing the reward gap between clinicians and public health workers, improving public health workers' social cognition and status by various channels was found necessary. The burnout of municipal and county respondents were influenced by income and training. Improving the role of income as incentive and reforming trainings programmes would be necessary.

Psychological impact of 2019 novel coronavirus (2019-nCoV) outbreak in health workers in China.

The first case of 2019-nCoV pneumonia infection occurred in Wuhan, Hubei Province, South China Seafood Market in December 2019. As a group with a high probability of infection, health workers are faced with a certain degree of psychological challenges in the process of facing the epidemic. This study attempts to evaluate the impact of 2019-nCoV outbreak on the psychological state of Chinese health workers and to explore the influencing factors. During the period from 31 January 2020 to 4 February 2020, the 'Questionnaire Star' electronic questionnaire system was used to collect data. The 2019-nCoV impact questionnaire and The Impact of Event Scale (IES) were used to check the psychological status of health workers in China. A total of 442 valid data were collected in this study. Seventy-four (16.7%) male and 368 (83.3%) female individuals participated in this study. The average score of high arousal dimension was 5.15 (s.d. = 4.71), and the median score was 4.0 (IQR 2.0, 7.0). The average score of IES was 15.26 (s.d. = 11.23), and the median score was 13.5 (IQR 7.0, 21.0). Multiple regression analysis showed that there were critical statistical differences in high arousal scores among different gender groups (male 3.0 vs. female 5.0, P = 0.075). Whether being quarantined had significant statistical differences of IES scores (being quarantined 16.0 vs. not being quarantined 13.0, P = 0.021). The overall impact of the 2019-nCoV outbreak on health workers is at a mild level. Chinese health workers have good psychological coping ability in the face of public health emergencies.

Tribute to health workers in China: A group of respectable population during the outbreak of the COVID-19.

The health authorities reported that 3,019 Chinese health workers were infected with the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), of whom, ten died. This article explored relevant reasons and offered suggestions to reduce the risk of infection and provide emergency psychological response for this population.

Frequent attacks on health workers in China: social changes or historical origins?

Frequent attacks on health workers in China: social changes or historical origins?

Turnover intention of primary health workers in China: a systematic review

BackgroundPrimary health workers have great meaning for the whole health-care system. However, China faces a serious shortage of primary health workers in rural areas and urban communities because of their high turnover rates. We aimed to analyse the prevalence and determinants of turnover intention (the intent to change or leave current employment) in a systemic review and meta-analysis, to provide evidence for improving retention measures. MethodsIn this systemic review and meta-analysis, we searched five English language databases (PubMed, EMBASE, Cochrane Library, PsycINFO, and ASC) and three Chinese databases (CNKI, CSPD, and CBM) for studies published between Jan 1, 2000, and May 1, 2018. We used a combination of the terms “(Turnover Intention, Departure Intention, Demission Intention, or Leave Intention), (Primary, Community, Rural, Countryside, or Grass roots), (Health worker, Health Manpower, Health Personnel, Doctor, or Nurse), and (China, or Chinese)” to conduct the search. Eligible studies were observational or descriptive studies done in mainland China, with human participants. Number or percentage related to turnover intention of health workers and related exposures (potential risk factors) had to be explicitly reported in each included study. If it was not feasible to make a quantitative synthesis and conduct a meta-analysis with the data, we used a narrative approach and descriptive statistics by grouping studies that reported the same exposures, to compare their associations with turnover intention of health workers. We did all statistical analyses using Stata (version 13.0) and RevMan (version 5.3). FindingsWe identified 21 articles investigating a total of 21 466 workers in Chinese primary health institutions. The prevalence of turnover intention ranged from 11·80% to 78·40%. On the basis of our meta-analysis, age (younger vs older odds ratio [OR] 2·04, 95% CI 1·62–2·60), location (rural vs city 2·33, 1·85–2·68), position (junior job title vs senior job title 1·73, 1·45–2·16), salary (low salary vs high salary 2·37, 1·98–2·83), and working time (more than 8 h per day vs less than 8 h per day 2·20, 1·98–2·43) were significantly associated with turnover intention. Other risk factors including sex, attitude towards future career, education of children, and degree of education were identified using the narrative approach. InterpretationThe prevalence of turnover intention was relatively high among primary health workers in China. The determinants of turnover intention can be contained by the job embeddedness model, including two layers (on-the-job, [determinants directly related to the job] and off-the-job [determinants related to the family and community]) and three dimensions (links, fits, and sacrifices). More measures should be taken towards retaining primary health workers. FundingThe National Social Science Fund of China (grant number 17ZDA079).

Malaria training for community health workers in the setting of elimination: a qualitative study from China

BackgroundContinuous training of health workers is a key intervention to maintain their good performance and keep their vigilance during malaria elimination programmes. However, countries progressing toward malaria elimination have a largely decreased malaria disease burden, less frequent exposure of health workers to malaria patients, and new challenges in the epidemiology of the remaining malaria cases. Moreover, competing health priorities and usually a decline in resources and in political commitment also pose challenges to the elimination programme. As a consequence, the acceptability, sustainability, and impact of malaria training and education programmes face challenges. However, little is known of the perceptions and expectations of malaria training and education programmes of health workers being engaged in countries with malaria elimination programmes.MethodsThis qualitative study provides information on perceptions and expectations of health workers of malaria training programmes from China, which aims to malaria elimination by the year 2020. This study was embedded into a larger study on the challenges and lessons learned during the malaria surveillance strategy in China, involving 42 interviews with malaria experts, health staff, laboratory practitioners, and village doctors at the provincial, city, county, township, and village levels from Gansu province (northwestern China) and Jiangsu province (southeastern China).ResultsIn the context of an increasing number of imported malaria cases in China, the majority of respondents emphasized the necessity and importance of such programmes and complained about a decreasing frequency of training courses. Moreover, they called for innovative strategies to improve the implementation and sustainability of the malaria training programmes until the elimination goal has been achieved. Perceptions and expectations of health workers from different health centres were quite different. Health workers from higher-level facilities were more concerned about technical training aspects, while health workers from periphery of the health system expected to receive more training on field work coordination and on specific public health actions with regard to case detection and focus investigation.ConclusionsThere is need to guarantee an ongoing good training of health workers in China on malaria aspects until the year 2020 and probably beyond.

Effect of an incentive-led intervention to address the shortage of village health workers in China: a community-based, non-randomised controlled trial

BackgroundProblems with recruitment and retention of village doctors have led to shortages in many parts of rural China. The situation has been deteriorating since 2009, when health reforms led to an increase in patient flow to township facilities, reducing village clinic attendance and doctors' income. We aimed to assess an intervention to reverse the decline in village doctor numbers in Jiangshan County, Zhejiang province. MethodsThis community-based prospective, non-randomised controlled trial was done across Jiangshan County, Zhejiang province, between January, 2012, and December, 2014. Our intervention group consisted of village clinics in Jiangshan County who voluntarily agreed to join the intervention group during the course of the study, with the remainder serving as controls. Clinics joined the intervention in a stepwise fashion: 17 in February, 2012, 17 in December, 2012, five in June, 2013, 47 in October, 2013, ten in January 2014, and eight in November, 2014. 104 village clinics (including five newly built clinics) had joined the intervention by the end of 2014. The remaining 83 village clinics served as controls. The intervention consisted of four components: (1) shift of the village clinic from private to collective ownership; (2) payments by local government to village doctors of ¥800 RMB per month, plus ¥4 RMB per patient visit; (3) introduction of a ¥5 RMB consultation fee, covered by health insurance; and (4) introduction of the zero-profit essential drug list (as in township hospitals) to discourage overprescribing and encourage patient attendance. Clinic records and doctors' views regarding job satisfaction and trust by patients, assessed by face-to-face interview, were compared at baseline and 36 months after initiation of the intervention. We obtained ethics approval from Zhejiang University, and participants gave oral informed consent. FindingsOur sample consisted of 104 village doctors working at 104 clinics who received the intervention and 83 doctors at 83 clinics who did not (controls). In the 64 intervention clinics for which we had data for January to December, 2014 (the final year of assessment), patient visits increased from an annual mean of 2494 (SD 1214) per clinic in the year preceding baseline to 4316 (1223) in the final year of assessment (mean difference vs 40 controls, 2163; p<0·0001). Doctors' mean income increased from ¥44 900 RMB (SD ¥13 700) at baseline to ¥63 500 RMB (¥16 000) in the final year of assessment and the mean cost per visit fell from ¥50 RMB (SD 14) to ¥32 RMB (7). In the 64 intervention clinics analysed, the proportion of patients who were prescribed antibiotics or intravenous injections out of all attending patients, per patient visit, reduced from 69% to 44% (difference vs 40 controls 30·2%; p<0·0001), and 71% to 49% (difference vs controls 16·5%; p<0·0001), respectively. Between baseline and 36 months, 28 clinics opened in villages previously without a doctor. Of 64 doctors randomly selected for interview in intervention village clinics, 53 [83%] were very satisfied with the intervention, 49 (77%) were very satisfied with their income, 47 (73%) thought patient care had improved, and 55 (86%) thought that the doctor–patient relationship had improved. All the control clinics in Jiangshan have since joined the intervention. InterpretationIn areas of rural China where local government can provide the necessary resources, the model we describe can address the shortfalls in health services at the village level. FundingZhejiang University Zijin Talent Programme.