Chinese General Practice

Antibody Responses to SARS-CoV-2 in Naturally Infected Population Worldwide　

LI Jincheng，LIU Min，LIU Jue

2021, 24(10): 1173-1178. DOI: 10.12114/j.issn.1007-9572.2021.00.177

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COVID-19 has spread to more than 220 countries and regions in the world，becoming a global pandemic. Serological testing of specific antibodies against SARS-CoV-2 can estimate the status of infection in the population，and help retrospectively assess the scale or degree of infection in the study population. This article reviews the SARS-CoV-2-specific antibody responses in naturally infected general population worldwide，and special populations such as medical workers，children，and pregnant women，aiming to provide important information for better understanding of SARS-CoV-2-specific serological features and patterns in populations in times of COVID-19，and for enhanced perception and containment of COVID-19. It has been found that the seroprevalence of SARS-CoV-2 antibodies reported globally for natural infections varies in different countries or regions，ranging from less than 0.1% to more than 20%，which may be associated with the differences in serological testing methods，and stages of COVID-19 pandemic during which the testing is performed. The seropositivity rate of children is lower than that of other age groups. But the seropositivity rate of medical workers or pregnant women is similar to that of the general population. To estimate the burden caused by COVID-19 and offer scientific evidence for the containment of the disease，it is essential to continuously carry out seroprevalence surveillance for SARS-CoV-2.

Construction and Operation of COVID-19 Isolation Sites in Primary Healthcare Institutions：a Case Study of Wuhan　

ZHENG Yanling，YIN Delu，ZHOU Hejun，CHEN Tianmu

2021, 24(10): 1179-1182. DOI: 10.12114/j.issn.1007-9572.2021.00.171

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In Wuhan，various types of COVID-19 isolation sites played an important role in the implementation of different types of actions using a tiered approach to effectively contain the pandemic，during the period in which there was a social panic caused by the COVID-19 outbreak，and a run on and overdrawing of medical resources，and the first batch of mobile cabin hospitals and designated hospitals for COVID-19 patients were under construction. These isolation sites delivered essential healthcare services，especially Chinese medicine therapies，to patients suffering from COVID-19（and underlying diseases） as first-contact health services，greatly alleviating the patients' fear of failing to access to treatment，effectively stopping the spread of household and community COVID-19 transmissions，and alleviating the level of COVID-19 panic in the community. Wuhan's experience suggests that under limited conditions，efforts should be taken to divide the isolation site into three relatively separate zones: clean，buffer and contaminated. And classified management is recommended for isolated patients suffering from tuberculosis，AIDS and other infectious diseases.

Reflections and Recommendations on Setting up Fever Sentinel Surveillance Clinic in Primary Healthcare Institutions　

REN Yi, LIU Yanli, MA Li

2021, 24(10): 1183-1189. DOI: 10.12114/j.issn.1007-9572.2021.00.104

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In the system of public health emergency preparedness network，primary care plays an important role as the "bottom of the net". Establishing fever sentinel surveillance clinics in primary healthcare institutions is conducive to the realization of early detection，diagnosis，and isolation and timely reporting of public health emergencies，thus controlling the spread of an epidemic.Currently，China is stepping up efforts to construct fever sentinel surveillance clinics and fever clinics in primary healthcare institutions，but the construction standards and functions of such clinics are still preliminary exploration. According to the requirements of relevant regulations，the minimum standards of fever sentinel clinics in primary healthcare institutions should include three aspects: construction layout，hardware and software allocations. To make the fever sentinel surveillance clinic better perform its primary role in coping with public health emergencies，in view of the common problems in setting up a fever sentinel surveillance clinic in primary care，we put forward the following recommendations：strengthening the establishment of community health emergency system，extensively carrying out trainings about publish health emergencies for primary care professionals and work supervision，building a convenient and efficient information network，and standardizing the establishment of a fever sentinel surveillance clinic and managing its operation continuously.

Standards for Setting up a Fever Sentinel Surveillance Clinic in Primary Healthcare Institutions：Findings of a Qualitative Delphi Study　

YAN Yunyun, FAN Tengyang, WANG Haitang, ZHANG Jianmin, DU Zhaohui, SUN Xiaoming

2021, 24(10): 1190-1197. DOI: 10.12114/j.issn.1007-9572.2021.00.170

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Background　Many countries have carried out sentinel surveillance programs to monitor infectious diseases. As containing COVID-19 has become normalized，the Department of Primary Health of the National Health Commission of the People's Republic of China recommends primary healthcare institutions to set up a fever sentinel surveillance clinic. Objective　To develop a set of nationwide used standards for the establishment of a fever sentinel surveillance clinic in primary healthcare institutions with regional differences in healthcare level and medical resources taken into account，to surveil and contain possible regional epidemiology of COVID-19 and other infectious diseases in autumn and winter in China. Methods　We designed and carried out a two-round Delphi survey. The first round of survey was conducted with primary care experts selected from Shanghai's various institutions by purposive sampling to discuss setting up a fever sentinel surveillance clinic in primary care in Shanghai. And the second round of survey was implemented with a purposive sample of primary care experts from various healthcare institutions in different regions of China to improve the results of the first survey based on relevant national and regional government policy documents and the reviewing of relevant studies to draw up Draft Guiding Principles for Setting up a Fever Sentinel Surveillance Clinic in Primary Healthcare Institutions. Results　The developed standards include six domains：principles of setting up a fever sentinel surveillance clinic，functions of a fever sentinel surveillance clinic（items：daily functions and anti-epidemic functions），architectural and equipment specifications of a fever sentinel surveillance clinic（items：room，equipment and logo），staffing profile of a fever sentinel surveillance clinic（items：appropriate allocation of physicians，nurses，administrative workers，and handymen），working procedure of a fever sentinel surveillance clinic（fever pre-screening and triage，reception，management and health education and propaganda），profile of services delivered by a fever sentinel surveillance clinic（items：reception，preventive care，management，training，disinfection，supervision and support）. Conclusion　The construction of a fever sentinel surveillance clinic in primary healthcare institutions is a reflection of the capacity of such institutions. The functions of this clinic shall contain fever pre-screening and triage，reception and screening of fever patients，timely reporting suspected patients and proving supports for transferring the patients，and effective prevention of nosocomial infection. The detailed architectural and equipment specifications as well as staffing for the clinic can be settled according to the conditions of the institutions.

Criteria for the Establishment of a Simulation Center for GPs in the Community Health Center　

LI Yaling，WANG Haitang，SHAN Meiqing，DU Zhaohui

2021, 24(10): 1198-1204. DOI: 10.12114/j.issn.1007-9572.2020.00.417

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Background　Simulation center for GPs，an important platform for fostering and evaluating GPs，has been developed rapidly in the context of the requirement of improving GPs' clinical abilities. So it is urgent to establish a set of criteria for the building of simulation centers for GPs，to provide a reference for the functional configuration of such centers.Objective　To establish a set of scientific，practical and reasonable criteria for the building of a simulation center for GPs in the community health center. Methods　Literature review and practical experience were used to develop a draft content framework of criteria for the building of a simulation center for GPs in the community health center，which was used to formulate a questionnaire after being determined according to group discussion results. From May 28，2019 to July 10，2019，the questionnaire was revised in accordance with two rounds of consultations with 25 invited experts using the Delphi technique after the positive and authoritative coefficients of the experts and Kendall's W of their judgments were assessed as eligible. Based on the above，the final content of the criteria was determined. Results　The average years of working in their own field for the 25 experts were （14.42±6.90） years. The positive coefficients of the experts in the first and second rounds of consultations were 96.2% and 100.0%，respectively. For the hardware，software，and staffing configuration，the authoritative coefficients of the experts in the first round of consultation were 0.83，0.83，0.85，respectively，and were 0.90，0.89，0.89，respectively，in the second round of consultation. The Kendall's W values of the necessity were 0.133，0.498，respectively（P<0.001），and the availability were 0.280，0.390，respectively（P<0.001）. Finally，we established a set of criteria for the establishment of a simulation center for GPs in the community health center，including 3 first-level indicators（hardware，software，and staffing），13 second-level indicators，and 17 third-level indicators. Conclusion　The positive and authoritative coefficients of the experts were relatively high，and Kendall's W of their judgments was good in the consultations，indicating that our criteria are reliable，which can be applied and promoted.

Study on Satisfaction and Influencing Factors of Medication Service for Rural Elderly Chronic Patients Under Contracted Family Doctor Service　

WU Yi，HAN Xiangru，QIAN Dongfu，LIN Zhenping，HE Xiaojing，WANG Yiting，LIU Rugang

2021, 24(10): 1205-1210. DOI: 10.12114/j.issn.1007-9572.2020.00.411

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Background　To satisfy the healthcare needs of increased aging population and chronic disease population to improve the national health，it is essential to take actions to make full use of contracted family doctor services，and to improve the use of amount and quality of primary medication services，especially rational use of primary care in rural elderly chronic residents. Objective　To investigate the utilization of and satisfaction with medication services provided by the contracted family doctor in rural elderly chronic disease patients from Jiangsu Province. Methods　In July 2019，1 816 elderly patients with chronic diseases were selected by typical sampling and multi-stage stratified sampling in Jiangsu Province. The self-made questionnaire was used to investigate the utilization and satisfaction of elderly patients with chronic diseases in rural areas. Binary Logistic regression analysis was used to identify the associated factors of the satisfaction with medication services. Results　1 583 cases who effectively completed the questionnaire were finally enrolled. The prevalence of purchasing drugs from the village clinic or community health station，and from the township or community health center was 73.72%（1 167/1 583） and 11.62%（184/1 583），respectively. 1 449（91.53%） used the medication regimen developed by medical workers working at a village clinic or community health station and township health center or community health service center. 1 546（97.66%） took medicine according to the doctor's orders. 621（39.23%） had self purchase behavior. 1 402（88.57%） were satisfied with medication services provided by the family doctor. The satisfaction with medication services differed by household income，number of chronic diseases，place for drug purchase，source of medication regimen，and purchasing drugs by oneself（P<0.05）. Purchasing place was associated with the difference in the cost of drugs（P<0.05）. Purchasing place was associated with the difference in the cost of self-purchased drugs（P<0.05）. Binary Logistic regression showed that the degree of understandability of family doctor's explanation，condition control by the family doctor and the acceptability of cost of drugs prescribed by the family doctor were associated with the satisfaction with medication services（P<0.05）. Conclusion　The utilization of and satisfaction with the medication services provided by the contracted family doctor among rural elderly chronic patients were generally good. However，one-fourth of them purchased medications by themselves，which may suggest that medication services by the contracted family doctor could not fully meet their medication needs. Furthermore，their satisfaction with drug costs needs to be improved，which may be influenced mainly by the quality of medication services. To improve these contracted patients' use and satisfaction regarding primary medication services，we put forward the following recommendations：continuing to publicize favorable policies of medication services by the contracted family doctor，reducing the drug price to relieve contracted patients' disease burden，vigorously improving the professional level of family doctors，enriching the quantity and categories of available drugs，taking actions to provide medication convenience，and increasing long-term prescription services for chronic diseases.

Healthcare Human Resources in Community Health Centers in Beijing，2012—2018　

WANG Mei，GUO Moning，TAN Peng，LI Ang

2021, 24(10): 1211-1217. DOI: 10.12114/j.issn.1007-9572.2021.00.029

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Background　Healthcare human resources in community health centers（CHCs） play an essential role in promoting the development of primary health services and take a key role in the development of hierarchical medical system. Objective　To investigate the size and allocation of healthcare human resources in CHCs in Beijing from 2012 to 2018. Methods　Data were collected from the 2012—2018 annual reports and questionnaires regarding the essential information of healthcare human resources of Beijing's CHCs. The size，allocation，education levels and professional titles of healthcare human resources were studied. Results　In 2018，each CHC had 98 healthcare professionals，with 84.3% as the rate of occupied budgeted posts，and 6.4% as the annual turnover rate on average. From 2012 to 2018，the number of healthcare professionals in CHCs showed an increase trend generally. Specifically，the number of practising（assistant） TCM physicians had the highest annual growth rate（6.0%），while that of public health workers had the lowest（only 0.1%）. The proportion of general practitioners in the total number of practising physicians decreased by 6.7 percentage points. The average numbers of community healthcare professionals，practising（assistant） physicians，registered nurses，and practising（assistant） TCM physicians per 1 000 people increased from 1.05，0.52，0.33，0.10 in 2012 to 1.30，0.63，0.44，0.13 in 2018，respectively. The average number of general practitioners per 10 000 people increased from 2.75 in 2012 to 2.95 in 2018. The average number of public health workers per 1 000 people decreased from 0.06 in 2012 to 0.05 in 2018. The ratio of doctors to nurses improved from 1∶0.64 in 2012 to 1∶0.72 in 2018. The proportion of healthcare professionals with bachelor degree or above was 30.7%，which increased by 7.3 percentage points compared with that of 2012. The proportion of healthcare professionals with a senior professional title was 5.7%，which increased by 1.4 percentage points in comparison with that of 2012. Conclusion　During this period，Beijing's CHCs had a gradual increase in the size of healthcare human resources with improved education level，a yearly improvement in the vacancy of budgeted posts，and a yearly growth in the number of healthcare workers without a budgeted post，indicating that the allocation of healthcare workers has been improved. However，according to requirements of national governmental planning，there is a great shortage of registered general practitioners and nurses. Moreover，the proportion of healthcare workers with a senior professional title need to be increased. Based on the above analysis，it is suggested to innovate the construction of the personnel management system，improve the talent incentive mechanism，explore new modes for training general practitioners and strengthen the construction of nursing workforce.

Family Doctor Team Members' Perceptions of Contracted Services and Related Factors Based on Supplier Perspective 　

WANG Yiyuan，SUN Yanchun，WANG Wei，XU Fang，DENG Ziru，YAN Fei

2021, 24(10): 1218-1223. DOI: 10.12114/j.issn.1007-9572.2021.00.123

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Background　With the promotion of contracted services，the role of family doctor team members has been transforming from "gatekeeper" to "health manager" and finally to "health agent"，as they are the main provider of "all-round and whole health services". Their job perception plays a key role in ensuring the quality and smooth development of contracted services. Objective　To understand family doctor team members' the perceptions of contracted services，so as to provide a basis for further improving the quality and supportive policies of such services. Methods　By use of purposive and stratified sampling，a total of 1 042 family doctor team members were selected from Guizhou，Qinghai，Anhui，Guangdong，Fujian and Jiangsu provinces to attend a questionnaire survey regarding subjective evaluation of contracted services（service profile，delivery patterns，serving attitude，personal income and workload） from April to October 2019. Descriptive statistical method was used to analyze the job perception of the family doctor team members. Chi square test was used to analyze the differences of job perception among family doctor team members with different regions，positions，professional titles. Spearman's test was used to analyze the correlation between personal income and workload. Results　According to the respondents，compared to traditional non-contracted health services，the profile of contracted services increased〔85.93%（873/1 016）〕，the delivery patterns of contracted services were different〔86.86%（879/1 012）〕，and home-based delivery was an increased delivery pattern〔71.44%（628/879）〕，per consultation time for contracted services increased 〔32.99%（290/879）〕，follow-up service was thought to be an increased kind of services〔93.97%（826/879）〕，attitude in delivering contracted services was better〔40.77%（413/1 013）〕，personal income was reported to be increased after delivering contracted services〔58.61%（599/1 022）〕，the workload increased after delivering contracted services 〔81.94%（835/1 019）〕. 91.09%（930/1 021） of the respondents indicated that they were willing to provide contracted services for the elderly in the serving areas of their hospital，and 94.62%（967/1 022） believed that their team members cooperated well and orderly in delivering services，and 94.72%（968/1 022） thought that team-based delivery pattern could serve patients better. Spearman rank correlation test showed a correlation between workload and personal income（rs=0.121，P<0.01）. The perceptions of profile and delivery pattern of contracted services，and changes in personal income and workload after delivering contracted services differed significantly among the respondents by region（P<0.05）. The perceptions of profile and delivery pattern of contracted services，and changes in personal serving attitude and income after delivering contracted services differed significantly among the respondents by position（P<0.05）. The perceptions of changes in personal income and workload after delivering contracted services differed significantly among the respondents by professional title（P<0.05）. Conclusion　On the whole，in the opinion of these family team members，contracted services are more comprehensive and have more personalized delivery patterns compared with traditional non-contracted medical services，the management of family team in delivery services is good，and the value of such services is high. Moreover，almost all of these members are willing to provide contracted services for the elderly in the serving areas of their hospital. However，personal income is thought to be increased with workload，and this kind of thought varies by region，position and professional title.

Prevalence of Signing a Contract to Attend a Family Doctor Team and Associated Factors of Renewing the Contract upon the Termination Date among Medical Workers　

YI Fuliang，BAI Yunhui，CHEN Ailing，HU Lan5

2021, 24(10): 1224-1230. DOI: 10.12114/j.issn.1007-9572.2021.00.016

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Background　The implementation of family doctor services is a major task for promoting the allocation of high-quality medical resources to primary care since the healthcare reform initiated in 2009 in China. Sichuan and Chongqing are located in the southwest of China. Family doctor service is related to the livelihood of the local people. In the new era of basic medical and health services and other services，it is of great significance to understand the situation of family doctor service supply side contract signing. Objective　To investigate the prevalence of signing a contract to attend a family doctor team and intention and associated factors of renewing the contract upon the termination date among medical workers in Sichuan and Chongqing，providing a reference for promoting supply-side structural reform of family doctor services，and improving relevant performance allocation and assessment systems as well as supervision and inspection system in these regions. Methods　By using the method of multi-stage sampling，1 550 medical workers from 60 medical institutions in Sichuan and Chongqing were selected and received a questionnaire survey from March to August 2019. The content of the questionnaire includes basic information, cognition, attitude and willingness of the contracted family doctor team. Binary Logistic regression was used to analyze the associated factors of renewing the contract upon the termination date among medical workers. Results　1 402（97.91%） valid questionnaires were collected and 752（53.64%）medical workers were willing to renew their contracts. The intention of renewing the contract upon the termination date among medical workers differed by the age，the level of hospitals and the annual income（P<0.05）. The intention of renewing the contract upon the termination date varied by medical workers' perceptions and attitudes regarding policies and scope items related to family doctor services，and the necessity of implementing the services，improvement degree of systems associated with family doctor service programs，prospect of family doctor service programs，and the duration of the contract（P<0.05）. Logistic regression analysis showed that age，the level of mastering policies related to family doctor services，understanding of the necessity of implementing the services，and attitudes toward the prospect of such services were associated with renewing the contract upon the termination date（P<0.05）. Conclusion　The willingness to renew the contract on the supply side of family doctor service in Sichuan and Chongqing is not very high. The medical staff who are older，have a clear understanding of the family doctor service policy，think it is necessary to implement the family doctor service project，and are more optimistic about the prospect of the family doctor service project are more willing to renew the contract.

Primary Care Workers' Opinions on the Feasibility of the Manual on Contracted Family Doctor Services for Persons with Disabilities：a Qualitative Study　

CAI Shu，DU Xueping，LIU Yuchun，DING Jing，DING Lan

2021, 24(10): 1231-1235. DOI: 10.12114/j.issn.1007-9572.2020.00.536

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Background　In 2018，the Rehabilitation Department of the China Disabled Persons' Federation and Department of Primary Health，the National Health Commission of the People's Republic of China complied the Manual on Contracted Family Doctor Services for Persons with Disabilities（hereinafter referred to as the Manual），and promoted its nationwide use，so as to effectively improve the serving ability of family doctor teams in domestic primary care for persons with disabilities. Objective　To investigate the feasibility and practicability of the Manual in primary practice，to provide a reference for its further improvement. Methods　A qualitative study was implemented in October 2019 using a phenomenology approach. Semi-structured interviews were conducted among 9 doctors and 6 nurses with an experience of delivering contracted family doctor services for persons with disabilities from Yuetan Community Health Center，Fuxing Hospital，Capital Medical University. The interviews were recorded，transcribed and coded，with themes were summarized，and verified by the interviewees. Results　 All the 15 interviewees expressed that they could provide the services by a family doctor team required in the Manual，such as managing common diseases and frequently occurring diseases，essential public health services，priority outpatient referral services，and referral services. And the Manual offered guidance for them in practice. But 9 of them said that home services were not sustainable. 13 said that part of the extended services in the Manual needed to be enriched to meet actual needs. Conclusion　The Manual is feasible，and it can provide guidance for contracted family doctor services for persons with disabilities. As members in the family doctor team need a large amount of knowledge related to the rehabilitation of disabled people，so corresponding contents need to be added. And the Manual needs to be improved according to the actual local situation.

Family Doctor Team Members and Disability Patients' Perspectives on the Effectiveness of Contracted Services：a Qualitative Study　

LIU Yuchun，CAI Shu，DU Xueping，ZHANG Zhijuan，DING Jing，DING Lan

2021, 24(10): 1236-1241. DOI: 10.12114/j.issn.1007-9572.2021.00.165

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Background　People with disability are a priority group covered by contracted family doctor services.It is necessary to study what family doctor team members should do（including targeted services） to satisfy the needs of people with disability，improve their sense of gain and satisfaction，achieving a win-win situation for both of them. Objective　To identify problems in the delivery of contracted family doctor services for people with disability via a survey and put forward improvement recommendations，to provide useful information for the management of family doctor team and the delivery of such services for this group. Methods　This survey was conducted in Yuetan Community Health Center，Fuxing Hospital，Capital Medical University，Beijing's Xicheng District，from October 2018 to September 2019. Six focus groups were set up，of which three were composed of 25 members of the family doctor service team for the disabled，and the other three were composed of 21 persons with five different types of disabled who signed the contract. Taking four kinds of barriers（physical，attitude，professional and systemic barriers） as the theoretical framework，the in-depth interviews were carried out with Guidebook for Family Physicians Providing Contracted Services for People with Disabilities（hereinafter referred to as the Guidebook）. Field notes，recording and transcription were used to encode and refine the theme. Results　All the interviewees approved the content and practicability of the Guidebook，reported self-perceived requirements for current contracted services for those with disabilities and proposed improvement recommendations. Three themes were identified after analyzing the interviews with family doctor team members：longer time needed for consultation，including physical examination，communication and identification of the disease；providing trainings related to care for people with disabilities for physicians and nurses，including special care for this group；retraining medical workers with the services for people with disabilities that are not included in the scope of primary care. Four themes were identified after analyzing the interviews with adults with disabilities and guardians of children with disabilities：physical，service attitude，professional and system barriers in the interaction process with the healthcare system. Conclusion　The Guidebook with comprehensive and reasonable contents has good practicability，providing primary healthcare workers with a useful method for the delivery of services for people with disabilities，and instructive solutions to common problems occurring in the delivery of services for special groups.

Cardiovascular Disease Risk Changes in 2 926 Type 2 Diabetics with Community-based Multifactorial Interventions：a 9-year Study　

ZHANG Xuelian，YUAN Shenyuan，WAN Gang，YUAN Mingxia，YANG Guangran，FU Hanjing，ZHU Liangxiang，BCDS Group

2021, 24(10): 1242-1248. DOI: 10.12114/j.issn.1007-9572.2021.00.102

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Background　Type 2 diabetes（T2DM） patients have elevated risk of cardiovascular disease（CVD） and death，but CVD events in them with different levels of CVD risk are rarely reported. Objective　To observe the changes of CVD risk in T2DM patients receiving long-term mutifactorial interventions living in urban communities of Beijing. Methods　A total of 2 926 T2DM patients from 15 communities of Beijing were enrolled in 2008，including 824 without complications，1 267 with hypertension，and 835 with CVD with different levels of 10-year CVD risk〔low，medium and high（<10%，10%-20%，>20%）〕 stratified by using the improved Framingham Risk Score（I-FRS）. All patients received a follow-up with standardized management as of December 2017 to assess the changes in cardiovascular risk during this period，including clinical characteristics，I-FRS and endpoint events. Cox regression model was used to analyze the influencing factors of endpoint events. Results　Among patients with medium 10-year CVD risk，those with CVD had greater mean age，longer mean duration of T2DM and higher mean baseline blood pressure than those with only diabetes or with hypertension（P<0.01）. Those with only diabetes showed much higher mean baseline levels of fasting blood glucose（FPG），glycosylated hemoglobin（HbA1c），total cholesterol（TC），low-density lipoprotein cholesterol（LDL-C） compared with those complicated with CVD or hypertension（P<0.01）. Among patients with high 10-year CVD risk，those with CVD had greater mean age than those with only diabetes or with hypertension（P<0.01）. Those with only diabetes showed much lower mean baseline systolic blood pressure，and much higher mean baseline FPG，HbA1c，TC and LDL-C than those with CVD or hypertension （P<0.01）. Among patients with medium 10-year CVD risk，the levels of blood pressure，TC and LDL-C in CVD group and HTN group were significant decrease when compared with baseline. Meantime，in DM group，the levels of diastolic blood pressure，FPG，HbA1c，TC and LDL-C were much lower than baseline. Compared with baseline in patients with high 10-year CVD risk，CVD group and HTN group had much lower levels in blood pressure，FPG，TG and LDL-C；while in DM group，the levels of HbA1c and TC significant decreased at the end of follow-up. In those with medium and high 10-year CVD risk，the I-FRS at the end of follow-up changed significantly compared with the baseline levels，regardless of having CVD or hypertension or not（P<0.05）. Those with CVD or hypertension showed significant elevated cumulative incidence of all-cause death and CVD events compared with those without complications（P<0.017）. In Cox regression analyses，after adjusting for age and sex，increased risk of endpoint events was found in those with hypertension（HR=1.542） and in those with CVD（HR=1.923）. Conclusion　The outcome of community-living T2DM patients with CVD was poor，so it is important to deliver multifactorial interventions to them to reduce CVD risk factors. Attentions should be paid to those with high I-FRS，regardless of having complications or not，to conduct individualized assessment for them to reduce CVD risk factors.

Paths for Family Social Capital Affecting Health Status Mediated by Health Literacy　

GUO Keqiang，LI Yuyang，YU Xiyang，MENG Jiayu，YAN Congcong

2021, 24(10): 1249-1253. DOI: 10.12114/j.issn.1007-9572.2021.00.126

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Background　In contrast to western people who often access to health resources in the mature community，Chinese people are more prone to acquiring health resources via family connections. So studying the mechanism of action of family social capital affecting health mediated by health literacy has a meaning for establishing a family-centered health education pattern. Objective　To explore the impact of family social capital on health status mediated by health literacy by analyzing the survey data from Hangzhou residents，providing a reference for policy-making regarding community health education and promotion. Methods　900 Hangzhou residents were selected by multi-stage stratified random sampling method and investigated by self-designed questionnaire. The questionnaire includes four parts：family social capital, health literacy，health status and general demographic characteristics. The Cronbach's α was used to evaluate the reliability of the family social capital subscale，and factor analysis was used to evaluate its validity. Structural equation modeling was used to model the paths of health literacy mediating the impact of family social capital on self-rated health and to quantify the effect size. Results　In total，848（94.2%） of the 900 residents returned responsive questionnaires. The Cronbach's α for the family social capital subscale was tested to be as high as 0.826，and the factor loading of each item in the corresponding domain in the rotation factor loading diagram was greater than 0.5. The results of the structural equation model show that all fitting indicators were within an acceptable range，illustrating that the model fitted well. Among the five domains of health literacy subscale，healthy lifestyle was influenced most directly by family social capital（0.63）. Among the paths for family social capital affecting health status mediated by health literacy，the effect size of the indirect effect of healthcare utilization was the largest（0.14），followed by healthy lifestyle（0.12），while that of health concepts was the smallest（0.07）. Conclusion　The effect size of family social capital affecting health status mediated by health literacy may be varied by paths（direct and indirect），which is suggested to be considered accordingly when formulating health policies and social intervention programs for family health education.

Depressive Symptoms Prevalence and Influencing Factors among Urban and Rural Elderly Patients with Chronic Diseases　

CHANG Yunqi，ZHENG Xiao，LI Mimi，XUE Yaqing，HOU Lihong，ZHENG Jianzhong，ZHANG Chichen

2021, 24(10): 1254-1259. DOI: 10.12114/j.issn.1007-9572.2021.00.129

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Background　Depression is a common mental health problem among the elderly，which is even more prevalent in the elderly with chronic diseases. Currently，studies about depression prevalence in elderly people mostly focus on those living in the urban community，but seldom concern about those living in rural areas or comparatively analyze urban and rural differences in this population. Objective　To explore the differences of depressive symptoms prevalence and influencing factors between urban and rural elderly people with chronic diseases，to provide a reference for improving the mental health of elderly people with chronic conditions. Methods　A multi-stage random cluster sampling was used to enroll 2 504 urban and rural elderly patients with chronic diseases from Taiyuan，Shanxi Province，China in October 2018. They were surveyed with a questionnaire including general demographic information，behavioral factors，number of chronic diseases and depressive symptoms（screened using the 15-item Geriatric Depression Scale）. Binary Logistic regression model was used to analyze the influencing factors of depressive symptoms. Results　Urban and rural elderly patients with chronic diseases accounted for 55.39%（1 387/2 504） and 44.61%（1 117/2 504） of the total cases，respectively. The sex ratio，distributions of age，education level，marital status，major source of income，relationships with offspring，relationship with spouse，physical activity level，and number of chronic diseases，and smoking prevalence showed statistically significant differences between urban and rural respondents（P<0.05）. Depressive symptoms prevalence was 37.02%（927/2 504）in all the respondents. Rural respondents showed a higher prevalence than their counterparts〔45.66%（510/1 117） vs 30.06%（417/1 387）〕. The results of binary Logistic regression analysis showed that the relationship with offspring，the relationship with spouse and the level of physical activity were associated with depressive symptoms in both urban and rural respondents（P<0.05）. In addition，age and the number of chronic diseases were also associated with depressive symptoms in urban respondents（P<0.05），smoking prevalence，drinking prevalence and major source of income were also associated with depressive symptoms in rural respondents（P<0.05）. Conclusion　The factors associated with depressive symptoms in urban and rural elderly people with chronic diseases were partially different. So urban-rural differences should be considered when delivering preventive interventions or improving treatment interventions for such people.

Establishment of the Norms of Sub-Health Measurement Scale Version 1.0 for Harbin Urban Residents　

FENG Yefang，ZHANG Zhong，WU Weixuan，XUE Yunlian，XU Jun

2021, 24(10): 1260-1265. DOI: 10.12114/j.issn.1007-9572.2020.00.535

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Background　The sub-health of urban residents has become a major problem facing China nowadays.Although proper management evaluations and personalized prevention can help reduce the incidence of sub-health，there is lack of effective methods for diagnosing sub-health status because sub-health has no obvious clinical symptoms causing difficulty to reach a consensus in actual diagnosis and different evaluation standards. Objective　To make exploratory establishment of the norms of Sub-Health Measurement Scale Version 1.0（SHMS V1.0）for Harbin urban residents. Methods　From April to August of 2018，stratified random sampling method was used to select 1 600 urban residents from four districts in Harbin to accept SHMS V1.0
questionnaire test，including Nangang District，Daoli District，Dao wai District and Xiangfang District. The mean norm，percentile norm and demarcation norm were established according to different gender and age groups. Results　A total of 1 538（96.13%） questionnaires of Harbin urban residents were received effectively. The mean norms of SHMS V1.0 total scores were（65.79±11.74） while the physical，mental and social scores（GS） in Harbin urban residents were（68.55±12.83），（66.16±14.30），（60.99±15.44）；The mean and percentile norms of total，physical，mental and social sub-health of Chinese urban residents were established according to gender and different age groups（14-24，25-39，40-49，50-59 and ≥60 years）；The threshold norms of SHMS V1.0 was divided as 5 health states，namely disease，severe sub-health，moderate sub health，mild sub-health and healthy states according to the（±s） and （±0.5s） of the converted scores.According to the demarcation norm，the detection rate of sub-health of urban residents in Harbin is 65.73%（1 011/1 538）. Conclusion　This study has initially constructed the SHMS V1.0 norm for urban residents in Harbin，which is convenient for health screening and provides scientific theoretical basis for the study of sub-health status and influencing factors of the population.

Capacity for General Practitioner Training of General Practice Department in Tertiary General Hospitals：a Study Based on the Disease Profile Analysis of General Medical Inpatients　

ZHOU Hairong，YAN Fengjuan，ZHOU Lei，DUAN Xueyan，ZHANG Shaopeng

2021, 24(10): 1266-1270. DOI: 10.12114/j.issn.1007-9572.2021.00.172

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Background　General practice has obtained some developments in China since its introduction in the 1980s，with priority initiatives taken by the government. Most general hospitals have set up a general practice department，but the roles of the department，including its role in training general practitioners（GPs） are still under exploration. Objective　To explore the roles of general medical ward in a tertiary general hospital，including its role in training GPs，by analyzing the disease profile in general medical inpatients. Methods　Retrospective analysis of the general conditions，discharge diagnosis and resettlement of 1 728 patients admitted to the General Medical Ward，Longhua District Central Hospital，Shenzhen，from September 2017 to December 2019，through Shenzhen Longhua District Central Hospital Information Center. Results　Among the totaled 261 types of diseases suffered by the included inpatients， respiratory system diseases were the most reason for visits〔379 cases（21.93%）〕，followed by circulatory system diseases〔272 cases（15.74%）〕，endocrine system diseases〔242 cases（14.00%）〕，digestive system diseases〔182 cases（10.53%）〕，nervous system diseases〔152 cases（8.80%）〕. The top 10 in terms of number of visits were pneumonia，type 2 diabetes，hypertension，cerebral infarction，cardiac neurology，bronchitis，hyperthyroidism，acute gastroenteritis，rotified gastritis，and arrhythmia，with a total of 803 cases（46.47%） . The top 3 diagnoses during September to December 2017 were hypertension〔30 cases（15.79%）〕，pneumonia〔24 cases（12.63%）〕，and type 2 diabetes〔22 cases（11.58%）〕. They remained the top 3 in 2018〔83 cases of pneumonia（10.30%），71 cases of hypertension（8.81%） and 70 cases of type 2 diabetes（8.68%）〕，and in 2019〔113 cases of pneumonia（15.44%），82 cases of type 2 diabetes（11.20%） and 64 cases of hypertension（8.74%）〕. 93 patients（5.38%） were diagnosed with one disease at hospital discharge，and other 1 635（94.62%） with 2 or more chronic diseases. After general treatment，627 cases（36.28%） who were improved or cured were transferred to community hospitals for community-based rehabilitation. Conclusion　The disease profile of patients treated in general medical ward of the tertiary general hospital covers common diseases of various systems，and frequently-occurring diseases，and the types of diseases are similar to those suffered by patients treated in community care. This analysis indicates that the establishment of general practice department in general hospitals helps GPs to master the diagnosis and treatment of common diseases and frequently-occurring diseases as well as the management of chronic diseases and effectively develop ideas of general practice，and contributes to the cultivation of qualified GPs performing general care in the community.

Near Point of Convergence and Associated Factors in a Community Population　

LIU Bing，QI Zhanjiao，QIU Yuezhi，WANG Weilai，LUO Yanzhi

2021, 24(10): 1271-1273. DOI: 10.12114/j.issn.1007-9572.2021.00.164

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Background　 Patients with receded near point of convergence are often found with heterophoria clinically. Studies about near point of convergence mostly focus on its distribution and its association with age，sex and refractive error，but rarely on its association with heterophoria. Objective　To investigate the near point of convergence and influencing factors in community-dwelling people with corrected-to-normal vision，providing a basis for screening for convergence insufficiency in the community. Methods　In January 2020，197 individuals living in Chunfeng Community，Shenzhen's Luohu District were screened for near point of convergence，far and near heterophoria，refraction and axial length by convenience sampling method. Linear regression was used to estimate the association of near point of convergence with age，refraction，axial length and far and near heterophoria. Bivariate correlation analysis was used to estimate the association of near point of convergence with age and far and near heterophoria. Results　Finally，112 eligible cases with complete data were enrolled，with age，near point of convergence，axial length，degrees of far and near heterophoria，refractive degrees of right and left eyes on average were（36.9±19.9）years，（5.18±4.60） cm，（23.27±1.10）cm，（-0.34±1.78）PD，（-4.79±5.28）PD，（-1.20±2.18）D，and（-1.01±1.98）D, respectively. Multiple linear regression analysis showed age and near heterophoria were associated with near point of convergence（P<0.05）. Near point of convergence was positively correlated with age（r=0.36，P<0.01），and negatively correlated with the degree of near heterophoria（r=-0.20，P=0.03）. Conclusion　Near point of convergence was associated with near heterphoria and age. This study indicates that it is feasible to carry out the screening for near point of convergence in the community.

Consideration of Sample Size in Qualitative Interviews Based on Information Power　

CHU Hongling，ZHOU Yunxian，NI Kaiwen，LI Fengwei，ZHAO Yiming

2021, 24(10): 1274-1276. DOI: 10.12114/j.issn.1007-9572.2020.00.415

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The use of qualitative methods in general practice research has important practical significance，which can better reflect the features of patient-centered care and promote the development of primary health care services. Qualitative research in general practice has reached a relatively mature stage in foreign countries，but it is still in a preliminary stage in China，and many practical problems will be encountered when conducting relevant studies，among them，a common problem is about sample size. However，there is no a standard answer to it. In general，the depth and breadth in one study are interdependent. As qualitative research focuses on a deeper and more detailed understanding of the research phenomenon，it is generally believed that the richness of data in qualitative research is far more important than the number of samples，and the sample size needs not to be too large. However，the sample size and its related reference dimensions still need to be considered when writing a qualitative research proposal. This article introduces the estimation of the sample size of qualitative interviews based on information power，to provide a reference for qualitative researchers.

Application of Qualitative Research Methods in General Practice Research in China　

PAN Zihan，PANG Hui，CHI Chunhua，WU Yangfeng，ZHENG Jiaqiang

2021, 24(10): 1277-1283. DOI: 10.12114/j.issn.1007-9572.2020.00.419

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Background　Qualitative research methods have been widely used in medical research，and mastering their use is helpful for general practitioners（GPs） to carry out medical research. Objective　To review qualitative research methods used in general practice research in China，and analyze the problems and put forward improvement suggestions，to help GPs to better use such methods. Methods　From July 2019 to February 2020，we searched studies in Chinese included in CNKI，WANFANG DATA and VIP databases during 2009 to 2019 using "定性研究" "质性研究" "质的研究" "访谈" "全科医学" "全科医生" "家庭医生" "基层及社区" as subject words and keywords. Excel was used to store the extracted data，and information such as publication time，journal title，title of studies and research methods was analyzed using descriptive statistical analysis. Results　100 studies in general practice using qualitative research methods were included，covering 5（5.0%） masters' dissertations and 95（95.0%） journal articles，most of which〔52.0%（52/100）〕 were about general practice education and training，with interview as the most frequently used method for collecting qualitative data〔53.0%（53/100）〕，and 56.0%（56/100） had no clear sampling method. 2014 saw the largest percentage of publications〔18.0%（18/100）〕. The journal articles were published in 38 journals，with the largest proportion of 29.2%（28/95） in Chinese Journal of General Practice. Relevant problems in the studies were summarized as follows: There was no a unified Chinese translation for qualitative research method. There was no "定性研究" in the title or the list of key words of the studies. Only a few studies aimed to solve clinical problems. The application process of qualitative methodology needed to be more scientifically valid. Conclusion　In China，qualitative methodology is increasingly used in general practice research，mostly in studies regarding general practice education and training. Interview is the most commonly used method. However，there are also some problems during the application. The application needs to be more standardized.

Physicians and Nurses' Perspective of Barriers and Solutions to the Delivery of Home-based Pulmonary Rehabilitation for Patients with Chronic Obstructive Pulmonary Disease：a Qualitative Study　

FANG Hui，SHI Yan，LIU Xianliang，GUAN Jiabei

2021, 24(10): 1284-11288. DOI: 10.12114/j.issn.1007-9572.2021.00.034

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Background　The latest epidemiological survey shows that there are about 100 million patients with chronic obstructive pulmonary disease（COPD） in China，about 1 million people die of respiratory diseases each year，and more than 5 million people become disabled due to respiratory diseases. The effectiveness of home-based pulmonary rehabilitation is as good as hospital and community pulmonary rehabilitation in improving the quality of life and lung function of COPD patients. However，there are few studies showing the barriers to the delivery of home-based pulmonary rehabilitation from the perspective of physicians and nurses. Objective　To investigate the barriers to the delivery of home-based pulmonary rehabilitation based on a survey of physicians and nurses blocking the quality of life and lung function of COPD. Methods　From July to November 2019，in-depth semi-structural interviews regarding the barriers to the delivery of home-based pulmonary rehabilitation based on a self-developed framework were carried out in a purposive sample of 14 medical workers from respiratory and rehabilitation departments of a grade A tertiary hospital in Shanghai. Content analysis was performed to sort out and analyze the recorded interview results. Results　Three themes with nine sub-themes（each including three sub-themes） were extracted：patients' negative health，cognitive，and psychological conditions（prevalence of multiple comorbidities and low motivation of receiving home-based pulmonary rehabilitation；insufficient knowledge of home-based pulmonary rehabilitation；distrust of the efficacy of home-based pulmonary rehabilitation and low exercise compliance）. Physicians and nurses' insufficient knowledge and trainings and attentions regarding home-based pulmonary rehabilitation（insufficient related knowledge and feeling incompetent to carry out home-based pulmonary rehabilitation；insufficient related standard trainings；insufficient attentions paid to home-based pulmonary rehabilitation by hospitals and related departments ）. Limited capacities at the organizational level for the delivery of home-based pulmonary rehabilitation（inadequate communication and cooperation among the hospital，community and family and imperfect follow-up monitoring system；insufficient medical professionals for delivering such services；lack of systematic rehabilitation training mode and simple and practical evaluation indicators）. Conclusion　There are many barriers to the delivery of home-based pulmonary rehabilitation. To address these barriers to make sure COPD patients can really benefit from home-based pulmonary rehabilitation，strengthened professional trainings for physicians and nurses to improve their knowledge，more attentions paid to the guidance on home-based pulmonary rehabilitation are needed，with the joint help of social supports as well.

Development of a Comprehensive Assessment System for Chronic Obstructive Pulmonary Disease Based on ICF　

WANG Lan，ZHENG Jinping，SHEN Yuehao，YU Xi

2021, 24(10): 1289-1293. DOI: 10.12114/j.issn.1007-9572.2021.00.093

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Background　The health management of chronic obstructive pulmonary disease（COPD） requires comprehensive and individualized treatment based on the whole person assessment，so as to improve the patients' physiological and psychological status and long-term compliance to healthy behaviors. Objective　To establish a comprehensive assessment system for COPD based on the International Classification of Functioning，Disability and Health （ICF），to offer a reference for the development of integrated intervention options involving physiology，psychology，functioning and social participation for such patients. Methods　From April to August，2019，we constructed a questionnaire based on the comprehensive ICF core set for COPD，and used it to carry out a two-round email-based survey with experts（in fields of clinical diagnosis and treatment，clinical nursing，nursing management，nursing education，pulmonary rehabilitation and psychological therapy related to COPD） using the Delphi technique，then in accordance with the survey results，we improved it and developed the final version. Results　The response rate and Cr were 100.0%（21/21） and 0.836，respectively，for the first round of survey，and were 95.2%（20/21） and 0.845，respectively，for the second round of survey. The Kendall's coefficient of concordance were 0.209 and 0.271 for indices and subindices. The average importance value of indices ranged from 3.55-4.90. The variation coefficients of indices ranged from 0.061-0.297，and full mark rate was 15%-90%. The Comprehensive ICF-COPD Assessment System consists of 4 indices，including physical and mental functions，body structure，activities and participation，and environmental factors，and 53 subindices. Conclusion　The development of Comprehensive ICF-COPD Assessment System is scientific and rational，which could ensure the comprehensiveness of the assessment content before the formulation of rehabilitation intervention plan.

Exercise Capacity and Prognosis Evaluation Methods for Patients with Chronic Obstructive Pulmonary Disease in the Community　

LI Haiyan, YANG Ting, YAO Fanxiu, LIU Hong

2021, 24(10): 1294-1297. DOI: 10.12114/j.issn.1007-9572.2021.00.031

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Background　Elderly patients are more easily to be found with chronic obstructive pulmonary disease （COPD），as well as its associated sarcopenia and decreased exercise capacity. Exercise capacity has an association with the prognosis，but there is little research on the evaluation methods of the two. Objective　To explore simple and accurate methods that can assess the exercise capacity and prognosis of patients with COPD in the community. Methods　A total of 100 patients with stable COPD were recruited from China-Japan Friendship Hospital from January 2018 to December 2019. The relationships of six-minute walking distance（6MWD） with Short Physical Performance Battery（SPPB） score and modified British Medical Research Council（mMRC） classification were analyzed. Results　The result of 6MWD increased with the decrease of mMRC score for classifying COPD （rs=-0.431，P=0.002）. The AUC of mMRC classification for predicting 6MWD was 0.749 （P<0.001），and the maximum Youden index was 0.426 when 6MWD was 483.5 meters，which was determined as the cut-off threshold. The SPPB was positively correlated with the intragroup data（P<0.001），and its correlation with 5-repetition sit-to-stand（5STS）was the strongest（rs=0.751）. Therefore，6MWD was correlated with 5STS（rs=0.291，P=0.038）. Conclusion　Both mMRC classification and 5STS test could be used as simple methods with relatively high accuracy for the assessment of exercise capacity and prognosis of patients with COPD in primary care，and they are partially correlated. When the 6MWD is less than 483.5 meters，dyspnea restricts movement greatly，and pulmonary rehabilitation can be carried out timely.

Smart Supply Chain Strategy for Promoting Physical Fitness of Elderly People　

QIU Heng，XU Jun，HUANG Chen，LIAO Shengwu，WU Weixuan，JIANG Lijie，LIU Qian

2021, 24(10): 1298-1301. DOI: 10.12114/j.issn.1007-9572.2020.00.531

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Accelerated population aging has brought severe challenges to socioeconomic development in China. Health-related physical fitness of the elderly is closely related to the quality of life and health status. How to integrate regional resources to meet the health needs of the elderly has become an urgent social issue to be solved. To promote the health-related physical fitness of the elderly，we developed a kind of smart supply chain strategy program in an explorative way using the supply chain theory，internet-based healthcare technologies and three-level prevention thought，namely，a whole life healthcare promotion program，which is implemented consecutively according to comprehensive assessment status of health-related physical fitness of the elderly，by integrating the regional resources of government，medical institutions and social organizations using smart service systems.

Evaluation Methods of Frailty in the Community-dwelling Elderly　

DONG Bingru, GU Jie

2021, 24(10): 1302-1308. DOI: 10.12114/j.issn.1007-9572.2021.00.012

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Frailty is a common clinical syndrome in the elderly. General practitioners，the gatekeepers for people's health，play an important role in the identification of frailty in the elderly. A large number of evaluation methods of frailty have been developed in foreign countries，but the research in this field is still in the early stage in China. To provide help for domestic general practitioners to evaluate frailty in elderly people and conduct related studies，we reviewed the evaluation methods of frailty with a concise description of their contents，strengths and limitations，as well as the application of their Chinese versions in evaluating frailty in community-dwelling Chinese older adults，and summarized the key points as follows：these methods may be classified into frailty screening methods and comprehensive evaluation methods. The Fried Frailty Phenotype，Tilburg Frailty Indicator，Groningen Frailty Indicator，the Frail Scale，Comprehensive Frailty Assessment Instrument，walking speed，grip strength and Timed Up-and-Go test are suggested to be used as screening methods of frailty in community outpatients，and Edmonton Frailty Scale and Frailty Index can be used for comprehensive evaluation. The applicability and effectiveness of the evaluation methods in different populations need to be verified in further research.

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