Table of Content

05 March 2022, Volume 25 Issue 07

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Survey & Investigation Report

The Availability of Essential Medicines and Diagnostic Devices for Chronic Obstructive Pulmonary Disease in Primary Care

PENG Bo, ZHANG Xiaojuan, JIANG Xiaotong, ZHENG Jianli, LI Yazi

2022, 25(07):  771-781.  DOI: 10.12114/j.issn.1007-9572.2022.00.001

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China has seen a significantly increased prevalence of chronic obstructive pulmonary disease (COPD) recently. But primary care institutions, the main "battlefield" for containing COPD, have shown relatively weak capabilities for the diagnosis and treatment of disease. As there are relatively few large-scale investigations and studies on medicines and diagnostic devices for COPD in primary care, we conducted this study to further understand the weaknesses of current COPD containment in primary care, by which the gap in related research may be made up.

To understand the allocation and availability rate of essential medicines for COPD, and availability rate of spirometer as well as the implementation of pulmonary function tests in primary care.

From February to March 2021, a multi-stage cluster sampling was adopted to select 8 176 community (township) health centers from 31 provinces of China to attend a survey. The rates of availability and allocation of each of the 16 essential medicines for COPD in the 2018 National Essential Medicines List were calculated to estimate the categories and number of these medicines in primary care institutions. The rate of availability of spirometer in these institutions was estimated. And the rate of implementation of pulmonary function tests in these institutions was estimated.

Altogether, 7 458 (91.22%) institutions who gave effective responses to the survey were included for analysis, including 5 901 (79.12%) township health centers, and 1 557 (20.88%) community health centers. Among the 16 essential medicines for COPD, less than 8 were available in 6 538 (87.66%) institutions, at least 1 inhaled antiasthmatic medicines were available in 4 992 (66.00%) institutions, and long-acting inhaled antiasthmatic medicines were available in 814 (10.91%) institutions. The average availability rate of 16 essential medicines for COPD was 33.30%. The highest ranked three medicines in terms of availability rate were ambroxol〔85.28% (6 360/7 458) 〕, aminophylline〔81.17% (6 054/7 458) 〕 and compound licorice〔74.48% (5 555/7 458) 〕. And the relatively low-ranked three were fluticasone propionate 〔4.89% (365/7 458) 〕, tiotropium bromide〔6.25% (466/7 458) 〕, budesonide forterol〔8.61% (642/7 458) 〕. The average availability rate of 6 inhaled antiasthmatic medicines in community health centers was 28.31%, and that in township health centers was 4.81%. The average availability rate of 2 long-acting inhaled antiasthmatic medicines in community health centers was 16.18%, and that in township health centers was 5.12%. The average availability rate of spirometers in primary care institutions was 8.94% (667/7 458) . The average availability rate of spirometers in community health centers was higher than that of township health centers〔18.56% (289/1 557) vs 6.41% (378/5 901) , P<0.05〕. Pulmonary function tests were implemented in 10.82% (807/7 458) of the institutions. The rate of community health centers was higher than that of township health centers in terms of offering pulmonary function testing services〔13.81% (215/1 557) vs 10.03% (592/5 901) , P<0.05〕.

The available essential medicines for COPD in these primary care institutions were insufficient with unbalanced distribution. Most of available medicines were oral preparations, and inhaled antiasthmatic medicines, especially long-acting inhaled antiasthmatic medicines, were poorly available. Moreover, the availability rate of spirometers and the implementation rate of pulmonary function tests were both relatively low. All these factors negatively influence early screening for and management of COPD in primary care. In view of this, it is recommended that increasing the availability levels of inhaled antiasthmatic medicines and portable spirometers, and the application of pulmonary function tests in primary care, as well as primary care physicians asompetencies and initiatives for the prevention, diagnosis, treatment and rehabilitation of COPD with the delivery of the national essential publish health services for COPD as the starting point of enhancement trainings.

Contracted Family Doctor Services

Barriers and Improving Paths to the Implementation of Contracted Family Doctor Services in China：an Analysis Using Smith's Policy Implementation Process Model

LIU Ruiming, CHEN Qin, XIAO Junhui, ZENG Libin, WANG Na

2022, 25(07):  782-790.  DOI: 10.12114/j.issn.1007-9572.2021.00.324

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The contracted family doctor services (CFDSs) is a key action selected to be implemented to deepen the reform of the pharmaceutical and healthcare system, enrich primary care services, and achieve the strategic goals of health China. Moreover, the implementation of CFDSs is a main approach to better safeguarding people's health. To effectively promote the development of CFDSs, China has successively launched various relevant supportive policies, and the local governments have been actively exploring practicing approaches. So far, remarkable results have been achieved nationwide, yet there are still many challenges, among which implementation difficulty is a major factor influencing further promotion of CFDSs. We analyzed the implementation process of CFDSs using Smith's policy implementation process model, and identified many barriers to the implementation of CFDSs, such as lack of rule of law, low level of policy executors, insufficient incentives, and impact of policy environment. In view of this, we put forward the following recommendations on exploring innovative policies for sustainable development of CFDSs: designing top-level policy objectives for CFDSs development from perspectives of law and system, improving qualities and professional identity of providers of CFDSs, establishing mutual trust between doctors and patients, and optimizing the policy implementation environment.

Recent Advances in Assessment Tools for Family Doctor Teams

MA Wenhan, SHI Dazhen, ZHAO Yali

2022, 25(07):  791-796.  DOI: 10.12114/j.issn.1007-9572.2021.00.192

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With the advancement and development of the family doctor system, family doctor teams have become a main provider of primary health services, which has raised new requirements for the evaluation of their services. We comprehensively reviewed recent developments in evaluation tools for family doctor teams: examples from the UK, the US, European countries, Australia and Canada have shown that traditional evaluation tools based on the structure-process-outcome model are being replaced by some models that focus more on the team's organizational environment, internal relationships, psychological state and continuous improvement. In China, the development of assessment tools for family doctor teams has been initiated recently, with major manifestations of various research approaches but lack of high-quality theoretical models, and high-quality reliability and validity tests. Moreover, the assessment tools are lack of diverse domains, and indicators for assessing team relationships, emotions and psychology as well as continuous improvement. On the basis of international experience, we recommend using the input-mediator-output-input model as a theoretical basis to develop highly applicable tools for assessing family doctor services in China.

Constructing Assessment Indicators Regarding Effectiveness of a Family Doctor Team Using the IMOI Framework：a Systematic Review

MA Wenhan, SHI Dazhen, ZHAO Yali

2022, 25(07):  797-802.  DOI: 10.12114/j.issn.1007-9572.2021.00.235

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Improving the effectiveness of a family doctor team, the main provider of primary healthcare, is an important means to enhance the effectiveness of community health services. The evaluation of team effectiveness has gained increasing attention.

To classify and summarize the assessment indicators and analyze the core dimensions of each indicator set regarding the effectiveness of a family doctor team using the input-mediator-output-input (IMOI) framework.

Studies about the development of indictors for assessing the effectiveness of a family doctor team were systematically retrieved from databases of PubMed, CNKI, Wanfang Data and VIP from January 2000 to October 2020. Indicator mapping was used to classify and compare the indictors according to the structure of IMOI framework.

Fourteen studies were included, 4 of which were published abroad, and 10 in China. The indicators were classified using the IMOI framework: organizational environment, team building, and team member quality were classified as input (I) , team emergent state and team process were classified as mediator (M) ; service achievement and personal feedback were classified as output (O) , but no indicators were classified as input (I') .

The qualities of theoretical models and research methods used for developing assessment indicators regarding the effectiveness of a family doctor team need to be improved. The assessment system developed based on the IMOI framework may be a good tool for evaluating team effectiveness, but the indicators need to be supplemented further.

Original Research·Population Health

Prevalence，Awareness，Treatment and Control Rates of Hypertension in Chinese Adults: Trend and Associated Factors from 1991 to 2015

YAO Xi, PEI Xiaoting, QU Zhe

2022, 25(07):  803-814.  DOI: 10.12114/j.issn.1007-9572.2022.00.004

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As a major common chronic noncommunicable in Chinese adults, hypertension is associated with increased risk of a variety of cardiovascular and cerebrovascular diseases such as coronary atherosclerosis and stroke. Hypertension has become a major public health issue in China due to increasing prevalence but low treatment and control rates.

To estimate the prevalence, awareness, treatment and control rates of hypertension in Chinese adults from 1991 to 2015.

Data were collected from nine waves of the China Health and Nutrition Survey conducted between 1991—2015, involving adults (≥18 years old) with complete information, including age, sex, blood pressure values, demographic characteristics, smoking, drinking status, height, weight, waist circumference, blood pressure value and disease history. The trends of hypertension prevalence, awareness, treatment and control rates and associated factors in adults during the period of 25 years were analyzed.

In 1991, the prevalence, awareness, treatment and control ratesof hypertension in adults were 14.77% (1 291/8 743) , 27.58% (356/1 291) , 15.80% (204/1 291) , and 5.89% (76/1 291) , respectively, while these four indicators in 2015 were 32.67% (4 520/13 834) , 48.08% (2 173/4 520) , 40.51% (1 831/4 520) , and 14.65% (662/4 520) , respectively. There was an increasing tread for prevalence of hypertension from 1991 to 2015. Increasing trends of awareness, treatment and control rates were found from 2000 to 2015. The prevalence, awareness, treatment and control rates of hypertension were alwaysaffected by age, gender, behavior habits, knowledge level and other factors.

The treatment and control rates of hypertension in Chinese adults are increasing, but still relatively lower in comparison to its increasing prevalence. So it is recommended for relevant government departments to take measures to enhance hypertension treatment and control rates in adults, so that the progression of hypertension would be delayed.

Spectrum of Mortality from Circulatory Diseases in China from 2004 to 2015

JIANG Shenyi, YU Xiaosong

2022, 25(07):  815-821.  DOI: 10.12114/j.issn.1007-9572.2022.00.005

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Two circulatory diseases, cardiovascular and cerebrovascular diseases have become the leading death causes in China, and their morbidity and mortality are still rising. Revealing the urban/rural-specific, gender-specific and region-specific differences in the order of circulatory diseases ranked by mortality and its changing trend will provide a scientific basis for the prevention and control of circulatory diseases.

To analyze the spectrum of mortality from circulatory diseases ranked by mortality, mainly cardiovascular and cerebrovascular diseases, in China from 2004 to 2015, by areas (urban/rural) , sex and region and its changing trend.

Information about deaths and mortality due to circulatory diseases stemmed from the data of circulatory disease from 2004 to 2015 defined by National Disease Surveillance System Cause-of-Death Surveillance Data Set. The urban/rural-specific, gender-specific and region-specific differences in the mortality from circulatory diseases and their changing trend were analyzed with χ² test by SPSS 13.0.

During 2004 to 2013, the six circulatory diseases leading to deaths ranked by mortality in a descending order were: cerebrovascular disease, ischemic heart disease, other circulatory diseases, hypertensive heart disease/kidney disease, rheumatic fever and rheumatic heart disease. And the order of these diseases from 2014—2015 was: cerebrovascular disease, ischemic heart disease, hypertensive heart disease/kidney disease, other circulatory diseases, rheumatic fever and rheumatic heart disease. From 2006 to 2015, the mortality of cerebrovascular and ischemic heart diseases increased year by year. From 2004 to 2015, the mortality of hypertensive heart disease/kidney disease increased slowly year by year. There was no significant change in the mortality of rheumatic fever and rheumatic heart disease but a double wave change in the mortality of other circulatory diseases with peaks in 2006 and 2013. The urban/rural-specific mortality: the difference was statistically significant for cerebrovascular disease each year, for rheumatic fever and rheumatic heart disease each year except in 2006 and 2015, for hypertensive heart disease/kidney disease each year except in 2005, for ischemic heart disease each year except in 2015, and for other diseases of the circulatory system each year except in 2004, 2005, 2011 and 2012 (P<0.05) . The gender-specific mortality: the difference was statistically significant for rheumatic fever and rheumatic heart disease, ischemic heart disease and cerebrovascular disease each year, for other diseases of the circulatory system each year except in 2005, and for hypertensive heart disease/kidney disease only in 2005 and 2015 (P<0.05) . The region-specific mortality: the difference was statistically significant for each disease in each year of the period (P<0.05) .

There were extremely significant urban/rural-specific, gender-specific and region-specific differences in the mortality of circulatory diseases. The incidence of ischemic heart disease was high in urban areas, while that of other circulatory diseases was high in rural areas. The incidence of rheumatic fever and rheumatic heart disease was high for females, while that of other circulatory diseases was high in males. The region-specific mortality difference was statistically significant for rheumatic fever and rheumatic heart disease, hypertensive heart disease/kidney disease, ischemic heart disease and cerebrovascular disease as well as other circulatory diseases. Therefore, prevention and treatment priorities for circulatory diseases should be determined and targeted interventions should be delivered according to region-specific differences.

Original Research·Practice Status of Primary Health Worker

Perceptions of Hierarchical Medical System and Associated Factors in Key Primary Care Practitioners

MA Cong, WANG Wei, YUAN Ying, SUN Yanchun, XU Fang, YAN Fei

2022, 25(07):  822-828.  DOI: 10.12114/j.issn.1007-9572.2022.00.008

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The establishment and improvement of hierarchical medical system will help optimize health resource allocation and develop a sound healthcare-seeking pattern. As the key practitioners of hierarchical medical system, primary care workers' perception of the system is vital to the implementation of the system, so studying their perception of the system and associated factors is of great significance.

To analyze primary care professionals' perceptions of hierarchical medical system and associated factors based on the results of 2018 Sixth China National Health Survey, providing a reference for further improvement of the system.

From April to October 2019, one representative urban district and one suburban county were chosen from each of six selected provinces in which hierarchical medical system has been implemented. Then by stratified random sampling, about six community health centers/township health centers were extracted from each district (county) (46 community health centers and 30 township health centers in total) , in which primary care professionals who were on duty on the day of survey were invited to attend a questionnaire survey for understanding their demographics, perceptions of the importance and effectiveness of, as well as barriers to the implementation of hierarchical medical system.

Altogether, 1 308 cases who effectively completed the survey were included for final analysis. According to the analysis, the benefits of implementing hierarchical medical system were: improving the health service system〔approved by 1 231 cases (94.11%) 〕, improving the healthcare services for patients and residents〔agreed by 1 219 cases (93.20%) 〕; improving the quality of medical services〔1 209 (92.43%) 〕; improving the efficiency of medical services〔1 189 (90.90%) 〕; improving doctor-patient relationship〔1 087 (83.10%) 〕; reducing the medical risk〔786 (60.09%) 〕; reducing medical expenses〔611 (46.71%) 〕. As for the outcome of implementing hierarchical medical system, its implementation would not hinder the development of health institutions〔982 (75.08%) 〕. When it comes to the barriers to the implementation of hierarchical medical system, there were no relevant incentives〔759 (58.03%) 〕, patients and their families' were unwilling to accept hierarchical medical system due to getting used to free healthcare-seeking pattern〔753 (57.57%) 〕, there were no unified bi-directional referral criteria and system〔712 (54.43%) 〕, the implementation of hierarchical medical system may lead to conflict of interests between medical institutions〔451 (34.48%) 〕, there was no an effective referral route〔403 (30.81%) 〕, their medical institutions had insufficient capacities to effectively implement hierarchical medical system〔387 (29.59%) 〕. Univariate analysis revealed that primary care professionals' perceptions of hierarchical medical system differed significantly by province, sex, educational background, professional title, type of their medical institution, and type of post (P<0.05) . Multiple linear regression analysis indicated that province, sex, educational background, professional title, and officially budgeted post were associated with primary care professionals' perceptions of hierarchical medical system (P<0.05) .

These primary care professionals had good perceptions of the importance and effectiveness of the implementation of hierarchical medical system, but also showed their concerns about the barriers to its implementation. Professional title and province were associated with their perceptions of the system. To promote the implementation of hierarchical medical system, it is suggested that the government departments increase investment, improve policy details, provide corresponding incentives, and carry out targeted publicity and education.

Burnout and Associated Factors among Family Doctor Team Members in Different Types of Primary Healthcare Institutions：a Comparative Study

JING Yurong, HAN Wantong, QIN Wenzhe, HU Fangfang, ZHANG Jiao, GAO Zhaorong, HONG Zhuang, KONG Fanlei, XU Lingzhong

2022, 25(07):  829-836.  DOI: 10.12114/j.issn.1007-9572.2022.00.002

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Burnout has become a prominent issue as the increase of workload in family doctor team members in primary healthcare institutions during the promotion of contracted family doctor services. There is still a lack of research comparing the differences in burnout among family doctor team members in different types of primary healthcare institutions.

To compare burnout prevalence and associated factors between family doctors in community/township health centers, and those in community health stations/village clinics, providing a basis for improving the mental health status and team stability of family doctors, as well as the quality of services provided by them.

From August 1 to 21, 2020, a multistage cluster random sampling method was used to select 760 family doctor team members〔201 (26.4%) working at community/township health centers, and 559 (73.6%) working at community health stations/village clinics〕 as the participants from primary healthcare institutions in 6 counties/county-level cities /districts of Taian City, Shandong Province. They were invited to attend a survey to complete Demographic Questionnaire and the Chinese version of Maslach Burnout Inventory-General Survey (MBI-GS) .

Overall, the prevalence of burnout among the participants was 68.9% (524/760) . Overall, the prevalence of burnout among the participants was 68.9% (524/760) , and the prevalence of burnoutof family doctor team members in community/township health centers and community health stations/village clinics was 63.7% (128/201) and 70.8% (396/559) , respectively. The levels of burnout of family doctor team members in community health stations/village clinics was higher than that of those in community/township health centers, with a statistically significant difference (P<0.05) . Family doctor team members in community health stations/village clinics had higher total score of MBI-GS and higher subscale score of reduction of professional efficacy than did those in community /township health centers, with a statistically significant difference (P<0.05) . Multivariate Logistic regression analysis showed that: for family doctor team members in community/township health centers, the risk of burnout of those aged 41-50 years is higher than that aged≤30 years〔OR (95%CI) =7.119 (1.770, 28.638) 〕, the risk of burnout of those with monthly income >4 000 yuan is lower than that with monthly income <2 000 yuan〔OR (95%CI) =0.194 (0.040, 0.941) 〕, the risk of burnout of those with high/very high self-rated work pressure is higher than that of those without/little self-rated work pressure〔OR (95%CI) =3.629 (1.475, 8.929) 〕, the risk of job burnout of those who evaluated the incentive mechanism as ordinary and relative effective/very effective was lower than that evaluated the incentive mechanism as very ineffective/less effective〔OR (95%CI) were 0.196 (0.052, 0.739) and 0.235 (0.066, 0.834) 〕. For the family doctor team members in community health stations/village clinics, the risk of burnout in women is lower than that in men〔OR (95%CI) =0.603 (0.396, 0.920) 〕, the risk of job burnout of those with general and relatively high/very high self-assessment residents' recognition is lower than that with very low/relatively low self-assessment residents' recognition〔OR (95%CI) were 0.258 (0.113, 0.590) and 0.428 (0.199, 0.918) 〕, the risk of burnout of those with high/very high self-rated job stress is higher than that without/little self-rated job stress〔OR (95%CI) =2.320 (1.368, 3.935) 〕.

Family doctor team members in community health stations/village clinics demonstrated higher burnout prevalence, and lower professional efficacy. To reduce the burnout prevalence and improve professional efficacy in family doctor team members, it is suggested to strengthen trainings, increase salary and further improve incentive mechanism for those in community/township health centers, and to increase the number of officially budgeted posts, and promotion opportunities as well as the propaganda of contracted family doctor services for those in community health stations/village clinics. Moreover, the workflow of contracting family doctor services should be simplified in all these institutions.

Development of an Incentive Model for General Practitioners in Fengxian District of Shanghai Based on Herzberg's Motivation-hygiene Theory

PAN Danying, GU Chunmei, CAO Weiyi, PENG Yan, TANG Yan, JIN Jiahui, WENG Zhixian, ZHANG Jie

2022, 25(07):  837-845.  DOI: 10.12114/j.issn.1007-9572.2021.00.343

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In view of the shortage of general practitioners (GPs) and limited community healthcare resources, it is urgently necessary for community health institutions to find accurate and scientific incentive methods to retain GPs and help them to realize their full potential, as well as promote the development of both community health institutions and GPs, thereby benefiting the health promotion of community residents.

To develop an incentive model for GPs to test the performance and effectiveness of current incentives for GPs, so as to put forward suggestions to improve the mechanisms of employing and retaining GPs.

In August 2019, we recruited 204 GPs from 11 community health centers (CHCs) in Shanghai's Fengxian District using stratified random sampling to attend an online survey using a questionnaire named General Practitioners' Perception and Evaluation of Incentive Measures developed based on our previous research results and Herzberg's motivation-hygiene theory. Then from August to September 2019, we invited directors responsible for medical care or public health issues, and medical quality control department heads from the above-mentioned 11 CHCs to attend an online survey using a questionnaire named Workload for General Practitioners in Community Health Centers of Fengxian District developed by usbased on a literature review. Then under the guidance of Herzberg's motivation-hygiene theory, we constructed a structural equation to develop an incentive model for GPs within Fengxian District with representative incentive policies, systems and initiatives related to GPs selected from the survey results as latent independent variables to measure GPs' (responders') perception and assessment of incentives, and with willingness to work, service radius, and workload of GPs as dependent variables.

The average scores for the implementation of incentive measures, and its associated influence on GPs' work status assessed by the 204 GPs were (0.77±0.14) , and (0.73±0.19) , respectively. The assessment score for implementation of incentive measures for GPs differed significantly by personal health condition and administrative position in the respondents (P<0.05) . The assessment score for the influence of implementing incentive measures on GPs' work status differed significantly by personal health condition in the respondents (P<0.05) . Spearman correlation analysis showed that GPs' work status was associated with the implementation of 25 incentive measures (one incentive measure at the subdistrict level was not included for analysis) (P<0.05) . The top three most highly correlated incentive measures were performance distribution (r_s=0.652) , performance-based salary calculation (r_s=0.621) , and wages and benefits (r_s=0.614) . Partial correlation analysis indicated that, after controlling for variables such as the regional policy environment, the street and town government, and the work unit, the assessment score for implementation of either regional, or subdistrict or institutional incentive measures for GPs, was positively correlated with the assessment score for the influence of implementation of incentive measures for GPs on GPs' work status (r=0.381, 0.387, 0.528, P<0.001) . Theaverage assessment score for willingness to work by the respondents was (0.76±0.18) points. Theassessment scores of willingness to work by the respondents differed significantly by work unit (P<0.05) . Structural equation modeling revealed that the implementation of policy incentive measures influenced GPs' workload via GPs' willingness to work. Specifically, the implementation of policy incentive measures increased GPs' willingness to work (w1=0.43) , while GPs' willingness to work decreased with the increase of weighted workload (w2=-0.156) .

The GPs in Fengxian District showed higher level of willingness to work, namely, relatively high job stability, but they had not been incentivized by policy incentives to be competitive in obtaining improved performance, indicating that although policy incentives have produced partial effects on incentivizing GPs, the effects are still unsatisfactory. In the long run, it is necessary to consider whether there will be changes in GPs' retention status due to the lack of work initiative. For GPs, besides a guarantee of stable income, incentives to get more by doing more are also needed, which may be achieved by increasing the incentive authority and proportion of community health institutions when the total amount of incentives is limited.

Original Research·Clinical Practice and Improvement

Prevalence and Influencing Factors of Sedentary Behavior in Community Stroke Patients

FU Zhongrong, ZHANG Zhenxiang, LIN Beilei, MEI Yongxia, WANG Wenna

2022, 25(07):  846-850.  DOI: 10.12114/j.issn.1007-9572.2022.00.013

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As a kind of unhealthy lifestyle, sedentary behavior is closely related to poor prognosis of stroke patients. So it is of great significance to understand sedentary behavior prevalence in stroke patients, and to formulate intervention measures based on its influencing factors.

To investigate sedentary behavior prevalence and associated factors in stroke patients in the community, providing a reference for the development of targeted interventions.

From August to December 2020, by use of convenience sampling, 230 eligible community stroke patients from Zhengzhou (including individuals who underwent reexaminations in neurology and neurosurgery clinics of three grade A tertiary hospitals and those who were from three communities) were selected to attend a survey using Demographic Questionnaire, Sedentary Behavior Questionnaire, the Chinese version of Fatigue Severity Scale, the Chinese version of Stroke Self-Efficacy Questionnaire, and Social Support Scale. Binary Logistic regression analysis was used to explore associated factors of sedentary behavior.

The survey achieved a response rate of 97.8%. The average daily sedentary time of the respondents was (7.10±2.75) hours, and 179 cases (79.6%) had daily sedentary time ≥5 hours. The daily sedentary time differed significantly by age, living in rural or urban areas, education level, number of complications, number of chronic diseases and fatigue (P<0.05) . Binary Logistic regression analysis showed that age, number of complications, number of chronic diseases and fatigue had significant impacts on sedentary behavior (P<0.05) .

The prevalence of sedentary behavior in community-dwelling patients with stroke was high. It is recommended that health managers develop targeted interventions measures based on the above factors associated with sedentary behavior, thereby reducing sedentary behavior prevalence in this group.

A Comparative Study on the Accuracy of Prognosis of the End-of-life Assessment Form and Common Survival Prediction Scales in Advanced Cancer Patients

YU Wenkai, CHEN Jianlin, LEI Rui, LUO Wei, HU Min, LIU Deng, ZHU Yu, CHEN Qi

2022, 25(07):  851-858.  DOI: 10.12114/j.issn.1007-9572.2022.00.006

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Accurately predicting the survival period of patients with advanced cancer can not only lay the foundation for palliative care centers to regulate the admission of patients and provide standardized services, but also help reduce "meaningless" over-treatment in the process of palliative care.However, there is still a lack of comparative study on the common survival prediction scales in China.

To compare the accuracy of the End-of-life Assessment Form and common survival prediction scale〔Palliative Prognostic Index (PPI) 、Palliative Performance Scale (PPS) 、Karnofsky Score (KPS) 〕in predicting the survival of patients with advanced malignant tumors, in order to provide a basis for the selection of survival prediction tools for advanced cancer patients.

Patients with advanced malignant tumors admitted to the hospice ward of Linfen Road Community Health Service Center of Jing'an Distirct of Shanghai from April 1, 2018 to February 1, 2020 were retrospectively selected as researchsubjects. At the time of admission, the general information questionnaire, End-of-life Assessment Form, PPI, PPS, KPS were used to evaluate the patient, and the survival time of the patient was observed and recorded (from admission to the date of death) . The survival time of all patients was analyzed by Kaplan-Meier method, and the survival curve was drawn. The Kaplan-Meier method was used to calculate the median survival of patients in different groups of each scale, the log-rank test was used to compare the differences in survival among patients in different groups of each scale, and the survival curves were drawn. Finally, by comparing the predicted survival time and the actual survival time of patients with different score segments of each scale, the accuracy rate of the End-of-life Assessment Form, PPI, PPS and KPS in predicting the survival time of patients with advanced malignant tumors were calculated.

A total of 315 patients with advanced malignant tumors were included in this study, of which 266 (84.4%) patients died during hospitalization and 49 (15.6%) patients were censored (right censored, type Ⅲ censored) . The median survival time of 315 patients was 10.00〔95%CI (8.10, 11.90) 〕d. The median survival time of patients in groups of 20.0~35.0 points, 35.5~45.0 points, 45.5~50.0 points, 50.5~60.0 points and 60.0~100.0 points of the End-of-life Assessment Form were 1.00〔95%CI (0.79, 1.22) 〕d, 5.00〔95%CI (3.92, 6.08) 〕d, 10.00〔95%CI (7.83, 12.17) 〕d, 22.00〔95%CI (18.42, 25.58〕d and 45.00〔95%CI (26.23, 63.77〕d (χ²=360.561, P<0.001) , respectively; The median survival time of patients in groups of 10~20 points, 30~40 points and 50~100 points of KPS were 1.00〔95%CI (0.66, 1.34) 〕d、7.00〔95%CI (5.23, 8.77) 〕d and 30.00〔95%CI (20.87, 39.13) 〕d (χ²=137.280, P<0.001) , respectively; The median survival time of patients in groups of 60%~100%, 30%~50% and 10%~20% of PPS were 35.00〔95%CI (25.90, 44.10) 〕d、12.00〔95%CI (9.66, 14.34) 〕d and 2.00〔95%CI (0.85, 3.15) 〕d (χ²=139.311, P<0.001) , respectively; The median survival time of patients in groups of 0~3.5 points, 4.0~5.5 points, 6.0~7.5 points, 8.0~10.0 points and 10.5~15.0 points of PPI were 33.00〔95%CI (25.39, 40.61) 〕d、12.00〔95%CI (8.15, 15.85) 〕d、6.00〔95%CI (4.72, 7.28) 〕d、3.00〔95%CI (1.76, 4.24) 〕d and 1.00〔95%CI (0.89, 1.11) 〕d (χ²=289.831, P<0.001) , respectively. The accuracy rate of the End-of-life Assessment Form, KPS, PPS and PPI to predict the survival time were 81.27% (256/315) 、57.78% (182/315) 、57.46% (181/315) 、73.65% (232/315) , respectively.

The End-of-life Assessment Form, PPI, KPS and PPS can be used to predict the survival time of advanced malignant tumors, but the End-of-life Assessment Form is superior to PPI, KPS and PPS in predicting the survival time of advanced malignant tumors.

Participation in Advance Care Planning and Associated Factors among Surrogate Decision Makers of Patients with Hematologic Malignancies

WANG Tianhang, WANG Wen, SHEN Wenting, SHI Baoxin

2022, 25(07):  859-866.  DOI: 10.12114/j.issn.1007-9572.2021.00.332

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Advance care planning (ACP) helps patients to obtain medical care meeting their values, goals and preferencesunder the circumstances of loss of decision-making ability. The surrogate decision maker (SDM) plays a key role as the main participantinvolved in the process of ACP. But there are no studies on the participation and role of SDMs in ACP process in China.

To investigate the participation in ACP of SDMs of patients with hematologic malignancies and its associated factors, providing a reference for the development of localized strategies for ACP implementation, and for the promotion of ACP in China.

Convenient sampling was used to select the SDMs of 235 patients with hematologic malignancies recruited from Blood Diseases Hospital, Chinese Academy of Medical Sciences during October 2020 to March 2021. They were invited to compete a survey using the Chinese version of the 17-item Advance Care Planning Engagement Survey for Surrogate Decision Makers (C-ACP-SDM-17) , Chinese version of Mishel Uncertainty in Illness Scale-Family Member form (C-MUIS-FM) , Simplified Coping Style Questionnaire (SCSQ) , and Social Support Rating Scale (SSRS) . The C-ACP-SDM-17 scores were compared by demographic factors of the SDMs. Pearson correlation analysis was used to explore the correlation of C-ACP-SDM-17 score with C-MUIS-FM, SCSQ, and SSRS scores of SDMs. Multiple linear regression was used to analyze the factors associated with the participation in ACP of SDMs.

The average total scores of the C-ACP-SDM-17, C-MUIS-FM, and SSRS of the SDMs were (52.23±13.57) , (66.43±12.54) and (40.33±6.78) , respectively. And the average scores of two subscales of SCSQ of the SDMs, active coping and passive coping, were (24.34±6.94) , and (9.87±4.25) , respectively. Male, having experience of involvement in end-of-life medical decision making, awareness of life-sustaining treatment, and knowing of ACP were associated with statistically higher C-ACP-SDM-17 score of SDMs (P<0.05) . The total C-ACP-SDM-17 score of SDMs was negatively correlated with the total score of C-MUIS-FM, and scores of its two subscales, uncertainty and ambiguity, but was positively correlated with the score of active coping. Gender, involvement in end-of-life medical decision making, awareness of life-sustaining treatment, hearing about ACP, level of disease uncertainty, and level of active coping were factors associated with the involvement of SDMs in ACP (P<0.05) .

The ACP participation in SDMs of hematologic malignancies patients was above average. To increase their participation level, it is suggested for medical workers to encourage hematologic malignancies patients' male family members or family members with experience of involvement in end-of-life medical decision making to be SDMs, and give them ACP education, explanation of hematologic malignancies, as well as guide them to actively cope with the pressure of decision making.

Effect of Vestibular Training with Regular Rehabilitation on the Overall Development of Children with Global Developmental Delay and Hypotonia: a Randomized Controlled Trial

WANG Yan, WUYUN Tana, XIANG Dongliang, ZHAO Mingyue, YUAN Yiming

2022, 25(07):  867-873.  DOI: 10.12114/j.issn.1007-9572.2021.00.310

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The increase in the number of children with global developmental delay and hypotonia is a growing concern. However, clinical rehabilitation for these patients is often carried out using monotherapy approaches, and the period for achieving improvement is relatively long.

To observe the effect of vestibular training with regular rehabilitation on muscle tone and global developmental level in children with global developmental delay with hypotonia, providing evidence for improving treatment options for these children.

Sixty children with global developmental delay accompanied by hypotonia who received rehabilitation training in Department of Pediatric Rehabilitation, Rehabilitation Center, the Second Affiliated Hospital of Heilongjiang University of Chinese Medicine from April 2018 to January 2020 were selected, and equally randomized into a control group (regular rehabilitation) and an observation group (vestibular training with regular rehabilitation) . Both groups were treated once daily, 6 days per week, for consecutive 4 weeks. Changes in the normative percentages of Griffiths Mental Development Scales (GMDS) subscales and development quotient, and muscle tone grading of both groups were observed before and after treatment. The overall response rates of muscle tone improvement were compared between the groups.

The values of normative percentages of GMDS subscales and development quotient were similar in both groups at baseline (P>0.05) , but they were more higher in the observation group after intervention (P<0.05) . The post-intervention level of muscle tone of the observation group was higher than that in the control group (P<0.05) although intergroup difference in baseline muscle tone level was insignificant (P>0.05) . The observation group had a much higher overall response rate of muscle tone improvement 〔86.7% (26/30) : 17 (56.7%) with significant responses, 9 (30.0%) with fair responses, 4 (13.3%) with no responses〕 than the control group〔56.7% (17/30) : 9 (30.0%) with significant responses, 8 (26.7%) with fair responses, 13 (43.3%) with no responses〕 (χ²=13.658, P<0.001) .

Vestibular training with regular rehabilitation could improve the muscle tone and developmental delay in children with global developmental delay and hypotonia, which was superior to regular rehabilitation.

Original Research·Methods and Tools

Development and Applicability Verification of a Competency Evaluation Index System for General Practice Team Leaders

YANG Sen, FU Zhili, PAN Ying, ZHAO Huaxin, JIN Hua, SHI Jianwei, CHEN Chen, YU Dehua

2022, 25(07):  874-881.  DOI: 10.12114/j.issn.1007-9572.2021.00.305

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The general practice team leader is not only a community health practitioner, but also a manager, commander and coordinator of a general practice team. So choosing an eligible person for the post of general practice team leader is of primary importance.

To develop and verify a competency evaluation system for general practice team leaders, providing a reference for scientifically assessing the competencies of a general practice team leader, and for selecting an eligible person as a general practice team leader.

By use of literature review and semi-structured reviews, we collected data regarding competencies for an eligible general practice team leader, and used them to initially develop a competency evaluation system for general practice team leaders. Then from July to October 2020, we conducted a three-round Delphi survey with a purposive sample of 20 experts (in the field of general medicine, medical education, public health management, or administrative management) to improve the system, and assess the indicators of the system using the analytic hierarchy process, and test the logic consistency among indicators, then the final system was formed. To assess values of the three-level indicators in the system, from November 1 to 30, 2020, we carried out a survey on wjx.cn (an online questionnaire survey platform) using a self-administered questionnaire developed by us, and selected a stratified random sample of 32 cases (16 directors of community health centers, and 16 general practice team leaders from 8 central urban districts of Shanghai) to anonymously complete the survey via scanning the WeChat RQ code using a mobile phone or computer. The survey data were collected to input into a database, and analyzed for understanding the inter-rater differences in the importance of the top 15 indicators.

The response rate, authority coefficient, and Kendall's W were 90.0%, 0.912, and 0.183 (χ²=42.516, P<0.001) respectively, for the first round of survey, 95.0%, 0.933, and 0.359 (χ²=68.937, P<0.001) respectively, for the second round of survey, and 100.0%, 0.940, and 0.516 (χ²=87.329, P<0.001) , respectively, for the third round of survey. The final system is composed of 5 first-level indicators, 17 second-level indicators and 43 third-level indicators. The weights for the 5 first-level indicators were 0.344, 0.222, 0.192, 0.137 and 0.105, respectively. The consistency ratios for hierarchical arrangement of indicators were all <0.1. Among the top 15 third-level indicators in terms of importance, except for the importance of "the ability to provide referral services", and "the ability to assist in the handling and management of public health events", the importance of other 13 indicators rated by directors of community health centers and general practice team leaders showed no significant differences (P>0.05) .

The system developed by us has high scientificity and practicability with a rational structure and well-targeted indictors, which may be used as a tool for the selection and training of general practice team leader.

Development，Reliability and Validity of the Health Management Service Skills Training Evaluation Scale for Rural Doctors

LIAO Kang, WANG Nameng, FENG Mei, WANG Xiaoxu, LI Liqi

2022, 25(07):  882-887.  DOI: 10.12114/j.issn.1007-9572.2022.00.003

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Few studies have evaluated the effectiveness of health management services sills trainings for rural doctors, and there is a lack of effective evaluation toolsin China.

To develop the Health Management Service Skills Training Evaluation Scale for Rural Doctors (HMSSTESRD) , and test its reliability and validity.

The initial version of HMSSTESRD was developed using the framework of Kirkpatrick model, then was revised using expert consultation and group discussion, and was pretested using a survey with a sample of 100 cases conducted between May to June, 2021. The scale was further revised according to the survey, and analyzed using reliability analysis and exploratory factor analysis, then the formal version was determined. In July 2021, the formal scale was retested in a sample (n=306) , and was revised according to the test results, and was subjected to confirmatory factor analysis, homogeneous reliability analysis, composite reliability analysis, discriminant validity analysis, and structural validity analysis.

The formal scale consists of 15 entries in 4 dimensions: reaction, learning, behavior, and results. The KMO index was 0.847, Bartlett's test of sphericity was significant (χ²=1 862.826, P<0.05) , and the percentage of explained total variance in exploratory factor analysis was 87.575%. The results of the confirmatory factor analysis were χ²/df=3.906, RMSEA=0.098, CFI=0.961, IFI=0.961, and NFI=0.948, indicating that the model fit was basically good. When it comes to the formal scale, the Cronbach's α was 0.967. The Cronbach's α for each dimension (reaction, learning, behavior, and results) was 0.962, 0.958, 0.971, and 0.919, respectively. And the CR values for these dimensions were 0.963, 0.958, 0.971, and 0.919, respectively. The arithmetic square root of AVE was greater than the correlation coefficient between the factors. Theinter-dimension correlation coefficients were 0.538 to 0.842, and the dimension-scalecorrelation coefficients were 0.754 to 0.934.

The HMSSTESRD developed by us has been proved to have good reliability and validity, which could be used as an effective tool for assessingtheeffectiveness of health management service skills trainingsfor rural doctors.

Review

Recent Advances in Return-to-work Self-efficacy Assessment Tools

LIU Feng, ZHANG Zhenxiang, MEI Yongxia, CHANG Hong, CHEN Suyan

2022, 25(07):  888-892.  DOI: 10.12114/j.issn.1007-9572.2021.00.252

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Returning to work is an important sign of recovery and returning to normal life for patients. Most patients have a strong desire to return to work, however, their confidence is low. Return-to-work self-efficacy is not only a reflection of patients' confidence in returning to work but also an important predictor of his readiness to get back to work. Based on the concept and meaning of return-to-work self-efficacy, this study introduces its related theoretical models, summarizes the contents, scoring criteria, validity and reliability of related assessment tools, and conducts a comparative analysis of the tools, to provide Chinese rehabilitation care workers with evidence contributing to the selection of an appropriate return-to-work self-efficacy assessment tool.

Recent Advances in Evaluation Tools and Associated Factors for Patient Delay in Chronic Disease Patients

ZOU Hao, JIANG Dongxu, ZHANG Linlin

2022, 25(07):  893-898.  DOI: 10.12114/j.issn.1007-9572.2021.00.296

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Patient delay will lead to increased risk of complications, reduced treatment effectiveness and lowered quality of life in chronic disease patients. Early identifying individuals with chronic diseases at high risk of patient delay, and timely delivering targeted interventions to them may greatly improve current status of patient delay in this population. Based on a literature review, we systematically summarized several major evaluation tools (including Barriers to Access to Care Evaluation scale, Perceived Barriers to Health Care-seeking Decision, Stroke Pre-Hospital Delay Behavior Intention scale, Diabetes Mellitus Diagnosis and Treatment Delayed Cognitive Behavioral Intention Scale, and Attitudes toward Medical Help-seeking Scale developed by Fisher et al.) for patient delay in chronic disease patients, and analyzed controllable (mental and cognitive) and uncontrollable (sociodemographic and disease-specific) factors associated with patient delay, offering evidence for the assessment of patient delay and development of relevant interventions. We found that the applicability and clinical application rate of these tools are low, and their predictive efficacy and threshold have been rarely studied, and patient delay may be significantly associated with patients' insufficient knowledge of the disease, low economic level and low social support.