Launched in 2009, the National Essential Public Health Service Program has been conducted for 13 years. Among which the antihypertensive care ranks first among all types of antihypertensive care in terms of population coverage in China. To promote the sustainable development of the National Essential Public Health Services (NEPHSs) , it is important to understand the feedback of hypertensive population on the antihypertensive care.
To explore hypertension patients' self-rated improvement gained from and satisfaction with the NEPHSs and associated factors, providing a scientific basis for promoting the quality development of the services.
By use of multi-stage stratified sampling, 2 419 hypertensive patients (≥35 years old) were selected from 20 community (township) health centers in 10 districts (counties) of 5 cities in eastern, central and western China from November to December 2019. A questionnaire survey was conducted with them for understanding their general demographic information and management of hypertension.
The prevalence of having self-rated health improvement associated with the NEPHSs in the survey respondents was 86.26% (2 072/2 402) . The prevalence of self-reported satisfaction with healthcare workers' attitudes toward patients, and their care quality, physical examination, health education, TCM treatment, follow-up service, screening for hypertension complications, blood pressure control effect and overall services was 97.15% (2 349/2 418) , 94.09% (2 275/2 418) , 88.16% (2 129/2 415) , 87.81% (2 118/2 412) , 61.36% (1 469/2 394) , 95.04% (2 297/2 417) , 83.67% (2 013/2 406) , 82.34% (1 981/2 406) , and 95.53% (2 310/2 418) , respectively. The prevalence of self-rated improvement gained from the NEPHSs varied significantly by education level, self-rated health, prevalence of blood pressure abnormalities first detected in primary care, and the number of different follow-up services received within the past year (P<0.05) . The prevalence of self-reported satisfaction with overall services differed significantly by education level, prevalence of blood pressure abnormalities first detected in primary care, and the number of different follow-up services received within the past year (P<0.05) .
The prevalence of self-rated improvement gained from and self-reported satisfaction with the NEPHSs in hypertension patients were high on the whole. To promote the sound and sustainable development of these services, priority should be given to the standardization of the provision of NEPHSs and the homogeneity of NEPHSs provided to both urban and rural areas.
The People-Centered Primary Care Measure (PCPCM) scale has proven to be able to evaluate the quality of primary care measures in a accurate, all-round and rapid manner in foreign studies. And after being translated and revised, its Chinese version has been developed by Hong Kong scholars. However, there is not yet any report on the applicability and metrological performance concerning the Chinese version of the PCPCM (PCPCM-C) in the culture and healthcare settings in Chinese mainland.
To evaluate the reliability and validity of the PCPCM-C scale, providing evidence for its feasibility in evaluating primary care measures in Chinese mainland.
By use of convenience sampling, patients were consecutively selected from six primary care settings (community health center, community health station, township health center and village clinic) located in Henan Province, Shanghai, and Heilongjiang Province from December 8th to 20th, 2021. They received a survey using the General Information Questionnaire developed by us, and the PCPCM-C. Then the PCPCM-C was revised in accordance with the survey results, and the assessment results by 10 Chinese professionals (public health managers, general practice experts and administrators of primary care settings) invited nationwide. After that, the PCPCM-C was analyzed using item, reliability and validity analyses.
Altogether, 683 cases who handed in responsive questionnaires were included for final analysis. The item-total correlation coefficients of the scale ranged from 0.843 to 0.923 (P<0.001) . The CR values of items ranged from 28.270 to 36.055 (P<0.001) . Leave-one-out analysis demonstrated that the Cronbach's α of the PCPCM-C ranged from 0.970 to 0.973 (<0.974) . The reliability analysis of the Cronbach's α, Guttman Split-half coefficient and test-retest reliability of the PCPCM-C was 0.974, 0.952, and 0.874, respectively. The inter-item correlation coefficients ranged from 0.667 to 0.913. The test-retest reliability of every item ranged from 0.724 to 0.886. The expert evaluation showed that content validity index (CVI) of every item was 0.800-1.000, the S-CVI/UA was 0.818, and the S-CVI/Ave was 0.973, the K* was 0.79-1.00. The value of KMO (0.960) and result of Bartlett's test of sphericity (χ2=4 538.461, P<0.001) derived from the exploratory factor analysis, suggested that the data sample was appropriate for factor analysis. One common factor with an eigenvalue >1.000 was extracted, and the cumulative variance explained by which was 78.715%, with the load value of each item of 0.826-0.925. The results of confirmatory factor analysis (CFA) showed that the fitting indicators of the initial model were undesirable. After the establishment of a covariance correlation between error variables e1 and e2, e3 and e9, and e10 and e11 according to the indication, the fitting indicators of the model were modified to be acceptable (modified CMIN: χ2/df=2.983, GFI=0.934, AGFI=0.894, RMSEA=0.081, NFI=0.966, RFI=0.954, IFI=0.977, TLI=0.969, CFI=0.977, standardized regression coefficients ranged from 0.790 to 0.900) . The results of known-group validity analysis showed that the total score of PCPCM-C among patients varied significantly by age, rural or urban hukou, household monthly income per person, self-rated health, and chronic disease prevalence, and region (P<0.05) .
This PCPCM-C has proven to be with good psychometric quality in Chinese mainland. But further research is needed to test the cross-cultural applicability and residents' conceptualization of the scale.
In March 2020, the Shanghai Municipal Health Commission proposed that fever alertness clinics should be set up in primary healthcare institutions (community health service centers) to deal with multi-site sporadic outbreaks by the principle of local emergency disposal combined with standardized and regular outbreak control.
To explore and construct a comprehensive and standardized evaluation index system for the operation of fever alertness clinics.
Two rounds of semi-structured in-depth interviews were conducted with 10 staff from three fever alertness clinics in downtown, suburban, and peri urban locations of Shanghai, respectively, using a purposive sampling method from January to April 2021. Raw data were obtained, interview materials were collated with the aid of the ROST CM6 software, and paradigm analyses were conducted using the Charmaz constructing grounded theory. Using a purposive sampling method, 12 experts familiar with the operating characteristics of fever alertness clinics (fever alertness clinics managers, researchers from universities, scholars from related associations, health development institutes, etc.) were invited as consulting objects to answer the correspondence questionnaire for 2 rounds from May to June 2021, and the weighting of indicators at each level was determined by hierarchical analysis to check the logical consistency of indicators at all levels, the evaluation index system of operation of fever alertness clinics was finally formed.
The evaluation index system for operation of fever alertness clinics, which was constructed based on the grounded theory, consisted of 5 primary indicators, 13 secondary indicators and 29 tertiary indicators. The effective recoveries rate of the two rounds of expert consultation questionnaires was 100.0%, the expert authority coefficient of the two rounds was all 0.81, Kendall's W coefficients were 0.265 (χ2=163.768, P<0.001) and 0.320 (χ2=130.323, P<0.001) , respectively. The final developed evaluation index system for operation of fever alertness clinics consisted of 5 primary indexes (functions and responsibilities, consulting room setting requirements, staffing, workflow and work specifications) , 13 secondary indexes and 25 tertiary indexes. The weights of the five primary indexes were 0.033 7, 0.056 4, 0.392 6, 0.377 8 and 0.139 5, respectively. The consistency ratio (CR) of indicators at all levels was 0.056 5、0.032 5、0.042 4 (<0.100 0) .
The application of grounded theory to the construction of evaluation index system for fever alertness clinics is highly operable, and the constructed evaluation index system has a certain scientific validity and application value. Follow up with the policy iterations, the evaluation index system can be further supplemented and improved with the aid of grounded theory.
Functional constipation (FC) is a common health problem in children and a high frequency of consultations among parents of children in outpatient clinics of primary medical and health institutions. Although constipation is not an emergency, it may cause serious complications if not managed properly, which then can affect the quality of life of children and their families.
To understand the capacity of primary-level doctors' diagnosis and treatment in children's FC, and provide a basis for improving primary-level doctors' capacity of diagnosis and management of children's FC.
In July 2020, 130 doctors who had access with children's patients in their daily diagnosis and treatment were selected from primary-level medical and health institutions in Xicheng District, Beijing. A self-designed questionnaire from our research group was administered to the included physicians. The content included awareness of the common symptoms of FC diagnosis for children ≥6 months of age, and the recommended treatment methods, recommended treatment drugs, medication timing and treatment duration for children with FC.
Questionnaires from 108 (83.1%) basic medical doctors were validly returned, including 34 (31.5%) from general practitioners, 30 (27.8%) from pediatricians, 30 (27.8%) from traditional Chinese medicine doctors, and the average monthly outpatient volume with pediatric patients (10.1±4.4) cases was obtained. For the diagnosis of FC in children: when children aged ≥6 months presented with less frequent bowel movements, hard stools, bleeding during defecation, fecal incontinence, difficulty in defecating, and crying symptoms before passing thick stools, 40.7% (44/108) , 39.8% (43/108) , 23.1% (25/108) , 9.3% (14/108) , 39.8% (43/108) , 23.1% (25/108) of the basic medical doctors would consider the diagnosis of FC; 51.9% (56/108) of the physicians considered FC to be diagnosed when two symptoms, including low frequency of defecation and difficulty in defecating, existed simultaneously; according to 25.0% (27/108) of the physicians, FC can be diagnosed when four symptoms including less frequent defecation, hard stools, bleeding during defecation, and difficulty in defecating were present at the same time. For the treatment of FC in children: pharmacotherapy was recommended as the main treatment of choice for FC in children by primary physicians in 37.0% (40/108) ; nonpharmacologic therapy was recommended as the preferred treatment by 63.0% (68/108) of the primary physicians, with 88.2% (60/68) recommending abdominal massage, 85.3% (58/68) recommending a high fiber diet, 82.4% (56/68) recommending toilet training, and 72.1% (49/68) recommending increased fluid intake. Lactulose therapy was recommended by 75.9% (82/108) of the primary physicians; 27.8% (30/108) of the primary physicians recommended combination therapy with microenemas of sodium citrate, sodium dodecylsulfonylacetate, and sorbitol as the rectal treatment, and 64.8% (70/108) of the primary physicians recommended rectal administration when children had particularly difficult bowel movements. According to the basic medical practitioners, the mean time from initiation of treatment to having a positive response was (4.1±2.6) days in children; the mean treatment duration of FC in children by primary physicians was (21.2±4.3) days; 88.9% of doctors believed that the average termination time of constipation treatment was (46.0±9.3) days. When the frequency and/or consistency of bowel movements returned to normal or the patient no longer had discomfort, 88.9% of physicians responded that they would consider discontinuing the treatment.
Although general primary doctors know some methods of diagnosis and treatment of children's constipation, their overall level of awareness still needs to be improved. It is recommended to further enhance the existing primary physicians' awareness and comprehensive management of FC in children, and to develop a comprehensive management model of FC in children in primary health facilities to improve the management level of children's functional constipation, thereby reducing the prevalence and increasing the cure rate.
The improvement of the overall health of residents and the sound development of the hierarchical medical system require the support of a large number of qualified general practitioners (GPs) . As of the end of 2020, the GPs-population ratio in Guangdong reached 3.13/10 000, but the job satisfaction of GPs has not received enough attention.
To assess the level and determinants of overall job satisfaction among GPs in Guangdong's primary care settings.
A self-administered questionnaire survey was conducted with 8 710 GPs selected from Guangdong's primary care settings by use of stratified, multistage cluster sampling from July 5th to 31st, 2021. The information collected include GPs' demographics, and services of GPs' teams as well as job satisfaction assessed using Minnesota Satisfaction Questionnaire-Short Form (MSQ-SF) . The determinants of job satisfaction were identified using the multiple linear regression model and analyzed using SPSS Statistics 24.0.
The survey obtained a response rate of 68.96% (6 006/8 710) . The overall satisfaction score of the respondent GPs was (3.70±0.87) points. The three highest-ranked items in terms of score were "The chance to do things for other people"〔 (4.03±0.64) points〕, "The chance to work aloneon the job"〔 (4.02±0.69) points〕, and "The way my co-workers get along with each other"〔 (3.99±0.61) points〕. The items scored relatively lower were "My pay and the amount of work I do"〔 (2.98±1.04) points], "The chances for advancement on this job"〔 (3.19±0.92) points〕, and "The praise I get for doing a good job"〔 (3.39±0.93) points〕. Multiple linear regression analysis found that annual income, administrative position, having a core position in the team, having privileged access to getting an appointment with experts working in secondary or tertiary medical institutions, providing long-term prescribing services for chronic diseases, delivering home sick-bed services, studying occupation-specific knowledge by oneself, and communicating with other teams for exchanging experience were associated with the job satisfaction of GPs (P<0.05) .
In a word, the overall job satisfaction level of GPs in Guangdong's primary care settings was relatively high. High annual income, administrative position, having privileged access to getting an appointment with experts working in secondary or tertiary medical institutions, delivering home sick-bed services and long-term prescribing services for chronic diseases, having a core position in the team, studying occupation-specific knowledge by oneself, communicating with other teams for exchanging experience, were associated with higher level of job satisfaction.
The implementation of bi-directional referrals may be affected directly by physicians since they play a crucial role in the process, but their performance in which will be facilitated by an orderly, efficient and interconnected referral system. So exploring the impact mechanism of informatization on physicians' performance in bi-directional referrals will greatly promote the implementation of such referrals and the development of hierarchical diagnosis and treatment.
To develop a qualitative model explaining the influence of informatization on physicians' intentions and behaviors regarding patient referrals, laying a foundation for relevant empirical research.
In April to October 2021, we performed a systematical review of studies about the influence of informatization on patient referrals collected from databases of CNKI, Wanfang Data, PubMed and Web of Science, then based on this and the framework of the Theory of Planned Behavior (TPB) , we developed a theoretical model explaining the impact of informatization on physicians' intentions and behaviors concerning patient referrals with self-defined latent variables and self-selected observed variables incorporated. After that, we used the theoretical model and the technology acceptance model to analyze patient referrals, then developed a corresponding business model.
The theoretical model contains six latent variables including behavior, intention, attitudes, subjective norm, perceived behavior control and informationization control-related factors, and observed variables for measuring each of the latent variables. The relationships between latent variables could be divided into correlation/covariance relationship and causality relationship. The business model could clearly reflect the influence of different levels of informatization on physicians' intention and behavior related to patient referrals. The business model indicates that the implementation of bi-directional referrals could be promoted with reduced difficulty only when information support sustains referral services delivered by hospitals in a collaborative way with patient information linked and shared, information system is further improved, and referral standards and information platforms are deeply integrated.
The development of this qualitative model may be a reference for constructing a quantitative model, and for the development of a bi-directional referral assessment system and the formulation of relevant policy documents in China, and may expand the applicable scope of the TPB.
Survival assessment, psychological counseling and other services included in the comprehensive hospice care program conform to the hospice care philosophy, and may be independently delivered to patients to satisfy their needs in a pioneering approach by some health institutions, but the expenses of them could not be reimbursed by health insurance due to lack of an official basis for charging, which may be a bottleneck restricting the development of hospice care.
To systematically assess the hospice care services whose expenses are ineligible for reimbursement by health insurance independently provided by community health centers (CHCs) in a pioneering approach, offering a basis for improving the services and price system of hospice care.
From July to October 2020, by use of typical sampling, one or two CHCs with relatively heavy workload of hospice care were selected from each district of Shanghai, then from which 30 were selected to attend a survey for understanding the implementation status of hospice care using a self-developed questionnaire named Pilot Hospice Care Services Pioneered by Shanghai Community Health Centers, involving inpatient and home hospice care (35 services belonging to five types) . Individuals in charge of hospice care delivery completed the questionnaire according to the status of hospice care implemented in their CHCs in the past year.
The survey obtained a response rate of 96.7% (29/30) . Among the respondent 29 CHCs, 28 (96.6%) delivered inpatient palliative care services, and the median number of services available was 27 (15) ; 25 (86.2%) provided home hospice care services, with 25 (15) as the median number of services available. There was no significant difference in the number of services belonging to five types delivered for inpatients and at home (P>0.05) . There were also no significant differences in the number of inpatient and home hospice care services delivered by CHCs in central urban, suburban, and exurban districts (P>0.05) . Among the hospice care services delivered for inpatients, the average proportions of five types of services, namely assessment services, comfort care, appropriate technology of hospice care, psychological support and humanistic care were 85.7%, 78.6%, 48.6%, 88.4% and 67.5%, respectively. Among the hospice care services delivered at home, the average proportions of above-mentioned five types of services were 86.3%, 60.0%, 42.0%, 84.0% and 62.0%, respectively.
Hospice care services have been widely implemented in Shanghai's CHCs with good availability and insignificant inter-district differences. To incentivize the CHCs and medical workers to provide hospice care, there is an urgent need to further standardize the hospice care services, develop relevant quality criteria, improve the price system, and reform the payment method.
The integrated medical-elderly-nursing (IMEN) services are promising to be very effective in addressing healthcare problems in multiple chronic disease patients in an aging society, but the quality of the services has been less focused.
To identify the factors associated with community-dwelling chronic disease patients' experience of IMEN services, so as to provide a reference for improving the quality of IMEN services and the experience of this group.
From June to September 2020, a questionnaire survey was conducted with a convenience sample of 525 community-dwelling chronic disease patients with IMEN services selected from Hanghou, Zhejiang Province, to collect their individual characteristics, process of IMEN services, and experience of IMEN services. The Chinese version of SERVQUAL developed based on the GAP Model of Service Quality was used to measure the discrepancy between patients' expectations for IMEN services and their perceptions of the services. With referring to the structure-process-outcome model, a structural equation model was developed, assuming that the features of IMEN services (process factors) were influenced by patients' individual characteristics (structure factors) , and both of them affected patients' experience of IMEN services (outcome factors) .
The total average score of feeling and expectation of IMEN services for community patients with chronic diseases in Hangzhou was (5.14±0.44) , (6.80±0.01) , and the total average score of the gap between feeling and expectation was (-1.65±0.44) . Multiple linear regression analysis showed that gender, monthly income, payment method of medical expenses, number of illnesses suffered, prevalence of changing the service team, service items and number of service delivery patterns were associated with the discrepancy between patients' expectations for IMEN services and their perceptions of the services (P<0.05) . The analysis based on the structural equation model revealed that patients' experience of IMEN services was mainly directly affected by the features (duration of contracting the IMEN services, service items, and delivery patterns, smart medical care) of IMEN services (path coefficient=-0.51, P<0.001; direct effect size=-0.51, P=0.002) . Moreover, patients' experience of IMEN services was also directly influenced by individual characteristics (age, education level, self-care ability, number of illnesses) (direct effect size=-0.14, P=0.026) , and indirectly influenced by such individual characteristics through features of IMEN services (indirect effect size=-0.24, P=0.002) .
Community-dwelling chronic disease patients accepted the IMEN services, but their service experience needed to be improved further by interventions such as improving the utilization of IMEN services, enriching the service delivery patterns, making full use of smart medical care and providing more personalized services.
