To review the strengths and limitations of the development of general practice in China during the last decade (2010—2020) and to assess the opportunities and challenges for its future development.

Data were collected from statistic reports, journal articles and official policies and guidelines regarding general practice development in China from 2010—2020. Donabedian model was applied to examine and assess the quality of essential general practice services in China. SWOT analysis was used to identify internal and external determinants of general practice development in China.

(1) Structural quality of general practice: the ten-year policies about general practice development were a continuation of the past relevant policies in essence but with developments, with highlights on continuous construction of general practice workforce and discipline, tiered diagnosis and treatment and regional medical consortium, but relevant fiscal and management policies still need improvements. The number of general medical workers has increased rapidly, while the lion's share of them are still allocated at tertiary hospitals. Full-time equivalent is suggested to be used to predict the staffing and assess the performance of these workers. The number of community health centres showed a steady increase, but its growth rate was still slower than that of hospital facilities. Relevant health economics data need to be further supplemented. (2) Process quality of general practice: in 2020, there were 2.045 billion visits in community health centers (stations) and township health centers, that is, 1.5 visits per person per year on average. There was a significant development when found only 1 visit per person per year for primary care in 2010. However, the frequency of visits for primary care was still lower than that of visiting hospital-based outpatients (an average of 2.7 visits per person per year) . The COVID-19 pandemic had a significant impact on community health services/general medical services, and the number of outpatient visits dropped by about 20%. The number of general practice research articles reached a peak in 2018, mainly focusing on bi-directional referrals, tiered diagnosis and treatment, general practitioners (GPs) /family doctors, general medicine, community health services, chronic disease management (especially hypertension and diabetes) , and analysis of factors associated with aspects involved in general medical services. General practice research is expected to provide more support for developing innovative and critical thoughts, more practice-based evidence for clinical services, and more assistance for service quality and patient outcomes improvement as the discipline advances. (3) Results of implementing general medical services: there is no sufficient evidence on the influence of general medical services on people's health. The experiences and views of people including healthy individuals and patients indicated that those receiving general medical services or contracted family doctor services perceived positive experience and expressed high satisfaction, but perceptions and views of general population in the community toward general medical services need to be explored. GPs' own experience and opinions on general practice were quite different. Gender, age, professional title, urban and rural areas, and geographical location may be associated with their experience and job satisfaction. There may be instability in the general practice workforce, mainly due to personal income, workload and time pressure. (4) The major strengths of developing general practice in China are as follows: strong policy-based promotion and government leadership; rapidly constructing and developing GPs teams owing to the excellent resource allocating ability shown by the centralized system from central to all local governments; significantly enhanced general practice education and training systems; increased core professionals as general practice educators and trainers; special development of general practice characterized by the integration of medical sciences and Chinese traditional humanistic theories. (5) The development of general practice in China has been facing limitations similar to those in other countries. Besides that, its special limitations include late development of the discipline, unsatisfactory quality of workforce, high work pressure and high prevalence of burnout in the workforce, as well as impact of generation gap on education and practice among GPs. In addition, the relation between specialists and GPs is on transition of from undifferentiated attachment to self-recognised uniquity, and further seeking transdisciplinary. The teaching competences of GPs teachers, especially those teaching community and clinical care, are inadequate. GPs team building and management need to advance from the formation to the storming and performing phases. (6) Opportunities for further development of general practice in China include strategies for achieving the goals of Healthy China, and an all-round well-off society, the important role of primary health care in sustainable development and universal health coverage reaffirmed by the Declaration of Astana, as well as significantly improved health literacy of people. (7) Challenges for the development of general practice in China include population ageing, and aging-related changes in burden of disease and socio-economic status, the aging and dynamic changes of GPs human resources, the variation of urban and rural areas and regional differences, and the inverted pyramid structure of allocation of medical and health resources (namely, the largest part is allocated to tertiary care while the smallest to primary care) . Relevant recommendations to address these challenges comprise strengthening the advocacy of the development of general practice services, establishing a wide-ranging community collaborative network, and developing general practice professional organizations.

The development of general practice in China is advancing, which is manifested as rapidly increased number of general medical workers, strong government promotion, quickly improved accessibility of essential medical services, and notably increased utilization rate of primary care services. However, the development is facing challenges, such as high discipline and social expectations regarding general practice, instability in the workforce due to high work pressure of the knowledge- and labor-intensive job, GPs' insufficient recognition of their self-identity, and unclear status of financial funding for general practice development. Given that there are unprecedented favorable conditions for general practice development, medical industries and general medical workers are suggested to make efforts to turn challenges into opportunities to develop general medical services, thereby universal health outcomes will be improved.

Strengtheningclinical quality control and supervision is one of the effective ways to ensure medical quality. Supervising the quality of general medical care in primary care settings in the local region could contribute to the systematical assessment of general medical care quality and identification of relevantproblems in such settings.

To analyze the supervision of quality of general medical care in Shanghai's primary care settings conducted in 2019 and 2020, and based on this, to give targeted, rational recommendations on the identified problems in quality management of general medical care.

The quality of general medical care in a cluster sample of community health centers (CHCs) of Shanghai was supervised in 2019 and 2020 by relevant experts from Shanghai's municipal and district general practice quality control departments using the Clinical Quality Control and Supervision Standards for General Medical Care in Shanghai's Community Health Centers (hereinafter referred to as CQCSS) developed by Shanghai General Practice Clinical Quality Control Center. In May 2021, the supervision results of the two years were analyzed using descriptive analysis, then compared, and the identified problems were summarized and analyzed.

Two hundred and forty-three CHCs were involved in the 2019 supervision, and 244 were involved in the 2020 supervision. The average total CQCSS score for 2019 was (87.32±5.97) points, and that for 2020 was (86.67±5.36) points. Compared to the results in 2019, the scores of first-level indicators of basic conditions (99.93% vs 99.80%) , staffing and determining job responsibilities of general practitioners (GPs) (93.44% vs 91.90%) , diagnosis and treatment ability of GPs (85.82% vs 85.72%) , chronic disease management ability of GPs (81.07% vs 80.95%) and scientific research and teaching levels (29.99% vs 28.87%) increased in 2020. The problems mentioned were mainly distributed in five aspects: staffing〔176 (22.03%) 〕, GPs' clinical management ability〔154 (19.27%) 〕, quality of inpatient medical records〔92 (11.51%) 〕, quality of home sickbed patients' medical records〔91 (11.39%) 〕, allocation of facilities〔91 (11.39%) 〕. In terms of the mentioned frequency, the top five problems were: ineligible senior GPs to registered GPs ratio〔84 (10.51%) 〕, poor scientific research〔84 (10.51%) 〕, less than 3.5 GPs per 1 000 residents〔61 (7.63%) 〕, unsatisfactory clinical skills〔40 (5.01%) 〕, and insufficient number of home sickbeds〔36 (4.51%) 〕.

These two years of quality control supervision has initially promoted the quality improvementof general medical care in CHCs. To further improve it, it is suggested to take actions to deepen the core essence of general medical care quality management, improve the diagnosis and treatment ability of GPs, as well as their teaching and research ability.

In China, the assessment of community health services has been increasingly valued as the development of such services advances, but relevant research is still at the exploratory stage. Therefore, establishing a community health service quality evaluation system suitable for China's national conditions is critical to domestic development of such services.

To perform a review of studies about community health service quality evaluation in China and abroad to identify the similarities and differences in terms of assessment perspectives and contents between them, providing theoretic evidence for further implementation of such evaluations in China.

Studies regarding community health service quality evaluation were systematically searched in databases of China National Knowledge Infrastructure, CQVIP, Wanfang and PubMed from inception to October 15, 2020. Two researchers performed literature screening, data extraction, and comparative analysis of community health service quality evaluation at home and abroad by assessment perspectives and contents, separately. Descriptive analysis was used to analyze the comparative results.

In total, 62 articles in English, and 16 articles in Chinese were included, among which 10 in English and 7 in Chinese evaluated the quality of community health services in terms of the major factors of features of community health services (first contact, humanization, accessibility, continuity, coordination and comprehensiveness) . The top 3 highlights of these 10 foreign articles were coordination (7/10) , humanization (6/10) and accessibility (5/10) , while those of 7 domestic articles were humanization (6/7) , comprehensiveness (4/7) and accessibility (4/7) . Fifty-two articles in English and 9 articles in Chinese assessed the quality of specific community health services, and these foreign articles mostly focused on the management of chronic diseases〔type 2 diabetes (12/52) , cardiovascular and cerebrovascular diseases (11/52) , hypertension (7/52) , respiratory diseases (7/52) , chronic kidney disease (5/52) 〕, followed by the use of antibiotics (5/52) , cancer screening (5/52) , medication safety (5/52) , child health care (5/52) and geriatric care (5/52) , while domestic articles mostly focused on the management of chronic diseases〔type 2 diabetes (3/9) , hypertension (3/9) 〕, and maternal health management (3/9) .

The quality of community health services is increasingly valued by relevant academic circles. Compared to foreign studies, domestic studies are far less concerned about first contact and coordination, and the assessed specific services in which are not complete, with no quality assessment of diagnosis and treatment of common diseases and frequently-occurring diseases. It is suggested to address the above-mentioned issues to promote the community health service quality evaluation, and improve the depth and breadth of relevant research, thereby the community health service quality evaluation system could be improved constantly.

Chronic diabetic complications are highly prevalent, which may be an underlying cause of diabetes-related disability and death. Regularly and continuously self-monitoring may contribute to early detection, diagnosis and treatment of various diabetic complications, which is essential to reducing the adverse consequences of diabetes, and is a key program in community-based management that should be highly valued.

To investigate the prevalence and associated factors (such as diabetes prevalence and monitoring and other factors) of behaviors of monitoring (self-observation and screening tests) to prevent chronic diabetic complications among type 2 diabetes patients receiving community-based management.

The convenience sampling was used to select 785 type 2 diabetes patients from Chengdu's central urban areas who received community-based type 2 diabetic management from May to November 2019. They were invited to attend a survey for understanding their socio-demographic information and monitoring behaviors to prevent chronic diabetic complications using a questionnaire developed by us.

Only 103 (13.1%) of the patients did not suffer from any chronic complications, and 435 (55.4%) suffered from both metabolic syndrome and chronic diabetic complications. The average total score for self-observation of chronic diabetic complications in the participants was (2.58±0.86) , but the average total score of regularly self-observation of pulsations of the dorsalis pedis artery was only (1.47±0.84) . The average total score of performing screening tests for chronic diabetic complications was (2.77±0.57) . The average score of diabetic retinopathy screening, peripheral neuropathy screening, and lower extremity vascular disease screening was (1.88±0.99) , (1.46±0.84) , and (1.47±0.84) , respectively. About 78.2% (614/785) of patients underwent screening tests following the doctors' advices. But only 9.9% (78/785) took the initiative to conduct regular tests. About 17.7% (139/785) and 49.0% (385/785) of the patients could not correctly manage the abnormal results of self-observation and the screening test results. Multiple linear regression analysis indicated that the duration of diabetes since diagnosis, prevalence of chronic diabetic complications, and management of self-observed abnormalities were associated with the score of self-observation of chronic diabetic complications (P<0.05) . The duration of diabetes since diagnosis, the most recently measured HbA_1c value, prevalence of chronic diabetic complications, causes and results management of screening tests for chronic diabetic complications were associated with average total score of performing screening tests for chronic diabetic complications (P<0.05) .

The prevalence of behaviors of monitoring to prevent chronic diabetic complications in community-dwelling type 2 diabetes patients was unsatisfactory, which was affected by the duration of diabetes since diagnosis, prevalence of chronic diabetic complications, the most recently measured HbA_1c value, causes and results management of screening tests for chronic diabetic complications. In view of this, in the delivery of community-based management services, attentions should be paid to improving patients' initiative to actively and regularly observe their conditions and undergo relevant screening tests, thereby improving early diagnosis and treatment rates of chronic type 2 diabetic complications.

Community-based elderly care may effectively contribute to the handling of serious elderly care challenges brought by an increasingly aging population in China.

To explore the factors associated with older adults' intention to choose community-based elderly care using the decision tree and Logistic regression models.

This questionnaire survey was conducted in three communities selected from Daqing by convenient sampling from August to December 2020. 500 eligible community-dwelling older adults (≥60 years old) were selected as the research objects. The decision tree and Logistic regression models were used to explore factors associated with these older adults' intention to choose community-based elderly care via analyzing their demographics, self-rated physical and mental health, and family and social support collected by the survey.

Altogether, 489 cases (97.8%) who effectively responded to the survey were included for analysis. The prevalence of intending to choose community-based elderly care in the respondents was 32.5% (159/489) . Logistic regression analysis revealed that the older adults' understanding level of community-based elderly care, views of elderly care, sense of loneliness, and intergenerational relationship had varying degrees of influence on their intention to choose community-based elderly care (P<0.05) . The decision tree analysis found that the older adults' understanding level of community-based elderly care, views of elderly care, sense of loneliness, social network, self-rated health, education level, and living status (alone or not) were key factors influencing their intention to choose community-based elderly care (P<0.05) . By both Logistic regression and decision tree analyses, understanding level of community-based elderly care, views of elderly care, and sense of loneliness were found to be three factors influencing older adults' intention to use community-based elderly care most. In exploring the factors associated with older adults' intention to choose community-based elderly care, Logistic regression analysis had an AUC of 0.985 (0.974, 0.996) with 94.34% sensitivity and 95.75% specificity, and decision tree analysis had an AUC of 0.980 (0.968, 0.992) with 88.05% sensitivity and 97.87% specificity, the performance of the two was similar (Z=-0.625, P=0.268) .

The combination of decision tree and Logistic regression model has high application value in the study of influencing factors of community pension willingness of the elderly. The prevalence of intending to use community-based elderly care was relatively low in Daqing older adults. To improve this, it is suggested to take actions to change older adults' traditional views of elderly care, to better their physical and mental health and family relationships.

Hypertension and diabetes have been included in the list of China's essential public health services since 2009. During these years, the use and associated factors of community health management services in community-living hypertensive and diabetic patients are not very clear and need to be further studied.

To investigate the use and potential associated factors of community health management services in Shenzhen community-living hypertensive and diabetic residents.

Data stemmed from the results of Shenzhen Epidemiological Survey on Chronic Non-communicable Diseases and Risk Factors conducted between September and November 2018. The chi-square test and multinomial Logistic regression were used to examine the association of sex, age, place of hukou registration (Shenzhen or not) , marital status, monthly household income per capita, occupation type, years of living in Shenzhen, prevalence of medical insurance enrollment, and the level of medical institutions making a definite diagnosis with the use of community health management services.

Altogether, 10 042 participants were finally enrolled, including 1 132 with self-reported hypertension, and 402 with self-reported diabetes. Among the hypertensive participants, 530 (46.82%) indicated that they received follow-up management of hypertension from the community health center. Specifically, 436 (82.31%) received blood pressure measurement by the doctor, and 399 (75.25%) received medication guidance from the doctor. Of the diabetic patients, 194 (48.26%) indicated that they received follow-up management of diabetes from the community health center. Specifically, 173 (89.37%) of the 193 cases (one case was excluded due to missed information) received blood glucose measurement by the doctor, and 154 (79.62%) received medication guidance from the doctor. The prevalence of hypertensive participants receiving guidance on smoking cessation or smoking less from the doctor was relatively low (lower than 40%) , and so was that of diabetic participants. The prevalence of hypertensive participants receiving guidance on drinking cessation or drinking less from the doctor was relatively low (lower than 40%) , and so was that of diabetic participants. Multinomial Logistic regression analysis revealed that sex, age, monthly household income per capita, years of living in Shenzhen, and prevalence of medical insurance enrollment were associated with the utilization of community health management services in hypertensive patients (P<0.05) . Age, occupational type, and monthly household income per capita were associated with the utilization of community health management services in diabetic patients (P<0.05) .

Less than half of the community-living hypertensive and diabetic participants used or were involved in community health management services. Being female, 18-44-year-old, low or moderate monthly household income per capita, and short years of living in Shenzhen were associated with lower rate of utilizing such services. Moreover, hypertensive cases without medical insurance, and diabetics engaging in a manual labor job were far less likely to utilize the services. In view of this, it is suggested to strengthen the publicity of essential public health services in the above-mentioned priority groups. Besides that, the awareness of doctors in community health centers should be strengthened to provide patients with guidance on developing healthy lifestyles, such as stopping smoking and drinking.

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.

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.

The low hypertension control rate or low glycemic control rate in people in the community have been attributed to patients' poor disease awareness and irregular medication in some studies. However, few studies have explored hypertension control rate and/or glycemic control rate in patients with good disease awareness and regular medication.

To investigate the adequate hypertension control rate and/or adequate glycemic control rate in hypertension and diabetic patients who are at high risk of atherosclerotic cardiovascular disease (ASCVD) but have good disease awareness and regular medication, and to explore the reasons for poor control, offering a theoretical basis for better prevention and control of ASCVD.

By use of cluster sampling, contracted patients with complete data of the China-PAR model who visited 10 community health centers in Shenzhen's Luohu District from August 2018 to April 2019 were selected, and received an assessment for screening the risk of 10-year ASCVD using the China-PAR model, and those with hypertension and/or diabetes who were at high risk of ASCVD (≥10 points) and volunteered to attend this study were further surveyed using a questionnaire developed by our research group. After that, those who were on regular medication with a good understanding of the threats of hypertension and/or diabetes, and targets for blood pressure control and/or fasting glycemia control, were finally enrolled. The rate of adequate hypertension control was compared between those with hypertension, the rate of adequate glycemic control was compared between those with diabetes, and the rates of adequate hypertension and glycemic control were compared between those with both hypertension and diabetes, by demographcihc factors. Then those who were found with inadequate hypertension and/or glycemic control were selected to attend an in-depth, semi-structured individual interview using a descriptive qualitative research design for understating the causes of inadequate hypertension and/or glycemic control. The contents of the interview were coded and categorized using NVivo 12, and were sorted, analyzed, and themes in which were identified using content analysis.

Totally 299 patients were finally enrolled, including 130 (43.5%) with hypertension, 9 (3.0%) with diabetes, and 160 (53.5%) with both hypertension and diabetes. Among the 290 hypertensive patients, 140 (48.3%) had adequate hypertension control. Among the 169 diabetics, 71 (42.0%) had adequate diabetes control. Among the 130 patients with simple hypertension, those with adequate hypertension control had older mean age than did those without (t'=3.758, P<0.001) . Among the 160 patients with both hypertension and diabetes, those with adequate hypertension control had older mean age than did those without (t'=2.203, P=0.031) . Among the 169 patients with diabetes, those with adequate control of fasting glycemia had lower rate of regular exercising (χ²=4.314, P=0.038) and shorter mean duration of diabetes (t=-3.180, P=0.002) , as well as lower mean frequency of blood glucose monitoring (Z=2.228, P=0.026) than did those without. Seven themes emerged from the interview: Patients did not feel compelled to reach the targets, feeling indifferent; Patients gave up after repeated treatments followed by failures to achieve the targets, feeling powerless; Patients took medicines regularly, but had problems in practical medication; Patients were restricted by various realistic factors; Patients were influenced by doctor-related factors, including doctors' irrelevant and ignorant attitudes; Patients had failures due to lack of self-control and unhealthy lifestyles; Other reasons, including unsuccessful medical insurance reimbursement, being afraid of over-control due to previous experiences of too low blood pressure or glucose, etc.

The high-risk population of ASCVD who had good disease awareness and took medications regularly still had low hypertension control rate and/or low glycemic control rate. Attention should be specially given to blood pressure levels in young hypertensive patients, and glycemic level in diabetic patients with regular exercising, a long history of diabetes, or frequent blood glucose monitoring. It is necessary to optimize the management of ASCVD in the community by encouraging patients to improve their mindset and change their unhealthy lifestyles, strengthening the promotion of standardized medication use, improving community health services, and improving patients' knowledge, beliefs and behaviors from the biopsychosocial perspective.

Treatment adherence is closely related to disease control for patients with diabetes. Primary care is general, and continuous, which may satisfy the general and continuous healthcare needs of diabetic patients. But the association of core values of general practices with adherence of diabetic patients is not yet clear.

To explore the effect of core values of general practice (first contact/first line care, continuity, accessibility, comprehensiveness, coordination and patient-oriented) on the adherence (medication adherence, diet adherence, exercise adherence, self-monitoring adherence and regular hospital visits adherence) of type 2 diabetic patients, providing a reference for improving the adherence of such patients by precisely enhancing the core values of general practices.

A survey was conducted between August and September 2019 with a convenience sample of type 2 diabetics receiving contacted family doctor services from Shayuan Community Health Center of Guangzhou using a questionnaire consisting of three parts〔demographic information, the Chinese version of Primary Care Assessment Survey (ASPC) , and Adherence to Out-of-hospital Treatment of Type 2 Diabetics (AOTTD) 〕. Treatment adherence was compared by various personal factors. Multiple linear regression was used to analyze the association of the core values of general practice with treatment adherence.

Altogether, 224 cases who handed in responsive questionnaires were included for final analysis. The average scores of AOTTD, and ASPC of the respondents were (80.57±11.27) and (72.95±11.40) , respectively. The scores of AOTTD differed significantly by sex and understanding level of type 2 diabetes (P<0.05) . The total score of ASPC and the score of its each domain were associated with the total score of AOTTD, or the domain score of regular hospital visits (P<0.10) . The scores of two domains (accessibility and coordination) of the ASPC were associated with the medication adherence score (P<0.10) . The domain score of coordination was associated with the diet adherence score (P<0.10) . The score of each domain of the ASPC (except for coordination) was associated with the self-monitoring adherence score (P<0.10) .

For type 2 diabetics, strengthening each of the core values of general practice could contribute to the increase of their treatment adherence, and regular hospital visits adherence. Improving the accessibility of general practice could enhance their medication adherence. Improving the coordination of general practice could enhance their medication adherence and diet adherence. Improving first contact/first line care, continuity, accessibility, comprehensiveness, coordination and patient-oriented values of general practice could contribute to the increase of their medication adherence. But no association was found between the core values of general practice and patients'exercise adherence, which suggests that providing more exercise resources and environmental support for these patients may be a solution.

The general practice clinic in community health centers is facing increasingly complex challenges to meet the medical needs of patients with chronic diseases. To improve chronic disease patients' health outcome and healthcare satisfaction, it will be of great significance to use shared decision-making (SDM) in the diagnostic and therapeutic process in the community, since SDM is a model based on doctor-patient mutual respect and cooperation and shows great promise as a possible major medical decision-making model.

To understand the status and associated factors of chronic disease patients involved in SDM in general outpatient care in the community, aiming to provide evidence for promoting the implementation of SDM in primary care.

We used cluster sampling to select seven general practitioners (GPs) in the clinic of Shuangyushu Community Health Center, Beijing, and 149 chronic disease patients seen by them between October 2019 and January 2020 as the participants. Through non-participant observation at the clinic, we used the Chinese version of the Observer OPTION 5 (OPTION-5) as an assessment tool to evaluate the extent to which GPs facilitated patient participating in SDM during the consultation. We used a self-developed general demographic questionnaire to collect patients' demographics, status of illness and treatment, as well as GPs' demographics. We compared the OPTION-5 score of the patients by demographic factors, and used stepwise multiple linear regression to explore the factors affecting patients' participation in SDM.

The mean visit length, and OPTION-5 score for the 149 patients were (4.1±2.7) minutes, and〔6.00 (3.00) 〕, respectively. The OPTION-5 score varied significantly across patients by age group and visit length (P<0.05) . Multiple linear regression analysis showed that patient visit length, prevalence of interruption of counseling due to other people, and prevalence of family member accompaniment to medical visits were associated with patients' participation in SDM (P<0.05) .

The participation of these patients in SDM was relatively low. Prolonging GP-patient communication time, ensuring that the diagnosis and treatment process is not interrupted, and giving patients a private space during diagnosis and treatment process may be feasible interventions to improve the participation of chronic disease patients in SDM in primary care.

Medical distrust in patients has been related with poor compliance to medications and suboptimal clinical outcomes. Effective interventions may improve medical distrust in patients which is warranted specific studies.

To evaluate the effect of health literacy and exercise interventions on medical mistrust in patients with type 2 diabetes (T2DM) .

This study was based on a cluster randomized-controlled trial conducted during February 2015 to March 2016. A total of 800 T2DM patients were recruited from four community health service centers in Minhang and Changning Districts of Shanghai by using a multi-stage sampling method. All patients were randomly divided into the control group and 3 intervention groups in the community. Routine care was provided to all the patients, and on this basis, health literacy intervention, exercise intervention and health literacy + exercise intervention (comprehensive intervention) were performed to the three intervention groups based on partnership to improve diabetes education (PRIDE) toolkit, respectively. Information was collected using the Chinese versions of Health Literacy Management Scale (c-HeLMS) , the 5-item Diabetes Numeracy Test Scale (c-DNT-5) , and Medical Mistrust Index (c-MMI) at baseline, 3-, 6-, 12- (end of intervention) and 24-months follow-up (post-intervention) . The generalized estimating equation was used to evaluate the effect of the interventions at each time point.

A total of 780 patients were recruited in this study. The c-MMI was a reliable and valid scale to measure medical mistrust in our subjects, with Cronbach's α of 0.826. The median score and interquartile range of c-MMI was 31 (7) at baseline while the rate of medical mistrust (scores≥30) was 65.9% (514/780) , both of which decreased at almost each follow-up survey in four groups. Compared with the control group, a lower risk of medical mistrust was observed at the 3-months〔OR (95%CI) =0.42 (0.23, 0.78) 〕 and 6-months of follow-up〔OR (95%CI) =0.46 (0.24, 0.88) 〕 for the health literacy group, at the 6-months〔OR (95%CI) =0.50 (0.25, 0.99) 〕, 12-months〔OR (95%CI) =0.43 (0.22, 0.86) 〕 and 24-months of follow-up〔OR (95%CI) =0.37 (0.19, 0.72) 〕 for the exercise group, and at the 6-months〔OR (95%CI) =0.30 (0.16, 0.56) 〕 for the comprehensive group.

Both health literacy and exercise intervention may effectively decrease the scores of c-MMI and reduce the risk of medical mistrust in diabetes patients.

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.

Chronic obstructive pulmonary disease (COPD) is a common chronic disease of the respiratory tract, and lung function is necessary for the diagnosis of COPD. However, conventional pulmonary function meters are not suitable for a large number of physical examinations in the community. In recent years, it is recommended to use spirometry for COPD screening and management both at home and abroad. However, there is still a lack of relevant data on its consistency and effectiveness with conventional lung function.

To explore the value of handheld COPD-6 spirometry for early COPD detection in high risk elderly population in community.

From January 2018 to December 2019 at Dongshan Community Health Service Center, Jiangning District, Nanjing City, a free physical examination was performed on the elder population over 60 years who had high risk factors of COPD. Handheld COPD-6 spirometry was performed pre- and post-bronchodilator, the forced expiratory volume in one second (FEV₁) , the forced expiratory volume in one second as a percentage of the predicted value (FEV₁%prep) , the forced expiratory volume in six second (FEV₆) , the percentage of forced expiratory volume in six second to the predicted value (FEV₆%prep) , and the value of FEV₁/FEV₆ were evaluated and recorded. With FEV₁/FEV₆<80% as the initial screening positive pre-bronchodilator, retests were performed both with handheld COPD-6 spirometry and confirmatory spirometry after inhaling bronchodilator. Using FEV₁/Forced vital capacity (FVC) <70% as the gold standard by confirmatory spirometry, receiver-operator characteristic (ROC) curve analysis was used to obtain the best diagnostic threshold of FEV₁/FEV₆. Sensitivity, specificity, positive predictive value, and negative predictive value were used to evaluate the diagnostic value of the handheld COPD-6 spirometer.

Out of the 382 participants, COPD was confirmed in 75 according to FEV₁/FVC<70% post-bronchodilator. There was no statistically significant difference between FEV₁%pred pre- and post-bronchodilator by handheld COPD-6 spirometry (t=-0.971, P=0.703) ; There was no statistically significant difference among FEV₁%pred in two tests (t=-2.352, -1.429; P=0.396, 0.058) . The FEV₁%pred detected by handheld COPD-6 spirometry post-bronchodilation was positively correlated with confirmatory spirometry (r=0.969, P<0.05) . Compared with FVC%pred and FEV₆%pred post-bronchodilation, the difference was statistically significant (t=-3.170, P=0.005) ; and the FEV₆%pred was positively correlated with the FVC%pred (r=0.653, P<0.05) . There was no statistically significant difference between FEV₁/FEV₆ and FEV₁/FVC post-bronchodilation (t=1.735, P=0.084) ; and there was substantial agreement between the two diagnostic (r=0.871, P<0.05) . The FEV₁/FEV₆ cut-off with the greatest sum of sensitivity and specificity was 71% pre-bronchodilator, the sensitivity, specificity, positive and negative predictive values were 80.0%, 79.2%, 90.6% and 48.5% respectively. The greatest sum of sensitivity and specificity was 75% post-bronchodilator, the sensitivity, specificity, positive and negative predictive values were 80.0%, 98.8%, 98.4% and 58.3% respectively.

It is feasible to use FEV₁/FEV₆ as an indicator to screen COPD patients in elderly high-risk populations. It is recommended to use FEV₁/FEV₆<71% before bronchodilation and FEV₁/FEV₆<75% after diastole as the screening criteria.

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.

Under the conditions of regular containment of COVID-19 epidemic, the levels of core competencies in emergency management of community public health emergency responders are directly associated with the effectiveness of management of public health emergencies. However, there are few studies on core competencies in emergency management of public health emergencies and areas in demand for improvement in community public health emergency responders.

To examine the core competencies in emergency management of COVID-19 pandemic, and associated factors as well as areas in demand for improvement within community public health emergency responders from Zhejiang Province.

Using the Core Response Competence Index System for Infectious Disease Emergencies among Medical Staff as a reference, we developed a questionnaire consisting of three parts: demographic and COVID-19 containment status, Core Competencies for Emergency Management of Public Health Emergencies (CCEMPHE) , and areas in demand for improvement, and used it to conduct an online survey with 749 community public health emergency responders selected from six counties (districts) of Zhejiang using stratified cluster sampling in September 2020.

The survey achieved a response rate of 93.3% (699/749) . The average score of CCEMPHE for the respondents was (118.38±27.60) , with a scoring rate of 62.3%. The scoring rates of three dimensions of the CCEMPHE from high to low were prevention ability (66.4%) , preparedness ability (63.7%) and rescue ability (62.0%) . Multiple linear regression analysis showed that education background (b=4.55) , physical quality for emergency work (b=9.26) , experiences of participating in developing emergency plan/technical proposal (b=6.43) , attending emergency training (b=6.35) , field epidemiology training (b=4.62) , on-site emergency disposal experience (b=5.32) , the number of theoretical trainings related to COVID-19 (b=4.29) , and the number of COVID-19 containment projects involved in (b=1.16) , were associated with the core competencies in emergency management of COVID-19 pandemic in community public health emergency responders (P<0.05) . In terms of areas in demand for improvement, the knowledge related to health emergency response and management (4.09±0.86) was in highest demand, on-site guidance (4.17±0.84) was the most popular training form and short-term training (3.93±0.92) was the most suitable training method.

The community public health emergency responders in Zhejiang Province had lower intermediate CCEMPHE, and a high demand for improvement. To improve the core competencies in emergency management of infectious disease emergencies of community public health emergency responders, it is suggested to health administrators to strengthen practice trainings for these responders based on their needs, especially on-site practice trainings, with a focus on practical skill training.