Special Issue: Primary Medical Resources Allocation
Healthcare workers have played a crucial role in preventing and controlling the COVID-19 pandemic. However, the heightened risk of infection and intense work schedules have not only induced occupational burnout among them but also significantly impacted their mental health and lifestyles. A large number of foreign studies have shown that the COVID-19 pandemic has led to unreasonable diet, reduced exercise, irregular work and rest, and decreased sleep quality among HCWs, increasing the risk of overweight and obesity. Despite this, research on weight and lifestyle changes among Chinese healthcare workers during the pandemic is limited, and the key lifestyle factors contributing to these weight changes remain unclear.
To analyze the predictors of overweight and obesity in Chinese healthcare workers by constructing a Bayesian network model, and to provide a scientific basis for the prevention and control of overweight and obesity.
In August 2022, Chinese healthcare workers in 100 medical institutions from five provinces/autonomous regions/municipalities were randomly sampled, and the questionnaire (Cronbach's α=0.820, AVCR=63.55%) was prepared by the researchers to collect data. All respondents were required to scan QR code generated by the "Wenjuanxing" to answer the e-questionnaire and submit. The "bnlearn" package of R 4.3.0 software was used to construct a Bayesian network model, and Netica 6.09 software was used for Bayesian network risk prediction.
The study surveyed a total of 20 261 healthcare workers, of whom females accounted for 67.57% (13 690/20 261) ; The average age was (40.2±9.2) years old; 73.28% (14 848/20 261) had a college or undergraduate education level. In 2019 and 2022, the overweight/obesity rates were 43.06% (8 726/20 261) and 45.71% (9 262/20 261), respectively. From 2019 to 2022, 12.64% (1 458/11 535) of survey respondents' BMI changed from underweight/normal to overweight/obese. The Bayesian network model included a total of 15 nodes, and the amount of consumption of vegetables and fruits, breakfast frequency, alcohol drinking, and appetite were the parent nodes of BMI changing from underweight/normal to overweight/obesity, and when there were "a reduction" in the consumption of vegetables and fruits, "no change" in frequency of eating breakfast, alcohol drinking consumption "no change", and "a great increase" in the appetite the risk of BMI changing from underweight/normal to overweight/obese was the highest (75.00%). And when there were "a great increase" in consumption of vegetables and fruits, "an increase" in the frequency of eating breakfast, "never or rarely" in alcohol drinking and "a reduction" in appetite, the risk of becoming overweight/obese was the lowest (2.04%) .
Consumption of vegetables and fruits, eating breakfast frequently, drinking alcohol and appetite are the direct predictors of overweight/obesity of Chinese healthcare workers. During the epidemic of major infectious diseases such as the COVID-19, on the premise of ensuring the normal operation of medical and health institutions, a reasonable rotation system is implemented to provide psychological support and lifestyle behavior intervention services, which is conducive to the prevention and control of obesity of healthcare workers.
The personnel building of public health is the key to improving the public health system and enhancing the emergency response capability of public health emergencies.
The study aims to analyse the status, advantages and deficiencies of human resources for public health in Beijing after public health emergencies. Then, the study put forward suggestions to optimise the construction of human resources for public health in Beijing.
The data on the sum of public health workforce, disaggregated by age, academic qualifications and job title, was collected from 2016 to 2021 Basic Information Survey on Manpower of Health Institutions in Beijing and the Compendium of Statistics on Community Health Work in Beijing. The data was collated between June and September in 2022 with the aims of analysing the sum, structure and configuration of human resources for professional and grassroots-level public health in Beijing in the context of public health emergencies.
From 2019 to 2021, the sum of human resources for public health in Beijing's professional public health institutions increased from 15 157 to 16 048. Additionally, the percentage of those with postgraduate qualifications increased by 0.93 percent, while the percentage of those with senior and intermediate titles increased by 2.29 and 3.87 percent, respectively. The sum of human resources for public health at the grassroots level increased from 3 701 to 4 017. Among these, the percentage of those with bachelor's degree or above increased by 5.36 percent, while the percentage of those with senior and intermediate titles increased by 0.72 and 1.70 percent, respectively. And the ratio of CDC force per 10 000 population decreased from 1.68 to 1.57, the number of health personnel in professional public health institutions per 1 000 population increased from 0.70 to 0.73, the number of grassroots public health personnel per 10 000 population increased from 1.72 to 1.84.
After the public health emergency, the sum of human resources for public health has increased in Beijing, yet staffing gaps persist. The echelon of public health institutions has been reinforced, although the quality of human resources for public health in different institutions varies considerably. Furthermore, the structure of titles of human resources for public health is becoming more logical. It is recommended that public health staffing standards be clarified to fill the gap in human resources for public health. Furthermore, it is essential to enhance the training methodology for human resources for public health and elevate the calibre of them. Additionally, there is a need to refine the mechanism for ensuring the advancement of the human resources for public health, with the objective of attracting and retaining talent.
Job demands and job resources are drivers of health and wellbeing of workfoce. This study aimed to explore the influence of personality traits on job stress in the Job Demands and Resources (JD-R) model.
May 2023, self-administered questionnaires for the Brief Job Stress Questionnaire (BJSQ) and the Ten Item Personality Inventory (TIPI) were distributed online to general practitioners (GPs) of 26 public community health centres of Luohu Hospital Group, Shenzhen China. 69.6% GPs completed the questionnaires. The BJSQ included job demands (8 items), job resources (8 task-level items, 11 workgroup-level items, 8 organisational-level items) and related outcomes (10 items). The personality traits including extraversion, agreeableness, conscientiousness, emotional stability, and openness. The median as well as the 25th and 75th percentiles were used to indicate the central tendency and the degree of dispersion of the items, and Pearson's correlation coefficient and ANOVA were used to test the correlational factors of the different personality traits and the JD-R model.
The personality traits of GPs, both male and female, were dominated by conscientiousness. agreeableness and conscientiousness were the dominant traits for those under 40 years of age and those in lower professional hierarchy, while emotional stability and conscientiousness were the dominant traits for those 40 years of age and over and those in higher professional hierarchy. The Big Five Personality Traits were related to interpersonal conflict, role conflict, job control, job adaptability, value of work, support from family and friends, job security, coping with organisational change, psychological stress, family satisfaction, job involvement, and job performance (P<0.01), but not to qualitative workload, or work predictability. Agreeableness (r=0.295, P<0.01) and emotional stability (r=0.196, P<0.01) were associated with workplace harassment. Correlation of emotional stability and JD-R model was evident statistically.
Personality traits are closely related to Chinese GPs work stress, psychosocial work environment and outcomes, and can be used as predictors with the JD-R model. Future research on professional burnout should consider personality traits as independent variable.
The authors suggest including personality, emotional intelligence, logical reasoning, and interpersonal relationship tests in the recruitment of students or trainees in medical schools and vocational training programs, in order to select and recruit suitable people for the delivery of medical services. Doctors with different personality traits could be supported with job demands and resources according to their individual characteristics to reduce professional burnout and improve work efficiency and patient care outcome. The authors called further studies on the relationship of Chinese doctor's personality traits and their study and working stress and performance.
Using discrete choice experiment (DCE) to study the employment preference of health personnel to choose jobs can provide scientific and efficient basis for the formulation of policies related to the attraction and retention of health personnel in rural and remote areas.
To review, summarize and generalize the researches on the application of DCE to the field of human resources for health, so as to provide reference for future research.
Web of Science, PubMed, CNKI, Wanfang and VIP were systematically searched for literature related to DCE application to the field of health human resources from February to April in 2022. The data of included studies such as study objectives, data analysis models, the choice item settings and results were extracted.
A total of 44 papers published from 2000 to 2020 were finally included. The study objects were mainly health workers in service and students; six studies were labeled and others were unlabeled in the included papers; the number of working attributes ranged from 4 to 8; the number of levels of working attributes was predominantly 2 to 4 (88.6%, 39/44). The teamwork of general practitioners and workload were used as working attributes in the studies in high-income countries; the most frequently selected working attribute in studies from low-and middle-income countries was housing (21 times), followed by essential equipment such as facilities and medications (19 times), and learning/training opportunities (16 times). Income (salary) was incorporated into the working attributes across the literature. Furthermore, we formulated a framework of working attributes containing four aspects: social aspects, including the hospital volume, social support/respect, identification (establishment or becoming a permanent employee) ; working aspects, including working location, working conditions, workload, working (management) atmosphere, teamwork, mentoring by supervisors (for primary health workers) ; career development aspects, including years of promotion, training (continuing education) opportunities, academic and research opportunities; life aspects, including income, housing, traffic, and children's education. Mixed Logit Model was the frequently used analytical model (19 times), followed by Conditional Logit Model (9 times), Generalized Multinomial Logit Model (3 times) .
The heterogeneity of research findings in this field is large, making it difficult to draw uniform conclusions. Moreover, the application of DCE in the field of human resources for health still needs to be promoted globally. Relevant studies are very limited and the evidence obtained needs to be confirmed by further research.
China's National Compulsory Service Programme (CSP) is an important measure to alleviate its shortage of primary health care (PHC) workforce and improve quality of care in rural areas. Currently, the work status and turnover intention of the CSP medical graduates (the fully-fledged general practitioners in China) have received considerable attention.
This article will investigate the medical graduates' workplace violence, burnout, and turnover intention, in order to provide policy recommendations to stabilize the general practitioners.
From December 2021 to February 2022, an online structural questionnaire survey was conducted in nine out of 22 provinces adopting a stratified random sampling method. The electronic questionnaires were distributed to medical graduates with the assistance of the Science and Education Department of the Provincial Health Commission. The burnout of medical graduates was assessed using the Maslach Burnout Inventory-Human Services Survey (MBI-HSS) . Workplace violence involved the verbal and physical violence. Turnover intention was measured by "Are you willing to continue serving at the PHC institutions upon the completion of the contract (the compulsory service) ?" Multivariate Logistic regression analysis was used to explore the impact of burnout and workplace violence on turnover intention.
A total of 3 615 questionnaires were effectively collected. 87.77% (3 173/3 615) of medical graduates were unwilling or unsure to continue their employment after finishing the contract. 17.46% (631/3 615) of medical graduates had experienced physical violence, and 60.33% (2 181/3 615) had experienced verbal violence. In addition, the detection rate of burnout was 55.82% (2 018/3615) , of which 60.80% (2 198/3 615) were in moderate or severe emotional exhaustion, while the proportions of depersonalization and personal accomplishment were 67.55% (2 442/3 615) and 83.76% (3 028/3 615) , respectively. Logistic regression analysis showed that after controlling for socio-economic factors such as gender, professional title, and personal monthly income, medical graduates who were experiencing burnout had a 4.92 times[95%CI (3.87-6.25) ] higher risk of leaving, a 1.92[95%CI (1.50-2.46) ]times higher risk of uncertain retention (P<0.05) . Medical graduates who experienced verbal and physical violence were 1.46 times[95%CI (1.12-1.91) ] and 0.38 times[95%CI (0.27-0.52) ] more likely to leave after the contract expires (P<0.05) .
Medical graduates have a high intention to leave, and it is expected that there will be a significant loss of general practitioners after the contract expires. Burnout is a significant and prevalent problem affecting turnover intention. Efforts should be made from multiple perspectives to alleviate medical graduates' negative emotions, and thus stabilize the general practitioners.
General practice in China has developed rapidly in recent years with remarkable progress, but the gap with developed countries in Europe and the United States is still large, and the training system of general practitioners still remains impefect. In Germany, the construction of the primary health care system and the training system of general practitioners have been well developed. Under the system of universal health insurance coverage and hierarchical diagnosis and treatment, a high level of health and patient satisfaction with primary healthcare services among residents have been achieved in Germany. Therefore, this study compares post-graduate education and continuing education of general practice in China and Germany, analyzes the challenges of general practice education reform in China, drawing on the conceptual framework of general practice education in Germany, and proposes targeted ideas and recommendations for solutions as follows: for the standardized residency training of general practice, increase the rotation flexibility as appropriate to facilitate the optimization of trainees' individualized competencies, incorporate the standardized curriculum of psychosomatic medicine and Balint group training to improve trainees' competence in psychosomatic medicine, establish standardized selection criteria and promote standardized training program for faculty of community hospital, and revisit the duration of general practice (including community) rotation after improving the qualifications of general practice faculty of community hospital; for the continuing education, incorporate the special interest and small specialties into the general practice continuing education system to strengthen the functional medical characteristics of general practice and promote the professional diversification of general practitioners, and establish a national unified platform for continuing education in general practice. More practical research and resources are needed to improve the training system of general practitioners in China in the future.
Currently, primary healthcare staff are under high pressure and prone to effort-reward imbalance and burnout, which hinders the development of primary health services and has not been sufficiently emphasized.
To study the situation of effort-reward imbalance and burnout among primary healthcare workers, and explore the relationship between the two, so as to provide reference for improving burnout among primary healthcare workers.
Primary healthcare workers from primary healthcare institutions (including community health service institutions and township health centers) in 4 streets and 28 townships in Dongguan City, Guangdong Province, were selected for the survey from March to May 2022 using the convenience sampling method. The questionnaire included general information, the Maslach Burnout Inventory-General Survey (MBI-GS) and the Effort-Reward Imbalance (ERI) . With MBI-GS score as the dependent variable, the effort-reward ratio and degree of overload in the effort-reward imbalance model as the independent variables, stratified regression analysis was used to explore the effects of the effort-reward imbalance model on burnout.
A total of 347 primary healthcare workers were included, the total score of MBI-GS for primary healthcare workers was (3.72±1.25) . Of the 347 primary healthcare workers, 93.4% were burnout, 76.7% were in effort-reward imbalance, and 35.2% were under a heavy workload. The total MBI-GS score of primary healthcare workers in effort-reward imbalance was higher than those in effort-reward balance (t=-5.20, P<0.001) ; the total MBI-GS score of primary healthcare workers under heavy workload was higher than those under normal or low workload (t=8.08, P<0.001) . The results of multivariate regression analysis showed positive predictive effects of effort-reward imbalance and heavy workload on burnout (b=0.414, 0.109, P<0.05) .
The condition of effort-reward imbalance is serious and job burnout is common among primary healthcare workers. The effort-reward imbalance model positively predicts burnout, it is recommended to reduce the workload of primary healthcare workers, improve their work reward and emphasize their psychological health.
The report of the 20th CPC National Congress pointed out that it is necessary to "develop and strengthen the medical and health care workforce, focusing efforts on rural areas and communities". General practitioners (GPs) are the "gatekeepers" of residents' health and medical expenses, and play an important role in basic medical and health services. Training applied and complex new-age GPs who can be deployed, retained and utilized is an important step in promoting the construction of a healthy China. On the basis of Training Development Report of GPs (2018), this report systematically reviews the team construction, training and education, reform of utilization and incentive mechanism of GPs in China from 2018 to the present, and puts forward the future outlook of GPs in China in the hope that it can provide information for further research on general practice in China.
At present, the problem of regional imbalance and lack of fairness in the allocation of medical resources in China remains prominent. The report of the 20th National Congress of the Communist Party of China clearly stated that it is necessary to promote the expansion of high-quality medical resources and balanced regional layout.
To explore the specific path to improve the efficiency of medical resource allocation in China, and provide scientific reference for realizing the rational and high-efficient allocation of medical resources in China and promoting the equalization of basic public services.
The study was conducted from September 2022 to February 2023, and the data were derived from the 2021 China Statistical Yearbook and 2021 China Health Statistics Yearbook. The data envelopment analysis (DEA) method was used to measure the efficiency of medical resource allocation in 31 provinces of China in 2020, considering the number of healthcare institutions, health technicians, and beds as input indicators, the number of visits and admissions as output indicators. Fuzzy-set Qualitative Comparative Analysis (fsQCA) was used to explore the synergistic influence mechanism of internal and external factors on the efficiency of medical resource allocation from a group perspective, taking resource allocation efficiency as the outcome variable, the ratio of health technicians, number of beds per 1 000 population, average hospitalization days of discharged patients, gross domestic product (GDP) per capita, disposable income of the residents, the fiscal revenue decentralization, and ratio of the budgetary expenditures on healthcare as conditional variables, to analyze the conditional configuration of high or non-high level of healthcare resource allocation efficiency, and clarify the multiple paths of efficient and inefficient allocation of medical resources.
In 2020, the overall level of medical resource allocation efficiency in 31 provinces of China is relatively high, with an average of 0.852, but there were large differences among provinces. The results of configuration analysis showed that the improvement of medical resource allocation efficiency is the result of multiple factors, there are three paths for efficient allocation of medical resources. Path 1: government-led driving path, taking Guangxi Zhuang Autonomous Region as a typical case; Path 2: internal and external coordination driving path, represented by Yunnan Province and Gansu Province; Path 3: balanced driving path, with Guangdong Province, Fujian Province and Hubei Province as representative cases. There are also three paths of non-high medical resource allocation efficiency. Path 1: government-restricted path; Path 2: economic-government dual restriction path, representative cases included Heilongjiang and Jilin Province; Path 3: internal and external constraints path, the typical cases were Shanxi Province and Tibet Autonomous Region.
The internal and external elements and synergies between elements jointly affect the allocation of medical resources in the process of benign interaction, it is necessary to optimize the internal and external environment, and effectively integrate the key resource elements to form a joint force to promote the rational allocation of regional medical resources.
The "Healthy China 2030" strategy has put forward higher demands for the allocation of health human resources, and more regional studies on the evaluation of the equity of health human resources have been conducted in China, but there is no overview of multiple categories of health human resources in various medical institutions from a national perspective.
To describe the trend and equity of 12 categories of health care institutions and 5 categories of health human resources in 31 provinces (autonomous regions and municipalities directly under the central government) nationwide from 2005-2021, so as to provide reference for the optimization of human resource allocation in various health institutions in the future.
National data on health human resources was collected from China Public Health Statistical Yearbook (2006-2012), China Health and Family Planning Statistical Yearbook (2013-2017) and China's Hygiene and Health Statistical Yearbook (2018-2022), demographic and economic data was collected from China Statistical Yearbook (2006-2022). The average annual growth rate and concentration index were calculated by collecting the per capita occupancy of each health human resource in medical and health institutions in each province (autonomous regions and municipalities directly under the central government) of China from 2005 to 2021, and the equity analysis was conducted based on the level of economic development.
The total number of health personnel in China continued to rise, with an average annual growth rate of 5.58%, with faster growth in rural areas at an average annual growth rate of 10.87%; the number of health personnel in community health service centers (stations) had the fastest growth rate (average annual growth rate of 18.05%), the number of personnel in health supervision offices grew at a lower rate (average annual growth rate of 0.18%), and the number of personnel in disease prevention and control centers showed a decreasing trend (average annual growth rate of -0.39%). Except for community health service centers (stations), the concentration index of the total number of health personnel in all types of medical institutions was <0.20.
The per capita occupancy of each health human resource in medical and health institutions is growing faster in rural areas, the equity of human resources across health institutions in China is good, but the total amount is insufficient, and important institutions and personnel categories need attention. Investment in human resources for rural health should continue to be strengthened, and the state and provinces should stabilize the public health workforce, improve the development of primary health service institutions, and expand equity and accessibility.
In Australia, 28% of the population live in remote and rural areas, where they face many health service utilization challenges due to geographical conditions, and generally have lower health status than those living in coastal metropolitan areas. To address the challenges of accessing health services in remote and rural areas, the Australian Government Department of Health and Aged Care has introduced a geographical classification system to help healthcare providers to improve healthcare services since 1994, and regularly updated the system to adapt to the latest sociodemographic and healthcare status, as well as formulated a range of complementary health policies to support rural and remote areas. From 2018, Australian Government Department of Health and Aged Care has adopted a new classification standard, the Modified Monash Model. We reviewed Australia's practices and concluded that, to better deliver high-quality and accessible healthcare services to areas with weak healthcare resources in China, Australia's experience could be used for reference, during taking actions to promote and refine the geographic classification system for healthcare services in a timely manner, formulating policies supporting the enhancement of access to health workers systematically, and taking advantage of modern, high and new technologies.
Coordinated Development of Primary Care Resource Allocation and Economy as Well as Associate Factors in China: a Fuzzy-set Qualitative Comparative Analysis
The allocation of medical resources in China has been in an "inverted triangle" state for a long time. The unreasonable allocation of grass-roots medical resources is difficult to meet the increasingly diversified needs of medical services. The coupling and coordination between the allocation of grass-roots medical resources and economic development will affect the level of regional economic development and the service capacity of grass-roots medical institutions. At present, there is a lack of research on the current situation of their coordinated development and how their influencing factors work through combination.
To assess the level of coordinated development of primary care resource allocation and economy in China, and to determine the associated factors, providing a decision-making basis for further improving medical resource allocation and planning.
The research was carried out from November 2020 to April 2021. Data were collected from China Health Statistics Yearbook 2019 and China Statistical Yearbook 2019. fsQCA was implemented to assess the influence of the number of licensed (assistant) doctors, number of registered nurses, financial subsidy for part of salary, number of beds, number of primary care institutions, regional gross domestic product (GDP) , regional fiscal revenue, per capita disposable income, and per capita GDP (used as conditional variables) on the level of interconnected, coordinated development level of primary care resource allocation and economic level (the outcome variable) in 31 regions of China.
In 2018, only the mean level of interconnected, and coordinated development of primary care resource allocation and economy in eastern China (0.61) was within the range (0.6, 1.0] of coordinated development, and that in central China (0.50) was within the transitional harmony range (0.4, 0.6], while that in western China (0.38) was within the range of imbalanced and recessional development[0, 0.4]. The coordinated development of primary care resource allocation and economic level were found to be affected by many factors, and it may be facilitated by four configurations of its associated factors revealed by the configuration analysis: (1) number of beds * number of licensed (assistant) doctors * number of registered nurses * number of primary care institutions * financial subsidy for part of salary* ~ per capita disposable income * ~ per capita GDP; (2) ~ number of beds * ~ number of licensed (assistant) doctors * number of registered nurses * number of primary care institutions * ~ financial subsidy for part of salary* regional GDP * ~ per capita disposable income * per capita GDP; (3) number of licensed (assistant) doctors * number of registered nurses * number of primary care institutions * financial subsidy for part of salary * regional GDP * regional fiscal revenue * per capita disposable income * per capita GDP; (4) ~ number of beds * ~ number of licensed (assistant) doctors * ~ number of registered nurses * ~ number of primary care institutions * financial subsidy for part of salary * regional GDP * regional financial income * per capita disposable income * per capita GDP (* for "and", ~ for "not") . And these four configurations could be classified into three types of paths: primary care resource allocation-driven type, primary care resource allocation and economic balance type, and economic development-driven type.
The overall level of coordinated development of primary care resource allocation and economy in China was unsatisfactory, with obvious regional differences, which was mainly affected by the number of registered nurses, regional GDP, and regional fiscal revenue, but may be facilitated greatly by the above-mentioned four configurations of associated factors. Therefore, it is suggested that each region chooses one path to achieve high level of interconnected, and coordinated development of primary care resource allocation and economy according to their own resources and conditions, so as to promote the rational primary care resource allocation, and the coordinated development of medical resources and economic level, thereby improving the level of primary care services in China.