- Research article
- Open Access
Achievements and challenges in health management for aged individuals in primary health care sectors: a survey in Southwest China
BMC Public Health volume 20, Article number: 338 (2020)
China has rapidly transformed into an ageing nation and will be one of the countries with the highest percentage of aged people in 2050. Healthcare management for the aged (HMA) in basic public health service (BPHS), which is delivered by lay healthcare workers (LHWs) in primary health care (PHC) sectors, is an important strategy to address the healthcare challenges that have resulted from ageing in China since 2009. This survey aimed to understand the achievements made and challenges faced by HMA in Southwest China.
A multilevel stratified random and consecutive sampling method was used to select study places and participants respectively, and mixed research methods were used to collect data from the aged individuals, LHWs and leaders in PHC sectors. SPSS 21.0 was used for data analysis.
Seven hundred seventy-two surveys with aged people (over 60 years old), 16 focus group discussions (FGDs) with 96 aged people, and 32 in-depth interviews with 16 LHWs and 16 leaders were completed in PHC sectors. More than 85% of aged individuals had knowledge and utilization of HMA, and over 94% of these respondents were satisfied with HMA. Meanwhile, challenges in HMA delivery included weakness (unmet items and lack of appropriate assessment indicators) in HMA design, low capacity of PHC sectors and competency of LHWs to deliver HMA, poor health literacy of aged individuals, insufficient funds and a lack of multi-sector cooperation.
Though significant achievements in HMA were observed, this study highlighted the challenges in further quality improvement of HMA delivery program in Southwest China. The “older-person-centered and integrated care” model provided a good theory to improve the quality of HMA by reinforcing the needs-based HMA design, building a comprehensive assessment strategy, improving the capacity of PHC sectors and the LHWs’ competency, and strengthening multi-sector cooperation.
In 2015, World Health Organization (WHO) reports on ageing and health reported that the population of ageing was rapidly increasing worldwide . With 10% of its population being over 60 years of age, China quickly transformed into an ageing nation in 1999. The doubling (from 7 to 14%) of the proportion of people aged 65 years and older was accomplished just in 26 years in China . By the end of 2017, the ageing population in China had increased to 17.4% . The speed and scale of the ageing population are unprecedented all over the world. By the year 2050, it is predicted that 337 to 400 million of the Chinese population will be aged 65+ (about 23.9 to 26.9% of the total population) and that 107 to 150 million will be aged 80+ [4, 5]. Accordingly, China will be one of the countries in the world with the highest percentage of aged people in 2050. Ageing has therefore become a pervasive social problem in China as the Chinese “become aged before rich”, the lack of preparation for an aging society, specifically planning for the health needs of the elderly in China, challenges the health and social care system of this country .
The rapidly growing population of aged individuals brings great challenges to the health care system, for example, a surge of age-associated diseases encompassing chronic non-communicable diseases (NCDs) and mental health disorders . Disease prevention, early diagnosis and maintenance of a healthy lifestyle through primary health care (PHC) are very important to address those health challenges among aged individuals . Thus, health management for aged individuals has become a promising strategy . In response to the accelerating ageing population, WHO put forth goals of healthy ageing in the world report on ageing and health in 2015 ; China launched BPHS incorporating HMA explicitly in 2009 [3, 8, 9] and quickly undertook the development of aged care service into the 13th five-year plan in the middle of 2015 . Basic public health services (BPHS) for all residents is one of the priorities of the new health reform in China which was launched in 2009. Since 2009, the national BPHS programs have been widely carried out across primary health care (PHC) sectors including community health centers (CHCs) and stations in urban areas, township hospital centers (THCs) and village clinics in rural areas of China. These play an important role in ensuring and improving the health condition of residents, and the equity and accessibility of public health have greatly improved [10, 11]. Though the content of BPHS had been modified three times by 2015, HMA was always listed as one of the core programs of BPHS . All items of HMA in BPHS are delivered by LHWs in primary health care sectors (PHCs).PHC sector, mainly provided and funded by the government in China, was a sector provided primary health care service for the residents who lived in the area of PHC sector, including disease control, management of chronic disease, health promotion and education. Free HMA for aged individuals (people aged 65+) included four items: lifestyle evaluation and health assessment (LE and HA), health check-up (HC) (such as measuring height, weight, waist circumference, vision tests, heart rate, and blood pressure), auxiliary exam (AE) (such as fasting-blood glucose test, electrocardiograms, and B-scan ultrasounds) and health guidance (HG) (such as disease prevention, self-care and injury prevention, self-rescue) .
Few studies have reported one or two aspects (satisfaction/needs/knowledge/utilization, separately) on the current situation of HMA, most of which have focused on investigating rate of the aged population using HMA or satisfaction to HMA [13,14,15,16,17,18,19,20,21,22,23,24,25,26]; some studies have assessed the situation of HMA delivery by LHWs in PHC [27, 28], while others have revealed that both quantity and quality of LHWs in PHC sectors need supplementation and improvement [29,30,31,32,33,34,35,36], with some basic hardware facilities required to have replenishment as well [32,33,34]. Additionally, a study by Hu XY  indicated the lack of a unified and quantifiable performance evaluation index system. However, there is no systematic assessment of HMA delivery in primary health care (PHC) sectors . Furthermore, a national assessment of BPHS delivery in PHC sectors has only been performed once in 2010, indicating that Southwest China lags behind Central and Eastern China in this aspect .
Therefore, this study selected Southwest China as the study region and aimed to provide a preliminary evaluation of the achievements of HMA and the associated factors, and assessment of the challenges faced by HMA.
This cross-sectional survey utilized mixed research methods to collect data from February 2015 to August 2016. Both quantitative and qualitative research methods were used to evaluate the delivery of HMA in PHC sectors from both aged individuals and providers (LHWs and leaders from PHC sectors).
In Southwest China, we purposively selected Chongqing municipality (as a region with more developed socio-economic development, with the Gross Domestic Product (GDP) at 2.04 trillion RMB and per capita GDP at 66.2 thousand RMB in Chongqing.) and Guizhou province (as a region with less developed socio-economic conditions, with 1.48 trillion RMB in Guizhou, per capita GDP was 41.4 thousand RMB in Guizhou) as the study regions . Southwest China is an underdeveloped area in China, whose per capita net income is much lower than that of Eastern and Central China .
A multi-stage random sampling was used and we selected one county/district to represent the socio-economic development of Guizhou and Chongqing respectively. Then the PHC sectors in the selected county/district were divided into THCs (in rural areas) and CHCs (in urban areas). According to the quality of BPHS delivery in previous year, THCs and CHCs were divided into developed and less developed groups for the sample representation and comprehensive understanding of the status of HMA. Finally, four THCs and four CHCs were random selected from each province, two THCs/CHCs that were more developed and another two less developed. In total, eight THCs and eight CHCs were chosen as the final study communities. The flow chart of study region selection was shown in Appendix A.
Chongqing transformed into an ageing society in 1994, which was 5 years earlier than China as a whole. The sixth census indicated that people aged 65+ comprised 11.56% of the population in Chongqing, which was much higher than the national level (8.87%), and this value became the highest among all provinces and regions in China . It is predicted that the estimated percentage of individuals aged 65+ will reach 28.15% by 2050 . Guizhou rapidly transformed into an ageing society in 2003; the percentage of individuals 65+ reached 8.71% in 2010 and will reach up to 21% by 2050 . However, the underdeveloped socio-economy cannot provide health security for aged individuals, and self-support is very weak in Guizhou province.
BPHS has been carried out since 2009 in Chongqing and 2010 in Guizhou. Recently, PHC sectors in Chongqing have developed quickly; almost all PHC sectors are held by the government  and have enough buildings (even more than required by the central government) . However, all PHC sectors are not only short of LHWs in number, but also lacked LHWs qualified for BPHS in terms of education background, skills and professional titles (approximately 70% of LHWs have only an education of college level or below either with a primary professional title or with no title) . PHC sectors are even less developed in Guizhou compared with those in Chongqing [43, 44]. In China, less than 20% of CHCs in urban areas are held and funded by the government, almost 60% of CHCs have to use the rented buildings, and only 31.5% of CHCs meet the infrastructure requirements to provide PHC; also, 58% of LHWs attain a secondary school education or below and 70% of LHWs have only a primary professional title or no title .
Study participants and data collection
We used consecutive sampling method to recruit participants. All people who showed up in the selected THCs/CHCs, met inclusion criteria and were interested in our study during our study period were recruited as participants. The inclusion criteria included the following: (1) people aged over 60 years old; and (2) those who are willing to participate in the survey. The exclusion criteria included the following: (1) those who were diagnosed with a mental illness or had disturbed consciousness; (2) those who had difficulties with speech or hearing; and (3) those who declined to participate in the survey. All participants completed an informed consent form. A total of 772 aged people was included in questionnaire surveys.
A structured questionnaire with 4 sections was adopted to collect the data, including socio-demographic information (age, gender, height, weight, education, residence, occupation before retirement, health insurance, and distance to PHC sectors), knowledge about HMA, utilization of HMA and satisfaction with HMA. Questionnaire was designed by our research team through reviewing the existing literature reports and consulting experts before pilot study. Then, the questionnaire was pilot tested with 100 participants. All questionnaires were executed by trained investigators from our research group and the completed questionnaires were checked and examined by trained investigators for quality control.
Focus group discussions (FGD) were conducted to determine the actual needs and identify the barriers to HMA delivery from the aged individuals; the aged people for the FGDs were purposively selected with the help of PHC sectors in the study region. The aim and procedures of the study were explained to and agreed by the participants though signing a consent form. We convened 16 FGDs comprised of 8 male and 8 female groups. In-depth interviews were utilized to explore barriers on the delivery of HMA from LHWs who provide HMA to aged individuals and leaders who are responsible for BPHS; 32 in-depth interviews with 16 LHWs and 16 leaders from the department of public health in PHC sectors enrolled in our study were purposively selected.
A semi-structured topic guide was used for all interviews. The Practical Robust Implementation and Sustainability Model (PRISM) , widely used as a theoretical framework in implementation research [46, 47], was used to guide the topic design. With the guide of the PRISM, this study collected data on barriers to HMA delivery in the following aspects: HMA design (interventions), PHC sectors’ characteristics and aged residents (recipients), cooperation across related institutions (external environment), and PHC infrastructure for HMA (organizational implementation and sustainability of the infrastructure). All interviews and FGDs were conducted in Mandarin in local meeting rooms. Three senior researchers (LiLi, Shili Liu, and Mei Wang) conducted all the interviews and FGDs. Each interview lasted approximately 40–60 min, and each FGD lasted 1–1.5 h. All interviews and FGDs were audio-recorded with consent of the participants and professionally transcribed for analysis.
Epi Data 3.1 was used to enter data, and Statistical Package for Social Science (SPSS 21.0 (IBM Corporation, Armonk, NY, USA)) was used for data analysis. A two-tailed probability level of p < 0.05 was chosen as the level of statistical significance. Missing data were excluded from the analysis. Descriptive statistics were used to describe study participants’ characteristics, knowledge about HMA, utilization of HMA and satisfaction with HMA provision. Factors associated with knowledge, utilization and satisfaction screened by the Chi-square test (p < 0.05) (Appendix B) were entered into multivariate logistic regression models (having no knowledge of HMA = 0, no use of HMA = 0, dissatisfaction with HMA = 0; having knowledge of HMA = 1, use of HMA = 1, satisfaction with HMA = 1), which were used to examine the effects of those factors on knowledge, utilization and satisfaction.
The framework approach [48, 49] was used to analyze all qualitative data following a five-step process: familiarizing, indexing each transcript with a framework, summarizing data in an analytical framework, data synthesis and interpretation of data [48, 50]. Following the framework approach, all interviews were transcribed into a Word document, and then all transcripts were coded and classified. We generated themes on barriers for each part of the PRISM. The names of all the participants in the interviews were removed from the quotations of the results to preserve anonymity.
Demographic characteristics of participants
A total of 772 aged people was included in the questionnaire survey (Table 1). Among them, more than half (56.9%) were aged 60–69 years old, 62.1% were female, 71.1% were aged people from Chongqing, 61.4% were urban residents and 75% were married. Meanwhile, 63.1% received HMA from THCs, and 56.3% received HMA from PHC with better quality. Among the respondents, 62.9% had only primary school education or no education, and more than 1/3 were peasant farmers. Basic health insurance covered almost all of the aged individuals, while nearly 80% lived close to PHC sectors (less than 1 km). Notably, close to 30% of the respondents were overweight, and 5.9% were obese. In addition, almost 30% of aged people self-reported unwell health, and 78.5% endured chronic non-infectious disease including hypertension, diabetes, heart disease, arthritis, cataracts, etc.
Ninety-six aged people were divided into 16 FGD groups comprised of 8 male and 8 female groups. The participants were aged 60–90, with an average age of 71. Most of these participants had an education level of junior high school or below, and lived with their spouse. All of them had health insurance mainly consisting of a new rural cooperative medical system and health insurance for urban residents. Remarkably, most aged people reported chronic disease. Conditions such as age distribution, education degree, marital status, insurance category and chronic disease are shown in Table 2. Sixteen HCWs of 22–44 years old including 2 males and 14 females providing HMA program to the aged were interviewed; among them, 9 HCWs had a college education and 7 HCWs had middle school education; 5 HCWs have worked in this area for less than 5 years, and 8 HCWs for 5–15 years, 3 HCWs for 15 years and more. Sixteen leaders (9 males and 7 females) of 31–57 years old from the department of public health in PHC sectors enrolled in our study had in-depth interviews; Among them except for one leader only having education of middle school, the rest had a college education; 5 leaders have worked in this area for 5–15 years, 11leaders for 15 years and more.
Knowledge, utilization of and satisfaction to HMA
We evaluated the knowledge, utilization of and satisfaction to HMA among the aged through questionnaire survey.
The knowledge of aged individuals for HC, AE, HG and LE and HA were 95.9, 95.2, 88.8, 84.4%, respectively (Fig. 1). Multivariate logistic regression (Table 3) showed that compared with Chongqing, aged people in Guizhou had less knowledge on LE and HA, as well as on HG. Aged people in PHCs with poor quality knew better about the four items of HMA. As for factor like occupation, peasant farmers had less knowledge about LE, HA and HG compared to people who employed in enterprises/institutions/government and others. Aged individuals with a BMI < 18.5 had less knowledge of LE and HA, while overweight aged people know more about LE and HA with a BMI increased.
The utilization of aged individuals for HC, AE, HG, LE and HA were 94.7, 94.3, 89.0, 86.3%, respectively (Fig. 1). Multivariate logistic regression (Table 3) showed that urban residents had lower utilization of HG. Compared with Chongqing, aged people in Guizhou had less utilization of LE and HA, as well as of HG. Aged people in PHCs with poor level were more likely to use LE and HA, HC and AE. As for factor like occupation, peasant farmers had less utilization of HG, whereas they had higher utilization of AE. Aged individuals with a BMI < 18.5 had less utilization of LE and HA, while overweight aged people were more likely to use LE and HA with a BMI increased.
The satisfaction of aged individuals for HC, AE, HG, LE and HA were 94.0, 94.1, 95.4, 95.3%, respectively (Fig. 1). Multivariate logistic regression (Table 3) showed that female aged people were more satisfied with LE and HA, HC and HG than male respondents. Aged people were less satisfied with AE delivered by CHCs compared with that delivered by THCs.
Challenges in HMA delivery
All interviews and FGDs indicated that the PHC sectors in Guizhou delivered all HMA items (LE and HA, HC, AE and HG) for aged 65+ in Guizhou according to the national BPHS guideline. In Chongqing, both LHWs and leaders reported that the PHC sectors provided all HMA items to all people aged 60+ in Chongqing with funding support from the local government. In addition, more HC items (including Ultrasonic B and chest radiography) were provided free to all people aged 60+ in Chongqing. However, results of the in-depth interviews with both LHWs and leaders together with results from FGDs showed numerous challenges in HMA delivery, which are summarized in the 4 PRISM domains in Table 4.
Firstly, the fixed HC items are unattractive to the aged people because the items could not meet the various needs of the aged people, so not all of the elderly were satisfied with the current HMA program. Secondly, the performance assessment was inappropriate because it mainly emphasized the universal coverage of HMA program (the rate of the elderly included in HMA program) assessing the quantity of the program, but it ignored the quality of the HMA program delivery. Thirdly, funds are insufficient not only for provision of HMA service but also for the salary payment of LHWs. Hence, that PHC sectors had to take “clinical support public health” measures (to improve salary for HCWs who deliver BPHS by using the revenue from the clinic department in PHC sectors) were reported by many leaders and HCWs.
Firstly, poor health literacy among the elderly or their families was one of the main obstacles for the elderly to actively participate in HMA program. Secondly, PHC sectors are extremely short of fully-qualified LHWs to undertake HMA program.
The perceived external barrier was less multi-sector cooperation in HMA publicity and the organizing residents to receive HMA. Moreover, some LHWs reported poor internal cooperation between clinical and public health departments when delivering HMA. Accordingly, LHWs delivering HMA in PHC sectors were not only responsible for providing HMA service but also for organizing the elderly to participate HMA.
In recent years, the infrastructure has been improved in most PHC sectors, especially the buildings. However, outdated equipment and limited medicines in PHC sectors were still often reported. Some PHC sectors were located in inconvenient transportation areas, which was an obstacle for aged people to participate in HMA program.
In China, all items of HMA in BPHS are delivered by LHWs in PHC sectors. However, HMA delivery varies substantially among different regions. LE and HA, HC, AE and HG were the four items of HMA, we evaluated the achievements of HMA delivery by participants’ knowledge and utilization of, and satisfaction to each item of HMA. Regarding knowledge of HMA, 64.4% of aged individuals are familiar with HMA in Chengdu, Sichuan , while only 58.38% are familiar with HMA in Hubei ; both values are much lower than what we discovered. Our study also disclosed that at least 86% of aged individuals in Southwest China are willing to use HMA; which is much higher than 65.27% in Urumqi City . More than 90% of aged individuals are satisfied with HMA in the Sichuan and Shandong provinces [13, 51], which is consistent with our study, while lower levels of satisfaction are found in Henan (49.3%) , Hubei (51.27%)  and Zhejiang (64.4%)  Provinces. We discovered that the knowledge, utilization and satisfaction of HMA are relatively higher in Southwest China compared to other regions [18, 20, 27, 51, 52]; especially the rate of satisfaction, which exceeds 94%.
Individual studies analyzed factors associated with HMA delivery found that the aged people in rural area were more likely satisfied with HMA program [15, 53], but another study reported that the aged people in urban area were more likely to use HMA . Our results from multivariate logistic regression model similarly found that characteristic of the aged population, including gender, occupation and BMI as well as the quality of PHC sectors and economy of living place, were associated with knowledge, utilization and satisfaction to HMA. Therefore, more attention should be focused on the aged people from less developed area and in PHCs of good quality with overweight/ female/farmers aged people, when implementation of HMA. These results hinted the strategy to deliver HMA program, which need adapt to the aged population with different characteristics.
This study also confirmed that HMA delivery is confronted with various and complex challenges, despite that all PHC sectors carrying out HMA have made many achievements in Southwest China.
Foremost, the HMA item itself has several barriers. Firstly, the equalization of BPHS emphasizes providing BPHS that is responsive to residents’ needs rather than providing the same BPHS to everybody. Thus, the one-size health check-up items in HMA cannot fit all the needs of aged individuals with increasing health needs of the elderly according to the qualitative study. Furthermore, our study disclosed that PHC sectors delivered the one-size HC in Guizhou to aged individuals, which is not attractive enough and cannot meet aged individuals’ actual needs; similar outcomes have been reported by Zhao HF  and Li L . Although HMA in a better economic region, such as Chongqing, increased several items of HC, it could still not meet all the needs. The WHO put forth “people-centered and integrated health service” in 2015 , which implied that the equalization of BPHS required a thorough and regular health needs assessment to detect the current health problems faced by local people, and the assessment can be used to design needs-based program. So, the HMA program design needs to continually update and conduct health needs assessment of aged individuals to be able to better respond to their health needs. Secondly, an appropriate performance assessment system is the key to ensure the orderly development of HMA items . Actually, consistent with the findings of Hu XY , we discovered that the present performance assessment focusing more on the rate of aged individuals participating in HMA in Southwest China is contrary to the policy of optional participation by aged individuals. Hence, performance assessment could be modified to consider both coverage and quality of HMA. Thirdly, as for insufficient funds for the HMA program, which has been reported in Hainan province , the majority of PHC sectors in Southwest China adopt a method with the definition of “clinical support public health” (to improve salary for HCWs who deliver BPHS by using the revenue from the clinic department in PHC sectors), which is unfortunately far from enough. On the other hand, funding for LHW employment is insufficient in PHC sectors , which results in LHWs’ low income and potential of aggravating the plight of LHWs shortage.
Poor health literacy is one of the main barriers among aged individuals. Wen XQ et al.  suggested that improving the health literacy of aged individuals could significantly increase the effective utilization of HMA and promote their health. Our study disclosed that some aged residents are reluctant to participate in HMA because they do not recognize the importance of prevention, and thus consider it was unnecessary to take the same check-up every year, which is similar to the report by Shi FF  in Chengdu. Furthermore, we found that some aged people are unwilling to encounter the pressure of diseases and associated economic burden, similar to the report by Jiang RQ . In addition, our study also found that in spite of possessing health literacy, some aged people still fail to access HMA for the poor health awareness of their family.
Furthermore, PHC capacity is the driving force of the quality of HMA. Although with great emphasis from the central government PHC sectors in China have developed rapidly since 2006, our study indicated that a low capacity of PHC is a key barrier to deliver qualified HMA. According to the people-centered model, LHWs should provide service that is responsive to the needs and expectations of older people [58, 59]. To achieve this goal, PHC sectors must have a multidisciplinary LHW team to provide integrated care with good quality . The team members must have strong professional competencies and take full advantages of these talents. In addition, it is important to ensure that LHWs have basic gerontological knowledge and skills, as well as general competencies to work in integrated systems, including communication, teamwork and other skills . Unfortunately, we found that all PHC sectors in Southwest China lack enough qualified LHWs. And LHWs for HMA often undertake multiple BPHS items with heavy workloads. Similarly, Liang XH  discovered that there is still a substantial shortage of LHWs for BPHS in Chongqing. Additionally, Yang L et al.  revealed that with increasing BPHS items, sufficient LHWs are not equipped simultaneously, which exacerbates the shortage of LHWs in PHC sectors. Furthermore, heavy workload and low income results in unstable work teams in PHC sectors . We found that PHC sectors are extremely short of general practitioners and that the current LHWs for HMA often have low education level and no related professional background, which is consistent with the findings of Cai XN  in Haikou. Meanwhile, Li W et al.  confirmed that there are currently “four low levels” of “low education, low professional ability, low technical title and low salary” among LHWs delivering BPHS in Chongqing. Healthcare workers with high education and professional titles are not willing to work in PHC sectors with low salaries, which may further lead to the loss of valuable LHW teams. Remarkably, limited knowledge prevents LHWs from providing efficient and qualified HMA for aged individuals.
Regarding the external environment, though we find 95% aged people know about HMA program, but qualitative results indicated the poor literacy of the elderly is the reason for them to inactively participate in HMA program, which has been consistently reported by Yu L  and Wei YL  in other cities. Our study disclosed that the utilization of HMA could be improved with support from the families of aged individuals. In China, PHC sectors are not well recognized by residents. All BPHS programs delivered by PHC sectors including HMA need multi-sector cooperation to disseminate the program information to residents, and to organize residents to participate in the programs, or to share health information. However, this study found the multi-sector cooperation or whole social participation in HMA is of great essentials and need to be attached more importance. We found that current propaganda work on BPHS only depends on PHC sectors themselves, whose work is far from enough to have aged individuals, their families or our society as a whole to accept the HMA program. The government and media fail to take their roles in HMA propaganda. LHWs do not receive support from sub-district offices, neighborhood committees, urban management, community management or superior hospitals during the implementation of HMA. PHC sectors work independently to provide HMA, resulting in difficulties in obtaining support and recognition from aged individuals and others.
The disease-based curative models should transform to the provision of older-person-centered integrated care . “Integrated care” ensures that people receive a continuum of health promotion, disease prevention, diagnosis, treatment, disease management, rehabilitation and palliative care services at different levels and sites of care within the health system, according to their needs throughout their whole life , which is indispensable from multi-sector cooperation. However, it is difficult to achieve “integrated care” only by contacting and coordinating PHCs. The joint effort of departments in PHC sectors and the cooperation between departments of social security and health care are necessary to further improve work efficiency and effectiveness of HMA programs.
Finally, insufficient materials and outdated equipment are common in PHCs . Although hardware conditions in PHCs have improved recently, there still exist problems such as lack of space, barrier-free facilities shortages and poor transportation in rural areas . Due to outdated equipment (for example, no computed tomography in most PHCs), some aged distrust the medical examination results, which may reduce their enthusiasm in the participation of HMA. The lack of common medicines, such as drugs for chronic diseases, have the aged individuals unable to enjoy “one-stop service” in PHC sectors, which also fortifies the difficulty of HMA implementation.
Strengths and limitations
A previous study on HMA in BPHS focused on the rate of HMA provision in PHCs [24,25,26,27], aged residents’ knowledge, and utilization or satisfaction with HMA [14,15,16,17,18,19,20,21,22,23,24, 63, 64], and only a few studies have explored the barriers in PHCs to implement HMA [28,29,30, 32, 55]. Our study is the first step towards a systematic assessment of HMA provision in Southwest China to discover the main challenges and provide further constructive countermeasures. However, we did not include policymakers from the local Health and Family Planning Commission, as our study focused on participants who could provide information about their difficulties of and suggestions on addressing barriers faced by PHC sectors, along with participants of a questionnaire survey who were recruited from PHC sectors rather than from the community. The aged people included in this study were recruited from PHCs and may be more likely to trust PHC sectors and be more accessible to HMA service than those who were excluded; thus, the rates of knowledge, utilization and satisfaction to HMA of study participants could be higher than those of the overall aged community, which would be a bias for questions on knowledge and utilization of, and satisfaction on HMAs in the structured interview.
HMA is aimed at the early detection of risk factors, controlling disease and promoting healthy ageing. The findings from this study may not generalize to other provinces in Central and Eastern China, where socio-economy and PHC sectors have developed better compared to those of Southwest China; however, based on evidence from this study, public health strategies can be taken on by regions in Western China or countries with the same socio-economic characteristics to promote healthy ageing. For each specific context, the exact mix of strategies can be developed, with local contexts, values and preferences taken into account .
Foremost, a comprehensive assessment with fully understanding the situation in each PHC, optimizing the performance assessment strategy and giving priority to performance appraisal orientation of the health needs of local aged is imperative for designing older-person-centered HMA programs. Secondly, sufficient funding is the precondition for the implementation of HMA in all fields, such as health demands assessment, health literacy improvement, and strengthening software and hardware in PHCs. Thirdly, by increasing and reinforcing government and media roles in the propaganda of HMA programs, the participation and self-care capacity will be further improved. Moreover, better health literacy could guarantee more real and effective results of health needs assessment, which is the main factor for the knowledge, utilization and satisfaction of HMA as well . Fourthly, the development of LHWs’ competency should be at the center of capacity building in PHC sectors. Emphasizing in-service training and continuing professional development are essential for consolidating knowledge and upgrading skills for LHWs. Some strategies and incentives such as the introduction of a pension program, support for professional promotion, and bonuses  are also essential to attract qualified LHWs. Last but not least, hardware capacity and more investment from the government are needed to reinforce basic infrastructure construction and extend the basic medication directory to narrow the gap with tertiary hospitals, in particular, to increase the amount of drugs needed to treat common diseases among aged individuals in PHCs.
Acceleration of ageing brings unprecedented challenges to the health system in developing countries such as China. The Chinese BPHS program has paid great attention to the health care of aged individuals, and HMA in BPHS has achieved progress, as demonstrated by the fact that the knowledge on and utilization of, satisfaction to HMA of aged people was higher in recent years in Southwest China compared with other regions in past years. However, HMA in this region is facing challenges in further quality improvement. The “older-person-centered and integrated care” model provides a sound and profound theoretical basis to address those challenges, including reinforcing the needs-based HMA design, building the capacity of PHC sectors, improving the LHWs’ competency as well as strengthening multi-sector cooperation.
Availability of data and materials
The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.
Basic Public Health Service
Community Health Center
Focus group discussion
Healthcare Management for the Aged
- LE and HA:
Lifestyle Evaluation and Health Assessment
Lay Healthcare Workers
Primary Health Care
Practical Robust Implementation and Sustainability Model
Statistical Package for Social Science
Township Hospital Center
World Health Organization. World report on ageing and health. 2015. Available from: http://apps.who.int/iris/bitstream/10665/186463/1/9789240694811_eng.pdf?ua=. Accessed 10 Oct 2017.
Prince MJ, Wu F, Guo YF, Gutierrez Robledo LM, O'Donnell M, Sullivan R, et al. The burden of disease in older people and implications for health policy and practice. Lancet. 2015;385:549–62.
Zheng GC. The National People's Congress and the Chinese Political Consultative Conference in 2018: Netease news; 2018. Available from: http://news.163.com/18/0312/16/DCN9NT6I0001899N.html. Accessed 12 Mar 2018.
Zeng Y. Towards deeper research and better policy for healthy aging—using the unique data of Chinese longitudinal healthy longevity survey. China Econ J. 2012;5:131–49.
Zeng Y, George LK. Population aging and old-age care in China. In: Dannefer D, Phillipson C, editors. Sage handbook of social gerontology. Thousand Oaks: Sage publications; 2010. p. 420–9.
Fang EF, Scheibye-Knudsen M, Jahn HJ, et al. A research agenda for aging in China in the 21st century. Ageing Res Rev. 2015;24:197–205.
Hunter DJ, Brown J. A review of health management research. Eur J Pub Health. 2007;17(Suppl 1):33–7.
Ministry of Health. National guideline of basic public health services (version in 2017). China: Ministry of Health; 2017. introduction.
Liang SX, Deng HY, Liu SL, Wang G, Li L, Wang M, et al. Competency building for lay health workers is an intangible force driving basic public health services in Southwest China. BMC Health Serv Res. 2019;19(1):596.
Li T, Lei T, Xie Z, Zhang T. Determinants of basic public health services provision by village doctors in China: using non-communicable diseases management as an example. BMC Health Serv Res. 2016;16:42.
Jin C, Cheng J, Lu Y, Huang Z, Cao F. Spatial inequity in access to healthcare facilities at a county level in a developing country: a case study of Deqing County, Zhejiang. Chin Int J Equity Health. 2015;14:67.
Ministry of Health. National guideline of basic public health services (version in 2009). China: Ministry of Health; 2009. p. 2–9.
Yao YX. JiJiHaErShi. Community old people health management needs and present situation investigation. China Health Ind. 2011;8(19):26–7.
Yu L, Gu LP, Hu JQ, Liu HX. Survey on health knowledge and basic public health service satisfaction among focus groups in Shinan District of Qingdao, Shandong Province. Chin J Health Educ. 2012;28:759–61.
Li L, Xu SS, Ji JM, Qin X, Liu YN, Li SX. Surveying the senior citizens health management situation in primary medical institution of Shandong Province. Chin Health Serv Manage. 2013;04:313–5.
Bao SM, Zhang KJ, Tang SZ. The analysis of demands for health management of the aged in Nanjing community. Chin J Gerontol. 2014;34:6753–5.
Hong M. Analysis and enlightenment on health management of the aged in China. Chin Rural Health Serv Adm. 2014;34:1516–8.
Shi FF, Li L, Liu ZJ, Liu DP, Zhang Q, Sun M. Qualitative assessment of health management service demands among aged residents in Urban Community: taking Chengdu as an example. J Prev Med Inf. 2014;30:101–4.
Wang YL. The role of basic public health services in the health management of the aged in community. World Latest Med Inf. 2015;15:157.
Zhou XC, Wang Y, Niu HY. Basic public health service in Zhejiang province. Chin J Gerontol. 2015;35:2528–9.
Dong F, Jiang ZQ, Wang J, Wang Q. Study on the health management needs and implementation path of aged residents in urban communities. Mod Pract Med. 2016;28:535–7.
Yao X, Zhao YF, Deng F. Current situation of service utilization and supply of community health service institutions in Urumqi City. Chin Gen Pract. 2016;19:4173–7.
Kang JM, Li XT, Zhao Y, Chen R, Zhang YQ. Investigation of awareness rate of basic public health service among rural aged in Jiangjin District. J Mod Med Health. 2017;33:2599–602.
Jiang RQ. Study on the current situation of health management service for the aged in community. Syst Med. 2017;2:124–7.
Shang XP, Ye CY, Yang Q. Investigation on the knowledge condition of basic public health service in Zhejiang province. Prev Med. 2017;29:1174–1177+1180.
Xie YY, Xie JJ, Wan XG, Wang DH. Study on survey analysis and countermeasures of aged health management services in Hainan province. Chongqing Med. 2017;46:4232–5.
Zhang L, Qiao C, Lou PA. Investigation of health management services for people above 64years old in Xunzhou rural areas. Chin Prim Health Care. 2015;29:1–3.
Tian L, Sun GF, Xie HF. The present situation and countermeasures of the health management of the aged in Urumqi on 2014. Chin J PHM. 2016;32:412–3.
Lv H, Hong X, Feng H, Huang SS, Zhang X. Supply analysis of health management service of rural aged in Henan province. Chin J Gerontol. 2016;36:4313–4.
Hu XY, Pu C, Lin H. Analysis of performance assessment situation of basic public health Services in Chongqing. Chin Gen Pract. 2014;17:3527–30.
Liang XH, Zhang P, Shen XL. Research on the Measurement of Public Health Service Manpower Costs of Chongqing. Chin Gen Pract. 2014;17:1477–1480, 1494.
Liu ZR, Yuan Y, Zhang R. Survey on service capacity of health management of township and community health centers in the aged in Meishan city. J Prev Med Inf. 2016;32:117–20.
Huang L, Zhang L. The current situation of community health service for the aged people in Chongqing. Chongqing Med. 2010;39:1362–5.
Sun YM, Yang XL, Feng XW. Implementation of essential public health Services of Primary Medical and Health Care Institutions in Chongqing. Chin Gen Pract. 2015;18:227–30.
Zhao Y, Cui S, Yang J, Wang W, Guo A, Liu Y, et al. Basic public health services delivered in an urban community: a qualitative study. Public Health. 2011;125:37–45.
Song KM, Xu L, Sun XJ. Analyzing the basic public health service function of primary health care sectors in urban and rural area. Chin J Health Inform Manage. 2012;1:23–5.
Ma JT. Commissioner. Press Release on Major Figures of the 2010 National Population Census. In: National Bureau of Statistic of China; 2011.
National Bureau of Statistics. China Statistical Yearbook: China Statistics Press; 2018. http://www.stats.gov.cn/tjsj/ndsj/2018/indexch.htm. Accessed 20 Sept 2018.
Fang F, Zhang HY, Xu D. Aging of Chongqing and its impacts on economic development. China Popul Resour Environ. 2015;S1:426–9.
Wei P, Wu XL. The aging history, characteristics and trends of population in Guizhou province. China Soc Welf. 2013;06:9–17.
Wang Q, Zhou YF. Community health Services in Chongqing to analyze the current situation and development countermeasure. Chin Prim Health Care. 2012;07:29–30.
Wang XQ, He ZC, Yang RX, Tang GZ. Status of human resource allocation in community health service centers in Chongqing central urban zone. Chin Gen Pract. 2011;13:1413–5.
Jing ZJ, Yang KQ, Wu XP, Xian YH. Investigation and analysis of City Community sanitary Service in Guizhou Province. Med Philos. 2007;05:22–23,32.
Sun Y. The development status and countermeasures of community hospital in Guiyang city. J Qiannan Med Coll Nationalities. 2016;4:259–60.
Feldstein AC, Glasgow RE. A practical, robust implementation and sustainability model (PRISM) for integrating research findings into practice. Jt Comm J Qual Patient Saf. 2008;34:228–43.
Schneider JL, Davis J, Kauffman TL, Reiss JA, McGinley C, Arnold K, et al. Stakeholder perspectives on implementing a universal lynch syndrome screening program: a qualitative study of early barriers and facilitators. Genet Med. 2016;18:152–61.
Liles EG, Schneider JL, Feldstein AC, Mosen DM, Perrin N, Rosales AG, et al. Implementation challenges and successes of a population-based colorectal cancer screening program: a qualitative study of stakeholder perspectives. Implement Sci. 2015;10:41.
Smith J, Firth J. Qualitative data analysis: the framework approach. Nurs Res. 2011;18:52–62.
Srivastava A, Thomson SB. Framework analysis: a qualitative methodology for applied policy research. J Adm Gov. 2009;4:72–9.
Ward DJ, Furber C, Tierney S, Swallow V. Using framework analysis in nursing research: a worked example. J Adv Nurs. 2013;69:2423–31.
Wei YL, Lu R, Zeng W, Xia JJ, Liang X, Peng Z. Analysis on Community-based Management for Elder Population in Chengdu. Chin J PHM. 2011;27:414–5.
Tian DW. Three officer Temple residents basic public health services use and Ser—vice satisfaction the current investigation. Chin Health Ind. 2016;13:181–3.
Cai XN, Zhu Q. Analysis on the health management of the aged in Haikou. Hainan Med J. 2016;27:3569–71.
Zhao HF, Li H. The current situation and development direction of the aged health management. Foreign Medl Sci (Geriatrics). 2008;29:187–9.
World Health Organization. WHO global strategy on people-centered and integrated health services. Interim report. 2015. Available from: http://apps.who.int/iris/bitstream/handle/10665/155002/WHO_HIS_SDS_2015.6_eng.pdf;jsessionid=9ACA6593FC45E14BDC4E8AFF2BF8D1B?sequence=1. Accessed 10 Oct 2017.
Liu SM, Wang XX, Tian XX, Zhang YX, Xie J, Zhang WQ. Investigation on the utilization of basic public health service in some rural areas of Shandong. Mod Med J China. 2015;17:1–4.
Wen XQ, Zhao J, Zeng QQ, Zheng YT, Chang C. Influence of increasing health literacy on utilization of essential public health services among aged population. Chin J Dis Control Prev. 2016;20:204–6.
National Ageing Research Institute. What is person-centered health care? Melbourne: Victorian Government Department of Human Services; 2006.
World Health Organization. Regional Office for the Western Pacific. International Symposium on People-Centered Health Care: Reorienting Health Systems in the 21st Century. The Tokyo International Forum 25 November 2007. Available from: http://iris.wpro.who.int/bitstream/handle/10665.1/5920/WPR_2007_ICP_MNH_2.4-E_eng.pdf. Accessed 10 Oct 2017.
Yang L, Yan X, Lin H. Research on the post responsibility of primary medical and health institutions in Chongqing. Chongqing Med. 2014;43:2093–4.
Lei W. Research on the health service of urban community in Chongqing. Chongqing: Chongqing Medicine University; 2012.
Liu LQ, Yang XH, Li J, Guo XH, Li CY, Liang WN. Equipment actuality of Chinese community health service centers and the compare among east, middle, west areas. Chin Gen Pract. 2005;15:1215–8.
Yang H, Muhemaiti M. Analysis of development of community health Service in Middle and Western Regions. Chin Gen Pract. 2007;23:1991–2.
Zeng QQ, Chang C, Jiang Y, Yuan YF, Wen XQ, Sun YH. Association between health literacy and utilization of basic public health services among urban aged residents. Chin J Health Educ. 2014;30:771–6.
Dai YY, He GP. The development trend and challenge of health management in China. Chin Prev Med. 2011;12:452–4.
The authors would like to thank the participants who responded our questionnaires. We also thank all LHWs and leaders in the PHCs in study places who participated in our interviews and supported this study by facilitating implementation of the field questionnaire survey of residents.
The study was funded by the fiftieth Scientific Research Foundation for the Returned Overseas Chinese Scholars State Education Ministry and Science and Technology Basic and Advanced Research projects in Chongqing (cstc2014jcyjA10069). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
Ethics approval and consent to participate
The study’s protocol and data collection procedure were approved by the Institutional Review Board of Preventive Medicine College, Army Medical University (Third Military Medical University), Chongqing, China. All participants had completed written informed consent.
Consent for publication
The authors declare that they have no competing interests.
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
About this article
Cite this article
Li, L., Zhang, R., Chen, Y. et al. Achievements and challenges in health management for aged individuals in primary health care sectors: a survey in Southwest China. BMC Public Health 20, 338 (2020). https://doi.org/10.1186/s12889-020-8210-2
- Health management
- Aged individuals
- Basic public health service
- Lay healthcare worker