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.