Improving primary healthcare quality in China through training needs analysis

Study subjects

The study population comprised Chinese healthcare workers. The inclusion criteria were (1) aged 18 years or older; (2) capable of independent decision-making; and (3) engagement in frontline clinical work in hospitals or clinics for at least six months. The exclusion criteria included (1) aged below 18 years; (2) non-frontline medical personnel; and (3) individuals with psychiatric disorders who cannot cooperate or is unwilling to participate.

Methods

Research design

This study utilized a cross-sectional survey design on a national scale. We developed an original survey titled “Strengthening Primary Care Medical Needs Questionnaire,” which included sections on personal demographics, previous training content/frequency, satisfaction with past training, current training needs, preferred training frequency, and anticipated future training topics and programs. To ensure that the survey design accurately reflects the needs of the target population, we conducted an extensive literature review and conducted field visits to several primary healthcare facilities to collect preliminary data. These preparatory efforts provided the basis for the targeted design of the questionnaire.

Healthcare facilities were categorized by administrative levels, including provinces, autonomous regions, municipalities, prefectures, counties, townships, communities, and villages. The focus was on the training needs of medical personnel at the county level/prefecture level and below, collectively referred to as primary healthcare facilities.

Survey design

The survey aimed to collect data on the training needs related to diagnostic and service enhancement skills of medical staff. It consisted of structured single and multiple-choice questions, rating/scale questions, and open-ended questions. Satisfaction was rated on a Likert scale from 1 (dissatisfied) to 5 (highly satisfied). To ensure the practicality of the survey, extensive literature review and field visits to primary healthcare units were conducted to gather preliminary data, which informed the targeted design of the survey.

Survey content

The questionnaire collected basic information such as gender, age, years of experience, professional title, and educational level. It also included sections on past training experiences (annual number of trainings, topics, and satisfaction), current training status (desired frequency, medical/technical skills, management, teaching/research needs, and preferences), and future training needs (most anticipated training topics such as clinical guidelines, new theories, technologies, methods, and teaching/research).

Survey evaluation

To ensure the practicality of the survey, we conducted preliminary survey preparation and an extensive literature review in early April 2023, prior to formal questionnaire distribution. In mid-April, we visited a remote township health center, where we delivered a training session on the latest version of “Clinical Diagnosis and Treatment Guidelines Interpretation and Clinical Medication Guidance” to local primary healthcare workers. After the training, participants expressed a strong desire for such sessions to be held regularly. Through face-to-face interviews with healthcare staff, we gained an initial understanding of their urgent need for clinical skill enhancement. Two weeks later, we revisited the same township health center and provided a more in-depth and systematic interpretation of the latest clinical guidelines and practical skills training. Based on their feedback regarding training needs, we conducted a preliminary survey to assess their demand for training aimed at improving clinical competence. The questionnaire was subsequently refined, incorporating the results of this pre-survey, to better reflect the actual needs of primary healthcare workers.

Questionnaire validation

To assess the reliability of the questionnaire, a revised version was sent to participants who completed the pre-survey two weeks after the initial administration, along with a follow-up explanation. A total of 124 healthcare workers participated in the pre-survey. For the pilot study, a reliability test was conducted, with test-retest reliability coefficients (for demographic data) exceeding 0.865. The satisfaction ratings demonstrated strong internal consistency, with a Cronbach’s alpha of 0.924 and a Kaiser-Meyer-Olkin (KMO) value of 0.836, indicating high reliability and validity of the questionnaire.

Sample size calculation

This study is a cross-sectional investigation aimed at estimating the demand for skill training among primary healthcare workers in China. Based on previous research and preliminary survey results, the rate of demand for training, which represents the proportion of primary healthcare workers estimated to express a need for skill training was anticipated to be 64%. A two-sided test was utilized with an alpha (α) of 0.05 and an allowable error margin of 0.02. Using PASS15.05 software(NCSS, LLC, Kaysville, UT, USA), the required sample size was calculated as N = 2261. Considering a non-response rate of 20%, at least 2827 participants had be included in the survey.

Data collection process

The survey was conducted from May 1, 2023 to January 31, 2024 using the “ platform. A convenience random sampling method was employed; to enhance the representativeness of the sample, we carefully considered different regions across China, including areas with varying levels of economic development, healthcare infrastructure, and medical needs. We selected medical facilities from Yunnan, Sichuan, Xinjiang Uygur Autonomous Region, Inner Mongolia Autonomous Region, Shanxi, Hebei, Shandong, and Zhejiang provinces for this nationwide cross-sectional survey. All selected facilities were nationally certified healthcare institutions. Through collaboration with local authorities, associations, and individual healthcare workers, we primarily included healthcare professionals from the prefecture/county- levels and below, which are the most representative of primary healthcare in these regions.

Medical personnel were invited to participate in the survey, through multiple channels, including corporate WeChat, Tencent QQ, hospital/department WeChat groups, professional associations/societies, and on-site conference surveys using a snowball sampling approach. Additionally, invitations were sent through the nationally authenticated medical personnel learning and exchange platform “Doctor Circle” application to professional groups and individuals. Each smartphone/IP address was restricted to submitting only one questionnaire, and submission was allowed only after all questions are answered, all of which were mandatory.

Quality control of questionnaires

Before the survey, a thorough understanding of the basic situation of the selected units was established. Liaison officers familiar with the operations of their institutions conducted pre-survey publicity and explanations to ensure the respondents could answer questions without reservations. During the implementation, all participants were required to confirm their identity as healthcare professionals before the survey, and strict monitoring was performed to eliminate non-medical personnel’s questionnaires. After the responses were collected, two trained data verification officers reviewed all the questionnaires, discarding those with excessively short completion times, contradictory logical answers, incorrect information, or non-medical professional respondents. Stringent quality control measures and management were maintained throughout the project to ensure data reliability.

Data analysis methods

The cleaned data were analyzed using IBM SPSS Statistics version 24.0(IBM Corp., Armonk, NY, USA).Descriptive statistical analysis was used to describe the basic characteristics of the participants, with frequency and percentage used to present categorical data and the χ2 test used for intergroup comparisons. Cronbach’s alpha coefficient, Pearson’s coefficient, and the KMO test were employed to evaluate the reliability and validity of the questionnaire. Differences in training needs between county-/prefecture-level and township-level primary healthcare facilities were initially analyzed using univariate analysis (χ2 test), followed by multivariate logistic regression analysis to analyze factors with P < 0.25 to avoid prematurely excluding variables that may have weaker associations in the univariate analysis but could become significant in the multivariate analysis after adjusting for other factors (a less stringent P-value of < 0.25 is typically used in the initial stage). Further analysis was conducted to explore the main factors affecting training at the grassroots level. A significance level of α = 0.05 was used, with P < 0.05 considered statistically significant.