| Background:Tuberculosis(TB)is a major infectious disease that seriously endangers the health of the public and is one of the major public health problems facing the world.China has the second highest burden of TB in the world,and the TB epidemic situation is severe.Primary healthcare institutions are not only the main implementers of China’s basic public health service projects,but also an important part of Chinese "Integrated" TB prevention and control service system,which plays a key role in the control of Chinese TB epidemic.However,in the western region where the TB epidemic is severe,the development of primary healthcare institutions is relatively backward,which affects the provision of TB prevention and treatment services.The TB prevention and health service provided by primary healthcare institutions to the public is an important public service.From the perspective of public services,we will comprehensively and systematically explore TB prevention and control in primary healthcare institutions in the western part of China where the epidemic is severe.Exploring the current status of TB services,existing problems and related influencing factors,so as to scientifically put forward targeted countermeasures and suggestions are of great significance to comprehensively improve local TB prevention and control services and address the TB epidemic.Research purposes:This study takes Chongqing City(Yu)and Guizhou Province(Qian)in the western region where the TB epidemic is severe in China as the research site.From the perspective of new public services,based on the PRISM(Practical,Robust Implementation and Sustainability Model)model,"patient-oriented Center" and "Integrating Health into All Policies" and integrating the perspectives of both health service supply and demand sides,this study comprehensively and systematically evaluated the status,existing problems and related influencing factors of TB prevention and control services in primary healthcare institutions in Chongqing and Guizhou.And forward based on scientific evidence,finally put forward targeted and feasible countermeasures and suggestions for promoting TB prevention and control services in primary healthcare institutions in Chongqing and Guizhou.Research methods:In this study,a mixed research method combining quantitative and qualitative methods was used,and stratified random sampling method was used to determine the research site,and the TB prevention and treatment medical personnel in the primary healthcare institutions(hereinafter referred to as ‘PHI’)in 28 counties/districts were finally selected.Quantitative research(questionnaire survey),and qualitative research(personal in-depth interviews)on TB healthcare workers(provider),TB prevention related leaders(management side)and TB patients(demand side)were conducted.1.Quantitative researchStratified random sampling method was used to determine the research site according to the epidemic level of counties/districts in the Yu-Qian area.Questionnaire survey was carried out among the TB health workers in PHIs with self-constructed and validated survey tools.The main contents include: the characteristics of TB health workers in primary healthcare institutions(including demographic characteristics,mastery of core knowledge of TB prevention and control,mastery of "patient-centered" doctor-patient communication skills,and TB related training),delivery status of TB prevention and control services,and existing problems and relevant influencing factors for the delivery of TB prevention and treatment services.Descriptive statistical analysis,correlation factor analysis(t test and chi-square test)and path analysis were used for quantitative data.Data analysis was performed using SPSS 22.0and AMOS 24.0 software.2.Qualitative researchThe purposive sampling method was used to select TB healthcare workers in PHIs,TB prevention and control related leaders,and TB patients as the research objects.The final sample size was determined by the principle of information saturation,and the semi-structured interview outline was used to conduct in-depth interviews with the research objects to explore the problems existing in the delivery of TB prevention and treatment services in PHIs in YuQian area.Qualitative data were analyzed using the Thematic framework approach,based on the perspective of the new public service theory and the PRISM theoretical model.Research results:1.Characteristics of the intervieweesQuantitative research surveyed 2720 TB healthcare workers in PHIs in Yu-Qian area,including 1270 at the township level and 1450 at the village level.The results of the study found that the primary TB healthcare workers in townships are mainly female,the age group is concentrated in 20-39 years old,the education level is mainly college or above,the specialty is clinical and nursing,and the professional titles are mainly junior or none.Most of the healthcare workers are male,mainly aged 40 and over,college degree or below,and most of them have received medical school education,majoring in clinical,general medicine and traditional Chinese medicine.Most of the professional titles are junior or none;the income of primary tuberculosis prevention and control medical personnel is all low.The work burden of primary TB healthcare workers in Yu-Qian area is heavy,especially at the village level.Most villagelevel healthcare workers undertake more than five health tasks.The turnover of primary TB healthcare workers is high,and 30% of the respondents have been engaged in TB work for less than 2 years,especially in Guizhou.In Chongqing and Guizhou,the TB prevention and control service capabilities of primary healthcare workers are generally poor,and the mastery status of core knowledge of TB prevention and control among primary mastery is low,especially in the contents of "patient treatment";"patient-centered" doctor-patient communication skills.In terms of training status,the coverage rate of TB prevention and control training among healthcare workers in Yu-Qian area is relatively high(93.5%),and the number of village-level healthcare workers receiving training is more than that of township medical staff.TB healthcare workers are willing to receive training(99.7% at both township and village levels).More than80% of primary TB healthcare workers have training needs in "doctor-patient communication skills",while village-level healthcare workers show higher training needs than township-level healthcare workers(≥ 2times/half a year and 1-2 times/year,respectively).Most of the healthcare workers hope to obtain online network training.Less than 50% of the primary TB healthcare workers in Yu-Qian are satisfied with their current work,especially in Chongqing,only 37.9% of township-level healthcare workers are satisfied with their work.And the main reasons for job dissatisfaction are low salary,high work intensity,high risk of infection,insufficient self-ability,limited career development,lack of preparation and unreasonable work assessment.The qualitative study completed the collection of in-depth interview data of 20 relevant personnel,including 7 primary TB prevention and treatment medical staff,9 TB prevention and treatment leaders,and 4 TB patients.2.Current situation and existing problems of TB prevention and treatment services in primary healthcare institutions in Yu-Qian areaThe total implementation rate of TB prevention and treatment services in PHIs in Yu-Qian area was 84.4%,which was lower than the 90% required by China’s norms.The township level(84.4%)was better off than the village level(79.3%).At the township level,Chongqing(87.5%)performed better than Guizhou(81.3%).At the village level,Guizhou(80.3%)performed better than Chongqing(76.4%).Among the various types of TB prevention and treatment services,PHIs in Yu-Qian need to focus on strengthening the supply of four types of TB prevention and treatment services: "targeting key groups","recommending patients","patient treatment management" and "other services for patients".The problems in the development of TB prevention and treatment services in PHIs in YuQian mainly include: such as the lack of "patient-centered" provision of TB prevention and treatment services,the imperfect incentive mechanism for TB prevention and treatment,the unscientific assessment mechanism,the lack of sufficient TB prevention and treatment medical personnel,the low ability of primary TB healthcare workers,the lack of high-quality TB training for primary TB healthcare workers,the low socio-economic and cultural level of TB patients,poor health literacy,sense of stigma,widespread social discrimination against TB,poor cooperation within the TB prevention and treatment service system(insufficient cooperation with the TB designated hospitals),the situation of the whole society participating in TB prevention and treatment has not really formed(insufficient cooperation among relevant departments of society,insufficient sharing of common benefit and common responsibility),lack of sufficient guarantee of public services related to TB prevention and treatment(health funds,material resources and medical insurance protection).3.Analysis of related factors in the delivery of TB prevention and treatment services in primary healthcare institutions in Yu-Qian areaAnalysis of the main factors affecting the delivery of TB prevention and treatment services in township-level PHIs: binary Logistic regression analysis found that the number of health tasks,training times and job satisfaction were related to the delivery of township-level TB prevention and treatment services.Township-level healthcare workers who undertake 2-3health tasks are less likely to implement TB prevention and treatment services than full-time TB healthcare workers(OR=0.662;95%CI: 0.482-0.909);township-level healthcare workers who have received twice trainings in the past six months are less likely to carry out TB prevention and treatment services than those received ≥3 times(OR=0.642;95%CI: 0.483-0.854);township healthcare workers with general /unsatisfactory job satisfaction had a lower probability of TB prevention and treatment service delivery rate ≥90% than those with job satisfaction(OR=0.511;95% CI: 0.387-0.676).The path analysis found that low job satisfaction has a direct negative effect on the delivery of TB prevention and treatment services for township healthcare workers.In addition,the increase in the number of undertake health tasks and high TB core knowledge(treatment management)scores can have an indirect negative effect on the delivery of TB prevention and treatment services for township healthcare workers by acting on job satisfaction.Analysis of the main influencing factors of village-level healthcare workers’ TB prevention and control services: binary Logistic regression analysis found that the local TB epidemic level,training times,training methods,job satisfaction and work willingness were related to the village-level healthcare workers’ TB prevention and control services.The probability of the implementation rate of TB prevention and treatment services ≥ 90% among village-level healthcare workers in the middle(OR=0.642;95%CI: 0.492-0.837)and high(OR=0.628;95%CI: 0.478-0.825)epidemic areas was lower than healthcare workers in lowendemic areas.Village-level healthcare workers who have received one training in the past six months are less likely to carry out TB prevention and treatment services ≥ 90% than healthcare workers who have received ≥ 3 trainings(OR=0.608;95%CI: 0.396-0.934).The probability of TB prevention and control service delivery ≥ 90% among village-level healthcare workers who received "online" training was lower than that of healthcare workers who received "online and offline" combined training(OR=0.612;95%CI :0.417-0.898);the probability of TB prevention and treatment service implementation rate ≥ 90% of village-level healthcare workers with general/dissatisfied job satisfaction is lower than that of healthcare workers with satisfactory job satisfaction(OR=0.529;95%CI:0.424-0.659).The village-level medical staff who are unwilling/uncertain to engage in TB prevention and treatment services for a long time are more likely to have a TB prevention and treatment service rate ≥ 90% than those who are willing to engage in TB prevention and treatment services for a long time(OR=0.668;95%CI: 0.516-0.864).At the same time,the path analysis found that low job satisfaction and low work intention have a direct negative effect on the development of TB prevention and treatment services among village-level healthcare workers.In addition,low training satisfaction can affect the two factors of job satisfaction and work intention,thereby indirectly affects the delivery of TB prevention and treatment services for village-level healthcare workers.Moreover,villagelevel healthcare workers who undertake more work and work for more years have received more TB prevention and control training in the past six months,and more training times has a negative effect on the willingness to work,which indirectly affects the delivery of TB prevention and treatment services.Conclusion:1.The primary TB healthcare workers in Yu-Qian area have heavy tasks,poor stability,and need to improve their capability level and job satisfaction.2.The delivery of TB prevention and treatment services in PHIs in Yu-Qian area needs to be further improved,especially the services of "targeting key groups","referring patients","TB patient treatment management" and "other services for TB patients".3.There are many problems in the delivery of TB prevention and treatment services in PHIs in Yu-Qian area,improvement should mainly focusing on delivery methods,human resources,assessment and incentive mechanisms,internal cooperation of TB prevention and treatment system,and public service guarantee.4.Job satisfaction,workload and knowledge of TB prevention and treatment of townshiplevel healthcare workers in Yu-Qian area are the influencing factors of the delivery of TB prevention and treatment services in township-level PHIs in Yu-Qian area.The job satisfaction,work willingness,training satisfaction,training frequency,number of work and working years of village-level healthcare workers are the influencing factors of the delivery of TB prevention and treatment services in village-level PHIs.Countermeasure suggestions:In view of the current situation and existing problems of the delivery of TB prevention and treatment health services in PHIs in Yu-Qian area,targeted and implementable countermeasures and suggestions based on the new public service theory,"patient-centered" and "integrating health into all policies" health guidelines mainly include:(1)deeply implement "patientcentered" TB prevention and treatment health services in PHIs;(2)take comprehensive measures to promote the construction of human resources for TB prevention and treatment services in PHIs;(3)implement incentives for TB healthcare workers to deliver TB prevention and control services,and scientificize the assessment of TB prevention and treatment work of healthcare workers;(4)comprehensively improve the health literacy of TB patients and community residents,and improve the ability of TB prevention and treatment;(5)accelerate the participation of the whole society in the construction of TB prevention and treatment service network,and provide a strong guarantee for TB prevention and treatment in PHIs. |
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