CHWs-based NCDs management play a key role in developing a continuous, effective and integrated care delivery system. CHWs who have frequent contact with patients are well positioned to provide counselling, as well as reliable sources of information from patients’ perspective. The objective of this study, therefore, was to conduct a situational analysis of current human resource and requirement of NCDs-related training in Chengdu with regard to address to understand the suggestions for improvement of challenges and barriers. In this study, a wide majority were women among CHWs, and doctors had higher levels of professional title and registration in general practice compared with nurses. In many primary health care programmes, females are the preferred gender because of the type of tasks required [27]. A study based on the individual-level data showed that a comparative low proportion of registered CHWs worked in primary health care [19]. Several previous studies showed that the fairness on distribution of primary health resources was poorer in China, due to geographical and economic disparity [20, 28, 29], which in turn leads to increasing inequalities between the rich and the poor with regard to health and the economic burden of health care. A shortage of CHWs could be a prominent barrier to scaling-up quality improvement of NCDs management and improve the satisfaction of patients on chronic care. It is necessary to issue the policies highlighting the human resources and encouraging higher continuing education, which is contributed to resolve the aforementioned challenges. In the meantime, nurse-doctor substitution has been perceived as an effective and available strategy to alleviate workforce shortages, to improve the quality and continuity of health care, and to reduce human capital investment [23, 30–32]. The measures could be generalized to our districts, but it should be taken the context-specific and tailored circumstances into consideration, such as type of service, reciprocal respect and collaboration between physicians and nurses, proper resources, and good referral systems [24]. Furthermore, encouraging the experts from tertiary hospitals to participate in CHWs’ daily work has been promulgated as the national policy to narrow the substantial gap in the overall primary health system and to increase CHWs’ competency.
We found that the top five NCDs managed by CHWs were hypertension, diabetes, cerebrovascular disease, chronic respiratory diseases and mental diseases. The disease composition of NCDs reflected that CHWs are more often dealing with primary and common diseases, which were substantially different from those worked in tertiary two or three hospitals. Significantly, mental diseases which are often ignored are considerable common at community. A number of published studies reported that anxiety and depressive disorders were common among patients with chronic diseases. Hypertension, diabetes, cerebrovascular disease, and chronic kidney disease were found to be associated with depressive symptoms [33–35]. Furthermore, a large-scale epidemiological survey conducted in China was revealed the relationship of NCDs with psychological symptoms: multimorbidities and a course of disease within 1 year or more than 5 years were associated with a higher risk of stress, anxiety and depression [36]. Besides, somatization was a frequent co-morbid psychiatric symptom among NCDs patients [37]. The prevalence of mental health problem is expected to pose a threat to the healthcare system in China. Accordingly, a modest amount of effort is still required to address screening, diagnosis and management of these diseases.
Doctors and nurses who are regarded as the main workforce in the community provide a broad range of services ranged from the distribution of health education to following up, establishing archives, medicine adjustment, treatment implementation, contacting with patients or health services and referral. These roles are a clear indication of CHWs’ efforts in assisting patients to achieve a better health outcome. However, shouldering various of responsibilities can reduce their ability to be efficient and job satisfaction [38, 39]. Notably, CHWs are at the forefront of preventing and controlling the virus during COVID-19 pandemic, which causes them to assume increasing responsibility and multitasking works, resulting in stressed and depressed [40]. Thus, it is necessary to define the clear role of CHWs, which not only meet their current needs but also contribute to community development. In addition, this study reported that the role performed by doctors and nurses was slightly different. Although, the primary health care model is based on traditional physician-centric care, mutual trust and cooperation among them on primary care might drive NCDs management to a promising prospect.
In our study, it was demonstrated that training-related NCDs that CHWs have received was matched with the NCDs managed by them. Studies have showed that training could boost CHWs’ working ability and self-confidence to be qualified for NCDs management [41–45]. In this survey, it revealed that CHWs were not satisfied with the contents and forms of training in our region. CHWs had the aspiration to receive further trainings on disease treatment, disease prevention, disease diagnosis, lifestyle guidance, rehabilitation knowledge, and doctor-patient communication. Additionally, psychological guidance was also expected to be included in the training list. CHWs were more likely to attend more on-the-job training, expert academic lectures, training course, further study in a tertiary hospital, and domestic academic conferences. The majority of CHWs have not obtained enough postgraduate or continuing educations and trainings to meet the basic work requirements and demands. As a result of this barrier, CHWs have limited ability to prevent, diagnose and treat NCDs. Improving risky lifestyle behaviours (smoking, alcohol abuse, sedentary life and unhealthy diet) is the most important strategy in preventing, reducing morbidity and burden of NCDs. However, counselling on lifestyle guidance from CHWs is insufficient and partly due to a lack of training. As doctor-patient communication is a subtle but important part of medical process. A bad doctor patient relationship is responsible for misunderstandings and conflicts and decreasing health care quality. Despite the advantages of effective and efficient doctor-patient communication on health care, patient-centred care and communication should be enhanced among CHWs. Furthermore, due to lack of professional mental health skills, CHWs were incompetent to screen and diagnose mental illness, and to provide psychological counseling [46]. In addition, eliminating discrimination against mental illness from CHWs was an intervention to improve the quality of mental health services [47, 48]. Hence, relevant trainings should be developed to enrich CHWs' professional knowledge about mental illness. Notably, the training program should be based on CHWs’ expectations so as to make CHWs mastered the key concepts, as well as included follow-up support and feedback that could strengthen more transfer of knowledge after training.
Some limitations should be considered in this survey. First, the sample population was relatively small, limiting the generalisability of the findings to other cultures and geographic regions in China. Second, this study used a cross-sectional design and no causal relationships can be speculated. Third, the study was restricted to the preferences of doctors and nurses, which may limit specificities to other professions and insights from the service recipients’ perspective. Fourth, participants made choices based on these selected variables, other variables had not been fully considered in the study. Furthermore, quantitative study is needed to improve these limitations.
In this study, we found that doctors and nurse are disproportionately at community in Chengdu: doctors had a higher level of qualification, professional title and registration in general practice compared with nurses. Although doctors and nurses are exposed to the same primary care management environment, doctors rather than nurses are perceived as the principal implementer in community-orientated primary care. The trainings on NCDs among CHWs are insufficient and not tailored. Considering the context and characteristics of CHWs, specific and standardised NCD training should be provided. Significantly, except for the basic and imperative job requirements, trainings-related mental illness and doctor-patient communication should be enhanced. To strengthen the roles of CHWs and to promote NCDs management programmes, more work-based learning opportunities such as on-the-job training and further study in a tertiary hospital should be provided and matched with the preferences and expectations of CHWs.