Background China has strengthened its primary care workforce and implemented a wide network of community health centres (CHCs). However, STI testing and management are not currently included in the ‘Essential Package of Primary Health Care in China’. Legislation change to encourage STI service delivery would be important, but it is also critical to determine if there are also provider-related opportunities and barriers for implementing effective STI programmes through CHCs if future legislation were to change.
Methods A national representative survey was conducted between September and December 2015 in a stratified random sample of 180 CHCs based in 20 cities in China. Primary care practitioners (PCPs) provided information on current experiences of STI testing as well as the barriers and facilitators for STI testing in CHCs. Multivariate logistic regression was conducted to determine factors associated with PCPs performing STI testing.
Results 3580 out of 4146 (86%) invited PCPs from 158 CHCs completed the survey. The majority (85%, 95% CI 84% to 87%) of doctors stated that STI testing was an important part of healthcare. However, less than a third (29%, 95% CI 27% to 31%) would perform an STI test if the patients asked. Barriers for performing STI testing included lack of training, concerns about reimbursement, concerns about damage to clinics’ reputations and the stigma against key populations. Respondents who reported that they would perform an STI test were likely to be younger, received a bachelor degree or higher, received specific training in STIs, believed that STI test was an important part of healthcare or had resources to perform STI testing.
Conclusions There is potential for improving STI management in China through upskilling the primary care workforce in CHCs. Specific training in STIs is needed, and other structural, logistical and attitudinal barriers are needed to be addressed.
- Infection control
- primary care
- community services
- health services research
- service delivery
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Globally, STIs are rising. It is estimated that in 2012 there were 357 million new cases of the four major STIs, namely chlamydia, gonorrhoea, syphilis and trichomoniasis, making them a major public health challenge.1 As an example, chlamydia is the most commonly notifiable disease in the European Union2 and USA.3 In 2014, over 1.4 million cases of chlamydia were reported to the US Centers for Disease Control and Prevention (CDC), the highest number of any infections ever reported.3 The lifetime direct medical cost of chlamydia in the USA had reached US$516.7 million (excluding indirect costs such as loss of productivity and other intangible costs) in 2008.4
In China, STIs have been among the top five notifiable diseases almost every year since 2004.5 Chlamydia has only been notifiable in the STI surveillance system since 20136 and reports from Guangdong province estimate the incidence rate of chlamydia was 51.27 per 100 000 population.7 Another data source for the burden of chlamydia is from the Chinese Health and Family Life Survey, carried out in mainland China between 1999 and 2000, which reported a chlamydia prevalence of 2.6% (95% CI 1.6% to 4.1%) among females and 2.1% (95% CI 1.3% to 3.3%) among males, with a fivefold higher prevalence in coastal South China (9.9%; 95% CI 7.5% to 13%).8 Syphilis, once thought to be approaching eradication,9 has become the third most common notifiable infectious disease (category B) in the country. Its annual incidence nearly tripled from 12.80 per 100 000 population in 2006 to 31.85 per 100 000 in 2015.5
Currently, most patients with STIs in mainland China seek care from public hospitals. One survey estimated that 46% of patients went to public hospitals, 29% to private clinics and 25% to pharmacies. Furthermore, in most settings in China, PCR testing for common STIs such as chlamydia or gonorrhoea or syphilis serology is only available in hospitals and takes place across many clinical settings such as dermatology, urology, obstetrics and gynaecology or internal medicine. In contrast, a survey in neighbouring Hong Kong reported that 80% of patients suspected of having an STI would seek help in the private sector in the community, not through public hospitals.10
In the past decade, there has been a greater focus on primary healthcare in China. Since 2009, the Chinese government has made a commitment to re-establishing primary healthcare and, by 2014, there was a network of 8669 community health centres (CHCs) employing over 300 000 health professionals.11 CHCs are providing basic public health services, diagnosis and treatment, nursing, rehabilitation for common diseases and management of frequently occurring diseases.12 Although STI management is not currently included in the ‘Essential Package of Primary Health Care in China’, the National Health and Family Planning Commission of China has stated that STI prevention and control work need be included in primary public health service gradually by the health administration and that primary health organisations should provide STI publicity and behaviour intervention to key populations.13 There is potential to use this vast network of CHCs to curb the STI epidemics in China by expanding STI testing and treatment through primary care. This is increasingly feasible with the recent development of clinic-based rapid real-time PCR testing with very high sensitivity and specificity that provides results within 90 min.14 The objectives of this survey were to determine the current availability of STI testing and care services at the community level in China and to assess barriers and facilitating factors for performing STI testing in CHCs.
A nationwide representative provider survey among CHCs using stratified random sampling methods was conducted between September and December 2015. The sampling frame was divided into eastern, central and western regions according to the China Health and Family Planning Statistics Yearbook 2015. Two provinces were randomly selected from these three regions, and within each region, two randomly selected district level cities and the capital city was chosen. Furthermore, two out of four municipalities (Beijing, Tianjin, Shanghai and Chongqing) were randomly selected. In total, 20 cities were selected, and from each city, nine CHCs were randomly selected (with an urban-to-suburban ratio of 2:1). In total, 180 CHCs from these 20 cities were selected. The provider survey instrument was developed by the study investigators and consisted of two questionnaires—one for the clinicians-in-charge of the CHC who was asked to provide organisational and service details of the CHC as well as patient characteristics, and another for all primary care practitioners (PCPs) (nurses and doctors) responsible for direct patient contact in the selected CHCs. The questionnaire and findings of the full survey are published elsewhere.15 This paper focuses on reporting the findings related to STI provision in CHCs in China. The questions regarding attitudes towards STI testing were adapted from a US Centers for Disease Control and Prevention evaluation resource.16 The content domains on sexual health used in the survey were availability of STI testing, experiences of testing and managing patients with STIs and identifying barriers and facilitators for initiating testing and management in certain key populations (men who have sex with men, transgender people, injecting drug users and sex workers). The surveys were pilot-tested twice in three CHCs and among 45 PCPs, after which we added the option of registered specialty in the demographic questions and clarified phrasing in some questions.
To maximise recruitment, we assigned and trained staff in each study site to issue the questionnaires to the study participants, who completed the questionnaires themselves. The surveys were collected in the CHC and mailed back to the researchers. If the questionnaire had not been received within a month, the researchers called the staff in the CHCs to follow-up any missing study participants. Ethics Committee approvals were obtained from a local board (HKU/HAW IRB: UW15-350) and the WHO Regional Office for the Western Pacific (2016.4.CHN.1.HSI).
Descriptive analyses were conducted to provide percentages and frequencies of key parameters. CIs for the sample proportions were calculated using the Agresti-Coull (adjusted Wald) method. The statistical modelling focused on determining factors associated with PCPs performing STI testing within CHCs. Univariate logistic regression was performed to assess explanatory factors such as composition of staff in the CHC, available medical services and availability of onsite testing. Purposeful selection was used to select explanatory variables (p<0.25) used in a multivariate logistic regression model. Results with a p value of <0.05 were considered statistically significant. Data were analysed using STATA (StataCorp, 2013, Stata Statistical Software: V.13).
One hundred and fifty-eight out of the 189 CHCs contacted participated (84% response rate). Out of 4146 PCPs invited from these 158 CHCs, 1734 doctors and 1846 nurses completed the survey (ie, 86% response rate). The demographics of study participants have been published in detail elsewhere.15 The mean age for doctors was 40 years (SD 11) and for nurses, mean age was 33 years (SD 9). The majority of doctors were female (61%), and almost all nurses were female (99%). Among the doctors, 55% held a bachelor degree or higher, while only 29% of nurses held a bachelor degree or higher. Nearly half the doctors (46%) had a primary registration as a general practitioner. The median years of working for doctors was 14 (IQR 7–23) and for nurses was 9 (IQR 4–8).
Table 1 summarises the current experience of STI management among doctors and nurses based in CHCs. There were some key differences between doctors and nurses working in CHCs, and this information may be valuable for institutions training these two professions. Specific training in STIs was variable, with one-third of doctors and nurses having received no training in STIs and, with fewer nurses (compared with doctors) trained in STI pretest and post-test counselling, clinical diagnosis and management of STIs. Although more than half the doctors and nurses stated they had enough resources to perform STI testing, two-thirds (64%) of this same group reported difficulties in providing privacy for STI testing, one-third (34%) reported difficulties in asking patients about their sexual orientation, a quarter (24%) reported difficulties in obtaining a sexual and reproductive health history from patients and only one-third (34%) would perform an STI test even if a patient asked. Only a minority of doctors (<10%) and nurses (<5%) had diagnosed patients with chlamydia, gonorrhoea or syphilis in the preceding month.
Table 2 summarises the perceived barriers and opportunities for performing STI testing in CHCs. The biggest barrier identified was lack of training (47% doctors and 53% nurses), and similarly, more training was reported by staff as a facilitating factor for conducting STI testing in CHCs. However, a substantial minority (18% doctors and 20% nurses) felt there was nothing to be gained by performing STI testing. There were also significant worries that performing STI testing in key populations within CHCs would drive other patients away (41% doctors and 46% nurses), that key populations were too difficult to manage (62% doctors and 60% nurses) and that PCPs feared being infected by their patients (28% doctors and 42% nurses).
Table 3 summarises attitudes towards performing STI testing in CHCs. Over half (60% doctors and 56% nurses) felt comfortable discussing STI testing, with the majority believing that their patients received adequate pretest and post-test information for STI testing. Furthermore, the majority (85%) of doctors and nurses agreed that STI testing was an important part of regular healthcare. However, the majority of PCPs raised concerns regarding financial issues, fearing that patients would be offended by being offered STI testing or that the offer would have a negative effect on the patient’s opinion of the clinic as patients would not expect to be offered STI testing.
Table 4 is the multivariate analysis that examined the demographics, clinical experiences and attitudinal factors associated with respondents who reported that they would perform an STI test if a patient requested one. Those who would perform an STI test when requested by the patient were more likely to be younger, worked in the west or eastern regions of China (compared with central), had received a bachelor degree or higher, received specific training in STIs, believed that STI test was an important part of healthcare, believed that patients received adequate post-test information about STI testing (with strong collinearity with adequate pretest information) and had resources available to perform STI testing.
There were regional differences regarding the aforementioned factors, and these are presented in online supplementary tables 1–3. Of note, PCPs in the western regions were more likely than those from the eastern or central regions to have received training in STIs, performed an STI test if a patient requested one and to have seen someone belonging to one of the key populations in the preceding month. Consequently, PCPs from the western regions felt more comfortable in discussing STI testing with their patients and also felt that their patients received adequate pretest and post-test information about STIs. More training was identified as a need before performing STI testing in more than half of all PCPs, especially those from the central region (64%).
Supplementary file 1
This is the first national survey of PCPs in China regarding their experiences in providing STI testing and management at the primary care level. Currently, STI testing and management are not key priorities in primary healthcare in China. Nevertheless, our research extends the literature on the role of primary care in STI control through providing evidence that PCPs in China are keen to be trained and upskilled in STI testing and management, but there are logistical, attitudinal and educational barriers to overcome. If these barriers can be addressed, providing STI testing and management among the increasing number of CHCs may help address the control of STIs in China.
Although the majority of PCPs believed that STI testing was an important part of healthcare, only a minority of PCPs would perform STI testing if a patient asked to be tested. While about half of PCPs reported that they had enough resources to provide STI testing in their CHC, this was not just a resource issue. Even among CHCs where adequate resources for STI testing were available, only 34% of these PCPs would perform an STI test if patients asked. This pointed towards factors at the practitioner’s level, where performing STI testing in CHC was positively associated with being younger, having a higher education level, stating that STI testing is an important part of healthcare and having received specific training in STI. We specifically noted the current training gaps where approximately half of PCPs did not feel comfortable to ask patients about their sexual orientation or obtain a sexual and reproductive health history. Due to the lack of specialised sexual health or genitourinary medicine clinics in China, a feasible alternative would be to upskill PCPs in China to provide testing and treatment for STIs, and this would help shift the patient burden away from secondary and tertiary hospitals. In Hong Kong SAR (China), patients with STIs and genitourinary symptoms find it acceptable to attend a primary care doctor for management.17
At the clinic level, logistical issues such as providing adequate privacy in asking patients about sexual history also needs to be addressed. A local study on setting up a sexual health clinic found privacy (among many other international standards) was lacking and recommended that by remodelling the clinic it would help to increase attendance and allow disclosure of sensitive issues.18 Furthermore, the majority of PCPs cited barriers to reimbursement in existing health insurance programmes; patients feeling offended by being asked about STIs; and potential harm to the reputation of the clinic by treating STIs, which may be related to the stigma associated with STI.
In recent years, there have been more projects and service delivery models integrating HIV and STI control and prevention.19 20 As a result, more researchers as well as the WHO are advocating for ‘combination HIV prevention’ by adding curable STI diagnosis and treatment to HIV programmes.21 22 In the latest version of WHO’s Consolidated Guidelines on HIV Prevention, Diagnosis, Treatment and Care for Key Populations - 2016 Update, it was highlighted that the screening, diagnosis and treatment of STIs should be routinely performed for key populations, as part of comprehensive HIV prevention and care services.23 If Chinese legislators were to encourage STI testing and management in CHCs, our research highlighted the importance of addressing stigma among PCPs towards key populations where a significant number of PCPs perceived that managing key populations would drive other patients away and that these patients were too difficult to manage and that some PCPs feared being infected by their patients.
The main strength of this study is that it is the first large nationally representative survey of PCPs allowing understanding of their current experience of providing STI testing in CHCs in mainland China. As this study provides an overview of key issues from many jurisdictions, we acknowledge that further qualitative and quantitative research at the local level should be conducted to determine the importance of the identified factors and ascertain other significant factors. In addition to the provider barriers we identified in this study, future research should also consider the role of other well recognised barriers to STI provision in primary care such as system level barriers (policy/guidelines support, long waiting times, user fees and clinic opening hours), broader societal barriers (fear and stigma related to STIs among the community, which may affect health seeking behaviours) and patient barriers (lack of knowledge about STIs). A helpful framework to overcome some of these barriers is provided in The WHO Global Health Sector strategy on STIs.24
There is potential for improving STI testing and management in China through upskilling the primary care workforce in CHCs. Policy change to include STI testing and management in the ‘Essential Package of Primary Health Care in China’ may be feasible given that although only a minority of PCPs in China provide STI testing currently, the majority of PCPs surveyed showed an interest in more training in this area. Specific training in STIs is needed, and other logistical and attitudinal barriers must also be addressed.
China has established a wide network of community health centres (CHCs) but have not legislated the inclusion of STI testing and management.
Our nationwide study demonstrates the potential for primary care providers in CHCs to be used to improve delivery of STI services in China.
Consideration should be given by policy makers to upskill and deploy this expanding workforce for STI control.
If an effective STI programme were to be established, provider barriers identified in this study must be addressed in addition to other known barriers to provision of STI services through primary care.
JJO and MP contributed equally.
Contributors WCWW and JJO designed the study. SJ and MP coordinated the collection of data. JJO did the analysis of the data. All authors contributed to writing the article, revising the manuscript and have given the final approval of this version to be published.
Funding JJO (number 1104781) is supported by the Australian National Health and Medical Research Council (NHMRC) Early Career Fellowship.
Competing interests None declared.
Ethics approval Hong Kong University; World Health Organization.
Provenance and peer review Not commissioned; externally peer reviewed.
Data sharing statement All data relevant to the study have been presented in the tables and supplementary tables. If additional clarification is needed, please write to the corresponding author.
Correction notice This article has been corrected since it was published Online First. The spelling of the author name “Sunfong Jiang” has been corrected to “Sunfang Jiang”.
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