Objectives To analyse the educational status and future training needs of China's rural doctors and provide a basis to improve their future training.
Methods A cross-sectional epidemiological survey was used for the analysis, and 17 954 rural doctors chosen randomly from the eastern, central and western regions of China in 2009–2010 were surveyed to ascertain their average training time and the methods used for and content of their training.
Results In general, 8671/17 778 (48.77%) of respondents received less than 12 days of training in a year. Conference sessions seemed to be the major route of training, with 10 150/17 925 respondents (56.62%). Clinical skills, with a response rate of 14 441/17 926 (80.56%), seemed to be the most popular training content. With regard to the general needs for training time received, 6547/18 255 (35.86%) of respondents hoped the average training time received a year would be less than 12 days; on-site guidance from a senior doctor was the most popular training method with response rate of 10 109/17 976 (56.24%), and clinical skills was what rural doctors wished to study the most, with a positive response of 16 744/17 962 (93.22%). Statistically significant differences existed in the current status and training time, training method and training content needs of China's rural doctors.
Conclusions Our results suggest that the training status and needs of China's rural doctors are still disjointed; measures including the introduction of remote education and clinical further education, extended training time and more clinical skills training should be adopted.
- EDUCATION & TRAINING (see Medical Education & Training)
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China has a large rural population, thought to number 712.88 million people by the year 2010.1 With health services underused and unbalanced, rural residents generally have a lower satisfaction rate for medical services.2 To tackle these problems, rural doctors, being the most basic health personnel in rural areas of China, will play a key role in health services for some time to come. The number of rural doctors in China is huge and growing, increasing from 643 022 in the year 1985 to 882 218 in 2007.3 ,4 Therefore, their training status and needs has always been a focus of studies concerning health professional human resource issues in rural areas.5 ,6
In China, the National Educational Planning for Rural Doctors (2001–2010) required that by the end of 2010, in areas with more developed economies and education levels, at least 30% of rural doctors should have obtained healthcare education at junior college level or above. In underdeveloped areas, more than 15% of rural doctors should have obtained healthcare education at junior college level or above.7 Now that this 10-year plan has come to an end, large-scale research is needed to ascertain the current training status as well as the future needs of China's rural doctors. In order to better improve future training initiatives, this study analysed the current educational status and needs of China's rural doctors and the problems that lie ahead through a large sample study (box 1).
Background of rural doctors in China
Rural doctors refer to those grassroots doctors who deliver primary health services in rural areas after passing a rural doctor's exam and obtaining a rural doctor's certificate issued by local health administrative governments.8
In China, rural doctors are primary healthcare providers and gatekeepers who are at the basic level of the three levels of rural health service systems (including county, township and village levels), which has been known as one of the ‘three magic weapons’ (which includes rural doctors, the Rural Cooperative Medical System and three levels of health care systems covering village, town and county of rural China. The three effective models to improve Chinese rural residents’ health) against China rural health works. According to the 4th China Health Service Survey, 57.3% of rural patients are first diagnosed and treated by rural doctors in village health agencies.2
Historically, rural doctors have been known as barefoot doctors, country doctors or village doctors, but their functions are unchanged and include providing basic medical, public health and other health services, and accepting supervision from local administrative departments of public health management and guidance from senior medical departments. Therefore, rural doctors are an important part of the health service provision for rural residents in China.9
In general, rural doctors in China have lower levels of education, than the training target of National Educational Planing for Rural Doctors (2001∼2010), with the percentage of those having completed secondary education or above standing at 52.31%; their specialties are mainly focused in clinical medicine, with a small percentage in nursing. Their training and education at present are mainly centred around school training and correspondence education, focusing on education with record of formal schooling and knowledge update, and their training sites are mainly county level health schools and health institutions.10
A cross-sectional epidemiological survey was used in our study. Firstly, according to geographical location and the economic development level of different provinces in China, the mainland can be subdivided into three economic zones: the eastern (including Beijing, Tianjin, Hebei, Liaoning, Shanghai, Jiangsu, Zhejiang, Fujian, Shandong, Guangdong, Guangxi and Hainan), central (including Shanxi, Inner Mongolia, Jilin, Heilongjiang, Anhui, Jiangxi, Henan, Hubei and Hunan) and western regions (including Chongqing, Sichuan, Guizhou, Yunnan, Tibet, Shanxi, Gansu, Ningxia, Qinghai and Xinjiang).9 A total of 10 provinces or municipalities or autonomous regions were chosen by random from the eastern, central and western regions. These were: Beijing, Jiangsu, Zhejiang, Hainan and Guangxi from the eastern regions, Shanxi and Jiangxi from the central regions and Guizhou, Yunnan and Gansu from the western regions. The survey sample was a random sample of rural doctors from the 10 provinces mentioned above from December 2009 to December 2010.
Based on a literature review and interviews, we improved the ‘Questionnaire of Current Status of the Chinese Rural Doctors’, which was reviewed by experts epidemiologists, statistician, health human resources managers, and Chinese rural doctors, and a pilot survey was conducted to verify its reliability and validity.
The survey included questions on demographic information, current education status, average amount of training received in a year (measured in days), training method (including via schools, distance education, self-study, taking proficiency tests, guidance from senior doctors, conference lectures, clinical further education, master/apprentice training) and training content (clinical skills, nursing skills, medication knowledge, disease prevention and healthcare knowledge). The survey concerning the needs of rural doctors included: training time received each year (measured by days), training method (as above) and training content (as above). By describing and comparing the distribution of current status and training needs of rural doctors in different research regions in our study, their differences of overall distribution will be elucidated.
Firstly we determined the investigative mandate for the 10 regions, which was used to regulate the participants selected, the survey field organised, the data collected and the obligation of related departments who participated in the survey. Secondly, we completed the recruitment and training of investigators recruited from local medical institutions and medical colleges, trained using the investigators training guide (which is a guide to regulate the survey process and control the information bias by the means of standardising the interviewing methods and data collection) to ensure the interview process was standardised. Then, an Investigation Executive Committee and the Working Group (IECWG) was formed to direct the survey process and take responsibility for quality control of the surveys. The final step was questionnaire collection, which was performed in the following two ways: either investigators went to the sampled townships and gave out questionnaires or notifications and helped with the completion of questionnaires, or questionnaires were issued to rural doctors attending organised training courses or conferences across the country. All the questionnaires were filled out using real names (ie, non-anonymous).
EPIDATA3.02 was used to build a database and double entry was conducted. By using SPSS 13.0, statistical analyses were mainly conducted using the following two methods: the training status and needs of rural doctors in China's central, western and eastern areas were described by calculating the frequency and percentage of who got the actual training and realised the needs of training among all the respondents, and the differences between training status and future needs of rural doctors from sampling areas were analysed using χ2 tests.
This study surveyed 17 954 participants, including 10 559 people from eastern regions, 3030 people from central regions and 4365 people from western regions. The distribution of gender in general shows that men accounted for 12 598/17 954 (70.17%) of the total no. of respondents. With regard to age distribution, with the exception of the western regions the results show a higher percentage (over 45%) of doctors in the 40–59 years age group in eastern as well as central regions. As to the education level of rural doctors, the high school diploma level covered a major part of the overall distribution, accounting for 13 207/16 086 (73.42%). Clinically-based specialties accounted for the largest proportion 12 177/18 137 (67.14%) of the total. Nursing accounted for the lowest proportion of specialty choice, accounting for only 79/10 651 (0.74%) in the eastern regions. As to the qualification of rural doctors, the proportion of rural doctors who had a rural doctor certificate was 12 304/17 913 (68.69%), and 14 605/17 913 (81.53%) of them had a rural doctor practicing certificate. People who had a practicing physician's certificate or a practicing assistant physician's certificate made up less than 10% of the all respondents. In all, 362/17 912 (2.02%) of rural doctors were without a practicing certificate of any kind (see table 1).
Current training status
As for the training time received in the past year, the results show overall 8671/17 778 (48.77%) of respondents received less than 12 days of training in a year, while only 4218/17 778 (23.73%) of them received more than 24 days of training. The statistical differences in training time in different regions shows there was a significantly higher proportion of training time in the eastern regions than that of the central and western regions.
As to the method of training, conference sessions seemed to be the major format, with an overall response rate of 10 150/17 925 (56.62%). The eastern, central and western regions all shared this same main training method; the proportions were 6552/10 577 (61.95%), 1340/2928 (45.77%) and 2258/4420 (51.08%), respectively. Conference sessions were followed by guidance from senior doctors, the proportion of which was 8063/17 925 (44.98%). The proportions in eastern, central and western regions were 4791/10 577 (45.30%), 1311/2928 (44.78%) and 1961/4420 (44.37%), respectively. Remote or video education had become an important method for the education of rural doctors in the western regions, the proportion of which reached 1759/4420 (39.80%), and this figure was much higher than the central and eastern regions.
As to the training content, clinical skills, with an overall selection rate of 14 441/17 926 (80.56%), seemed to be the most important factor. Next were medication knowledge and preventive healthcare knowledge, the selected rates of which were 11 746/17 877 (65.81%) and 11 735/17 923 (65.47%), respectively. Regional disparities in the training content manifested in the selection rate of clinical skills, which in the east (8982/10 565 (85.02%)) and central (2612/2940 (88.84%)) regions were higher than that in western regions (2847/4421 (64.40%)). Also, the selection rate of preventive health knowledge in eastern regions (8461/10 565(80.09%)) was much higher than for central (1803/2940 (61.33%)) and western (1471/4418 (33.30%)) regions (see table 2).
As for the general needs of training time received, 6547/18 255 (35.86%) of respondents hoped that the average training time received a year would be less than 12 days, while 5520/18 255 (30.24%) hoped it would be 12 to 24 days and 6188/18 255 (33.90%) of the respondents would like to choose more than 24 days per year. There was a statistically significant difference between different geographical distributions on training needs. In the eastern regions, 4463/10 731 (41.59%) of the respondents hoped the training time would be less than 12 days. In the central regions, 1115/3092 (36.06%) of them hoped the training time would be between 12–24 days. For the western regions, 2359/4432 (53.23%) of rural doctors wanted more than 24 days.
As to the training method, on-site guidance from a senior doctor appeared to be the most popular format according to our survey, with an overall response rate of 10 109/17 976 (56.24%). The second most popular training method was clinical further education (9585/17 976 (53.32%)). Clinical further education was the most popular way of training in central and western regions; the selection rates were 1671/2952 (56.61%) and 2510/4420 (56.79%), respectively.
As to the training content, clinical skills training appeared to be what rural doctors wished to receive the most according to our survey, which accounted for 16 744/17 962 (93.22%). This was followed by medication knowledge, with a selected rate of 13 390/17 692 (74.55%). For clinical skills training needs, the statistical differences across different regions shows the rate was higher in the western regions (4055/4419 (91.77%)) than that in the eastern (9944/10 584 (93.95%)) and central (2745/2959 (92.77%)) regions. Medication knowledge training needs in the eastern region (8091/10 584 (76.45%)) was much higher than that in central (2078/2959 (70.23%)) and west (3221/4419 (72.89%)) regions (see table 3).
The difference between overall status and needs of training
Statistically significant differences existed between the current status and training time needs of China's rural doctors. 4218/17 778 (23.73%) of respondents got the actual training time of more than 24 days in a year, whereas 6188/18 255 (33.39%) of them would like prefer that long training time, which shows the difference was near to 10%. As for the training time of 12-24 days and less than 12 days in a year, they changed from 4889/17 778 (27.50%) to 5520/18 255 (30.24%), and from 8671/17 778 (48.77%) to 6547/18 255 (35.86%), respectively. These results suggest that rural doctors wanted to extend the training time (see figure 1).
There were statistically significant differences between actual and expected training method, which reflected that there was a significantly higher demand for clinical further education, guidance from senior doctors, school training and the master/apprentice method, among which the biggest rise was clinical further education, from the current 3357/17 925 (18.73%) to the expected 9585/17 976 (53.32%). Those wanting guidance from a senior doctor rose from 8063/17 925 (44.98%) to 10 109/17 976 (56.24%). Among the selected training methods, conference sessions, self-education or proficiency testing and remote/video education decreased significantly, and the highest decline occurred in conference sessions, the level of need dropping from the current 10 150/17 925 (56.62%) to 5966/17 976 (33.19%), suggesting that practice-focused training (on-site guidance from senior doctors, clinical further education) was the major need of rural doctors (see figure 2).
From the overall demand for training content, clinical skills, nursing skills, medication knowledge and preventive healthcare knowledge all significantly increased. Clinical skills rose from the present 14 441/17 926 (80.56%) to the desired 16 744/17 962 (93.22%). These results show that in the year 2011, rural doctors had greater needs for clinical skills, preventive healthcare and medication knowledge education (see figure 3).
Rural doctors have dramatically improved access to healthcare in China's rural communities over the last few decades, therefore the education and training of rural doctors is vital to improve their level of practice.11 Thus, it is important to understand the current educational status and future training needs for rural doctors, which will be very helpful in improving the manpower of rural health professionals who have relatively low healthcare education, as the survey shows. Generally speaking, the current situation is still lagging behind the goal of college education in 30%,7 and a difference between the actual status and needs of rural doctors still exists, as the results shows. Therefore, we should invest more resources into their training and strive to achieve the planned 2010 objectives.
The results show that, in China, 8671/17 778 (48.77%) of respondents reported that they had training time per year of less than 12 days, which was similar to the result of 57.40% in 2007,12 and the training method for rural doctors was concentrated in the conference sessions, which was very similar to the results of Jun that showed that 62.3% of respondents had selected this training method.12 Another training method that the majority of rural doctors selected was guidance from a senior doctor, which was much higher than the results of 3.8% done by Qi and Wannian in 2004.13 Our survey, and another conducted by Jun, show clinical skills seemed to be the most important training content.12 All the above results suggest that the training time for rural doctors in China needs extension and the training methods and content are not rich. Furthermore, the results show that levels across regions were different, which in turn shows the influence that different economic and health statuses exert on the training of rural doctors.
As the results of the training needs investigation show, rural doctors prefer training dominated by guidance from senior doctors and clinical further education, which had similar results of 25.1% and 36.1%, respectively.13 The duration of such training would be best if less than 12 days, and the content should be based in clinical skills, which coincides with results of 31.7% by Qi and Wannian.13 All the above results show rural doctors in China would like to get more practical and efficient medical training.
By comparing the differences between the actual status and needs of rural doctors training in China, we can find their training actually received and their needs perceived are still disjointed, which can be summarised as follows.
For training time, rural doctors are more keen on long-term education rather than the current short-term training, which shows their desire to improve healthcare capacity is strong.
For training content, rural doctors want to get more clinical skills training and to learn more about the proper use of pharmaceuticals, which shows they would like to gain more practical and useful medical knowledge and skills.
For training methods, current training is mainly limited to clinical theoretical knowledge, while rural doctors want to experience direct clinical guidance and clinical education from senior doctors; if necessary, they accept to be trained full time, which reflects their desire to gain medical training via more efficient and direct methods.
Strengths and limitations
This study covers a considerably large sample survey taken in the last 10 years in many regions of China and had a good representation. Secondly, the investigation is comprehensive, as it includes training status and training demands, as well as their differences. Therefore, the research may provide useful healthcare education information for China and other similar countries worldwide. However, the research has the following limitations. First of all, the questionnaire adopted was improved by literature review and pilot survey, and its reliability and validity was not well verified. Secondly, this paper is only taken from the perspective of the current status and training needs of rural doctors, and did not involve the actual health service demands of residents. Thirdly, the knowledge and abilities of rural doctors were assessed only through filling out the questionnaire, not by practice examination or other tests. Fourthly, the samples were not completely randomised. A larger sample size and high proportion of respondents from Guangxi, Gansu and Jiangsu may have produced selection bias, while the sample size was relatively small in the other seven provinces.
Future direction of this work
A future survey will be conducted to investigate the health service demands of rural residents from rural doctors. A more completely random sampling method will be used to make the results more reliable. According to the results of the survey, a pilot test for rural doctor training will be carried out and its effectiveness evaluated.
Our results suggest that the training status and needs of China's rural doctors are still disjointed. The improvement of the professionalism of rural doctors through the implementation of educational planning to enable them to effectively adapt to the needs of rural health services seems necessary. Therefore, our study suggests that during the training of rural doctors, training objectives and method should be improved as follows: focus on rural doctors under the age of 45 and train them through clinical further education. Another method may also be the introduction of further remote education. Training time should also be extended by an appropriate amount. According to time that rural doctors can spare, full-time training for clinical skills should be carried out.
Rural health professionals in China who have relatively low healthcare education, as the survey shows, should be focused on.
The proportion receiving training time of more than 24 days in a year rose from the current status of 23.73% to reflect a need for 33.39%, suggesting that rural doctors wanted to extend the training time.
Our survey suggests that practice-focused training (on-site guidance from senior doctors, clinical further education) was the major training need for rural doctors.
Rural doctors had greater desire for clinical skills, preventive healthcare and medication knowledge education.
Current research questions
The differences between current educational status and demands of China's rural doctors.
The implications and suggestions for the deference analysis between current educational status and demands of China's rural doctors.
Centers for Statistics Information Ministry of Health of the People's Republic of China. An analysis report of national human resources survey in China, 2006. Beijing: Publishing House of Peking Union Medical College, 2006.
Bin L, Quan L. The current status and countermeasures of human resource of health care in the rural areas of China. Chin J Public Health 2009;11:1401–2.
Yan R. The development and function of China rural doctors. Chin Rural Health Serv Adm 2011;31:443–5.
Jingru Z, Xiaowei L, Junling X. Village doctor education current situation and training mode. Chin Rural Health Serv Manag 2011;31:1013–14.
Jun H. The analysis on the current status of rural doctor training in three provinces in China. Chin Rural Health Serv Adm 2009;11:822–4.
We appreciate all 1032 investigators who participated in this survey. We also give thanks to the Chinese Medical Board who gave us funding for the survey. Specifically, we extend our thanks to the rural doctors who offered great assistance in the process of data collection. Finally, we would like to express thanks to Dr Sohel who gave us English writing revision help.
Contributors XL conceived the study design, conceptualised the ideas and supervised analyses. JL and JH conducted the study design and the data collection and supervised the manuscript writing. YQ and LC provided technical support for the data analysis and drafting and revising the manuscript.
Funding Chinese Medical Board (CMB08-932).
Competing interests None.
Ethics approval The research protocol was reviewed and approved by the ethics committee of the Institute of Chinese Academy of Medical Sciences/Peking Union Medical College, School of Basic Medicine.
Provenance and peer review Not commissioned; externally peer reviewed.
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